Gastric cancer: which patients benefit from systematic lymphadenectomy?

AIMS: The purpose of this study was to evaluate the value of systematic lymphadenectomy (SLA) in curative resected gastric cancer patients with respect to long-term survival, peri-operative morbidity and mortality. METHODS: We reviewed our prospectively gathered database of 309 resected gastric cancer patients and analysed the outcome of 185 R0-resected patients (60%) with respect to peri-operative morbidity, mortality and long-term survival by comparing 81 patients resected with SLA (D2-group) versus 104 patients resected without SLA (D1-group). RESULTS: Overall 5-year survival rates of R0-resected patients (n = 173; exclusion of peri-operative mortality) amounted to 49% and did not differ significantly between D2- and D1-groups (53% vs 47%); P=0.344). Nevertheless, subgroups of patients taking a benefit from SLA could be defined. Gastric cancer patients without LN metastases (pTx pN0; n=78) and patients with LN metastases only in perigastric lymph nodes (pTx pN1; n=34) showed a significantly better long-term prognosis when SLA was performed (84% vs 51%; P=0.001). Regarding peri-operative morbidity (38% vs 39%) and mortality (6% in each case) we could not find any differences between the D2- and D1-groups. CONCLUSIONS: We conclude that SLA is able to improve long-term survival for some tumour stages. Therefore SLA should be recommended as a standard procedure in all gastric cancer patients resected with curative intention.     

What do patients want from their radiation oncologist? Initial results from a prospective trial

PURPOSE: To assess patients' initial physician preferences using a newly developed instrument. METHODS AND MATERIALS: A total of 182 patients with a primary diagnosis of prostate, breast, or lung cancer referred for consultation to the University of Pittsburgh Cancer Institute Department of Radiation Oncology enrolled in our institutional review board-approved protocol. All patients completed patient preference instrument surveys before meeting their radiation oncologist. Survey responses to 10 statements were categorized into three groups (agree, neutral, or disagree), and the association of survey responses by cancer site was tested with chi-squared tests. RESULTS: Ninety-nine percent of all patients preferred to be addressed by their first name in encounters with their radiation oncologist. There were significant associations of Item 3 (hand holding) with gender (p = 0.039) and education (p = 0.028). The responses to Item 5, a statement that patients would feel uncomfortable if the radiation oncologist offered to hug them at the end of treatment, was significantly associated with disease site (p < 0.0001). Further analysis was performed for Item 5 and revealed that the male lung cancer patients had a much higher rate of disagreement with Item 5 compared with prostate cancer patients (37% vs. 18%). CONCLUSIONS: Results of this study may afford greater insight and foster better understanding of what patients want from their radiation oncologist. For breast, lung, and prostate cancer patients, initial preferences for their radiation oncologist are generally similar, according to this tool. However, there are important difference among cancer sites (and gender) regarding physical contact at the end of treatment.     

Are patients with cancer receiving adequate thromboprophylaxis? Results from FRONTLINE

The FRONTLINE survey was designed in part to evaluate thromboprophylaxis regimens currently practised by clinicians worldwide for both surgical and medical patients with cancer. The survey showed that cancer patients undergoing surgery for their malignancy commonly receive thromboprophylaxis, but medical patients with cancer do not, with the exception of patients with a central venous catheter in place. Low-molecular-weight heparin is, overall, the most commonly used thromboprophylactic agent in cancer patients. Oral anticoagulants, however, are often used to prevent thrombosis in medical patients, and are the preferred agent in the USA. The duration of prophylaxis, when administered, is generally longer in medical patients compared with surgical patients. The perception of thrombosis risk for patients with central venous catheters is particularly high in North America where oral anticoagulants are used most commonly, in contrast to other geographical regions where low-molecular-weight heparin is favoured.     

What do breast cancer patients benefit from staging bone scintigraphy?

