Long-term sequelae after cancer therapy--survivorship after treatment for testicular cancer

This paper is based on a lecture given during the Oncological Forum, Oslo, in November 2002. Long-term morbidity in cancer survivors is exemplified by results of clinical research in testicular cancer survivors (TCSs). The most serious complication is the development of second, non-germ cell malignancies (relative risk [RR]: 1.4-1.6). After infradiaphragmatic radiotherapy, most solid malignancies are diagnosed within or near the target volume. Combined chemo-radiotherapy increases this risk. Chemotherapy-induced leukaemia is usually reported after 4-7 years. After 3 or 4 cycles of cisplatin-based chemotherapy, 15-20% of TCSs suffer from peripheral sensory neuropathy, Raynaud-like phenomena and/or ototoxicity. Hypogonadism is observed in 16%. The risk of cardiac complications is increased by hypercholestorolaemia and abnormal body mass. Pelvic radiotherapy and cisplatin-based chemotherapy are followed by transient oligo/azospermia with recovery after 6-12 months. The risk of surgery-related 'dry ejaculation' is significantly reduced after unilateral and nerve-sparing retroperitoneal lymph node dissection, but infertility remains a long-term problem in 10-15% of survivors. Most TCSs describe their quality of life as comparable with that of the age-matched male general population. Not all long-term complications are avoidable after curative treatment of cancer. Knowledge of post-treatment long-term morbidity is essential for early recognition and treatment of late complications, and enables adequate counselling of new cancer patients.     

Second cancers after testicular cancer diagnosed after 1980 in Sweden

BackgroundTesticular cancer treatment has become standardized in the 1980s involving radiotherapy preferentially for seminoma and chemotherapy for nonseminoma. The late effects of these therapeutic practices have not been properly evaluated because of the relatively short time since their application.Patients and methodsWe conducted a study among 5533 survivors of testicular cancer on the basis of Swedish Family-Cancer Database for which the cancer data were retrieved from the nationwide Cancer Registry. Standardized incidence ratios (SIRs) of second cancer were calculated by comparing with the rates of the first cancers. The follow-up was started in 1980 and carried on through 2006.ResultsA total of 370 second cancers (6.7% of all patients) were recorded, more in seminoma than in nonseminoma patients. Second testicular cancer showed an SIR of 29 after seminoma and an SIR of 13 after nonseminoma. A total of 10 discordant sites were increased after seminoma compared with seven sites after nonseminoma. Gastrointestinal tract cancers occurred mainly after seminoma and bladder cancers (SIR 8.6 when diagnosis before age 30) occurred after nonseminoma.ConclusionsOf the selective affected second tumors, it will be important to confirm the association of bladder cancer with nonseminoma treatment.     

Radiotherapy after prostatectomy

AIMS AND BACKGROUND: The role of radiotherapy after prostatectomy is controversial. This paper tries to give some guidelines for everyday practice through an analysis of literature data. METHODS: The potential role of radiotherapy in the adjuvant and salvage setting is discussed. We also report and interpret available literature data for both settings. RESULTS: As regards an increase in or detectable prostate-specific antigen (PSA) after radical prostatectomy, about 40-50% of patients are rendered bNED with local salvage radiotherapy, but only 10-50% are long-term (5 years) biochemically controlled. A timely salvage treatment is crucial to optimize control probability. As regards adjuvant radiotherapy for undetectable postoperative PSA in patients at high risk of failure as judged on pathology, results are more encouraging. Recent data report bNED rates > 70% at 5 years. CONCLUSIONS: Although results are far from satisfactory, salvage radiotherapy should be considered for every patient with an increased or detectable PSA after surgery. Adjuvant radiotherapy seems preferable to salvage radiotherapy for patients at high (> 30%) risk of failure.     

Half the deaths after surgery for lung cancer occur after discharge

Introduction

Mortality following surgery for lung cancer increases at 90 days. The objective of this study was to determine the rate, factors, time to death, hospital stay until discharge, time to death after discharge and causes of mortality at 90 days following surgery for lung cancer.

影响乳腺癌根治术后局部区域性复发后放疗的局部控制因素

目的分析影响乳腺癌根治术或改良根治术后胸壁和／或区域淋巴结复发者局部控制的因素，探讨放疗及与综合治疗配合在降低再次复发的意义。方法回顾分析255例乳腺癌根治术或改良根治术后以胸壁和／或区域淋巴结复发为首次治疗失败者，其中单纯胸壁复发109例，区域淋巴结复发114例，同时累及胸壁和区域淋巴结32例，共计累及复发部位304处。所有患者接受放疗，55例首先接受手术切除或活检，227例照射范围仅覆盖复发灶累及部位，28例对未复发部位进行预防性照射。照射42-74Gy，中位值60ey。190例接受了针对复发的全身治疗，其中171例化疗，69例内分泌治疗，41例先后接受化疗和内分泌治疗。结果随访9月至15．5年，中位值45个月。2、5、8年局部控制率分别为56．1％、36．3％、27．6％，中位局部控制时间为28个月。79处原发部位再次复发和83处其他部位后续复发，其中胸壁是再次复发频率最高部位。多因素分析证实复发灶未累及胸壁，病灶为单个或两个以上独立结节以及照射野覆盖完整的复发区域是影响原复发部位局部控制的独立预后因素，复发灶累及胸壁和内分泌治疗的运用是影响其他部位后续复发的独立预后因素。胸壁复发者采用全胸壁和局部小野照射的5年局部控制率分别为55．6％和33．6％（P=0．023）。结论放疗是乳腺癌根治术后局部和区域性复发有效的局部治疗手段，胸壁复发者需采用全胸壁照射以降低再次复发率。鉴于区域淋巴结复发者高比例的胸壁后续复发率，建议对该组患者进行胸壁预防性照射。内分泌治疗体现了降低其他部位后续复发的意义，但需更多临床前瞻性研究予以证实。     

大块异体骨移植的并发症

目的通过对深低温保存异体骨进行肿瘤切除后骨缺损重建的效果分析,了解异体骨移植后的并发症发生情况。方法本组149例患者中,男性82例,女性67例。平均年龄22.3岁(12～65岁)。疾病种类以骨巨细胞瘤和骨肉瘤为主。外科治疗以Enneking外科分期标准为原则,对肿瘤进行切除。主要发病部位为股骨上端、股骨下端及胫骨上端及肱骨上端。重建方式为1/2关节移植91例,1/4关节移植13例,异体骨-人工关节复合物11例,大块异体骨移植19例,骨干异体骨移植12例,骨盆异体骨移植3例。结果平均随访33.6个月。治疗满意率74.5%,复发率11.4%,死亡率5.3%,最终保肢率93.3%。并发症发生率46.3%,其中感染11.4%,骨端不愈合24.2%,内固定折断6%,关节不稳定8.7%,骨折7.4%。结论大块异体骨移植是一高并发症的重建方法,异体骨体积越小,并发症越少,肢体功能越好。感染及骨不愈合是主要的并发症。应用大块异体骨重建后,早期功能不佳,后期仍有并发症继续出现。降低并发症的发生率是提高保肢治疗效果的主要措施之一。     

Mid-facial reconstruction after maxillectomy

Reconstruction following extensive resectionof the maxilla has been a challenging problem in the fieldof head and neck cancer surgery. At our institutes, maxillectomy defects have been restored based on the principles of repair involving the important concept of maxillary buttress reconstruction. Reconstruction of the zygomaticomaxillary buttress (ZMB), including the orbital floor, is essential for prevention of the malpositioning of the eyeglobe in preservation of the orbital contents. ZMB reconstruction is also important to provide a good contour of malar prominence. Pterygomaxillary buttress (PMB) reconstruction provides sufficient support for the fitting of a dental prosthesis. In patients with extensive resection of buccal soft tissue, a PMB and nasomaxillary buttress (NMB) should be reconstructed to prevent superior and posterior deviation of the alar base and oral commissure. We advocate that critical assessment of skeletal defects, as well as associated soft-tissue defects, following various types of maxillectomies is essential for a rational approach to achieve satisfactory clinical results.     

Pregnancy after breast cancer

The issue of pregnancy in patients previously treated for breast cancer is controversial. This paper reviews the literature using Medline and Embase databases over the last 50 years to address the issue. Overall survival in patients treated for breast cancer who subsequently become pregnant compares favourably with controls. This paper also addresses the effects of adjuvant therapy (loco-regional and systemic) on subsequent pregnancy. Introduction of a national registry of these patients may help inform such patients in the future.     

Angiosarcoma after breast-conserving therapy

BACKGROUND: Angiosarcoma arising in the irradiated breast after breast-conserving therapy is being reported with increasing frequency. As more women undergo breast-conserving therapy, the incidence can be expected to increase. Surgeons, medical oncologists, and radiation oncologists will be faced with difficult management decisions for this aggressive disease. METHODS: A comprehensive review of all English-language reports of angiosarcomas after breast-conserving therapy was performed. Approximately 100 cases were reviewed for treatment details and outcome analysis was performed. RESULTS: Surgical excision is associated with very high rates of disease recurrence (55 of 75 patients with at least 1 year of follow-up; 73%). Local disease recurrences in the tumor bed or along the mastectomy scar are a component of almost all recurrences (96%). Distant metastases develop simultaneously or shortly after local recurrences. Hyperfractionated radiotherapy has successfully prevented local disease recurrences in a limited number of patients. CONCLUSIONS: Angiosarcoma after breast-conserving therapy is increasingly diagnosed in a small but significant portion of breast carcinoma survivors. The aggressive nature of this disease demands further investigation of adjuvant therapy to prevent recurrence of disease after surgery.     

Incomplete glandular ablation after salvage cryotherapy for recurrent prostate cancer after radiotherapy

PURPOSE: To determine the clinical variables associated with inadequate salvage cryotherapy and to correlate the disease-free survival rates associated with biopsy results in prostate cancer (CaP). METHODS AND MATERIALS: Between July 1992 and January 1995, 150 patients underwent salvage cryotherapy for locally recurrent CaP. Biopsy specimens were examined for the presence of cancer cells and normal or atypical glands, all of which were considered evidence of inadequate cryotherapy. Clinical variables, as predictors of biopsy results, were evaluated with univariate and multivariate analyses. The impact of the biopsy results on disease-free survival was also determined. RESULTS: The number of cryoprobes and freeze-thaw cycles correlated with inadequate cryotherapy (p = 0.037 and p = 0.0022, respectively). The number of freeze-thaw cycles was an independent predictor of inadequate cryotherapy (p = 0.003). The finding of cancer cells in the biopsy specimens was the only histopathologic variable that affected disease-free survival (p = 0.016). CONCLUSION: Complete ablation of the prostate gland and tumor is difficult to achieve with salvage cryotherapy. To optimize for complete ablation, salvage cryotherapy should include at least two freeze-thaw cycles and a minimum of five cryoprobes. The finding of atypical or normal epithelial tissue in biopsy specimens after salvage cryotherapy is not predictive of biochemical failure.