BACKGROUND: A review and analysis of breast cancer treatment records were conducted to establish criteria for performing disease staging by bone scintigraphy in Japanese breast cancer patients. METHODS: Records from 5538 consecutive Japanese breast cancer patients from January 1988 to December 1998 were reviewed and analyzed to determine bone metastasis status at the time of initial treatment. Correlation between metastasis to bone and factors known before and after surgery was analyzed using logistic regression. RESULTS: The overall incidence of metastasis to bone was 2.13% [95% confidence interval (CI): 1.77-2.55%, 118/5538]. Multivariate logistic analysis revealed that tumor size, nodal involvement and histopathology correlated with metastasis to bone. Patients with tumors larger than 30 mm had a significantly higher probability of metastasis to bone, as did patients with lymph node evaluation results N > or = 1. The incidence of metastasis to bone was 0% in patients with stage 0 disease, 0.08% in stage I patients, 1.09% in stage II patients, 9.96% in stage III patients and 34.04% in stage IV patients. Stage II patients were sub-classified by tumor size T (small, 21-30 mm; and large, 31-50 mm), nodal involvement N and histopathology. The incidence of metastasis to bone in stage II patients was higher in patients with large tumors, scirrhous carcinoma or invasive lobular carcinoma or both. CONCLUSION: Bone metastasis correlated with tumor size (T), lymph node involvement (N) and histopathology. Using the criteria that bone scintigraphy is not necessary in populations with a < 1% incidence of bone metastasis, but is recommended at incidence > 3%, the following conclusions were drawn. Staging by bone scintigraphy provided no benefit to patients whose disease was stage I or less, stage II with small tumors or stage II with large tumors marked by low-grade histopathology (papillotubular cancer). Bone scintigraphy is recommended in patients whose disease is stage II with large tumors marked by high-grade histopathology (scirrhous or invasive lobular cancer), stage III or stage IV. Consequently, staging by bone scintigraphy could be avoided in 71% (3943/5538) of Japanese breast cancer patients.     

Locally advanced gallbladder cancer: Which patients benefit from resection?

Objectives

Patients with T3–4 gallbladder cancers (GBCs) often require extended surgical procedures, and up to 30% of patients have N2 metastases. This study investigated which patients with T3–4 GBC benefit from resection.

Methods

Consecutive patients (n = 78) with T3–4 GBC who underwent resection between 1990 and 2011 were analysed (38 before 2003, 40 in 2003–2011). Forty patients required common bile duct (CBD) resection, 10 pancreatoduodenectomy, 4 right colectomy and 2 gastric resection. Fifty-two (67%) patients had LN metastases, including 22 with N2 metastases.

Results

The in-hospital mortality rate was 8%, 11% before 2003 vs. 5% in 2003–2011. The morbidity rate (47%) remained stable during the study. Undergoing liver and pancreatic resection did not increase severe morbidity (0%) or mortality (10%). Sixty-seven (86%) patients had R0 resection. The 5-year survival rate was 17% (median follow-up, 65 months). Survival improved after 2002 (26% vs. 9%, p = 0.04). R1 patients had poor 3-year survival (0% vs. 32%, p = 0.001). N+ patients also had low survival (5-year survival, 10% vs. 32% in N0, p = 0.019), but N1 and N2 patients had similar outcomes. CBD resection and major hepatectomy did not worsen prognosis. Patients requiring pancreatoduodenectomy, gastric or colonic resection had 0% 3-year survival (p = 0.036 in multivariate analysis).

Conclusions

Resection of T3–4 GBC is worthwhile only if R0 surgery is achievable. Outcomes improved in most recent years. N2 metastases should not preclude surgery. Good results are possible even with CBD resection or major hepatectomy, while benefits from surgery are doubtful if pancreatoduodenectomy or other organ resection is needed.     

Do patients with metastatic urothelial carcinoma benefit from docetaxel as second-line chemotherapy?

Purpose

To evaluate the efficacy and toxicity of docetaxel regimen as second-line after failure of a platinum-based chemotherapy.

Methods

Between May 2005 and June 2008, we retrospectively analyzed the data of 22 patients who had evidence of disease progression after one prior platinum-based regimen for metastatic urothelial carcinoma. Patients were treated with two different docetaxel dose schedules: (1) docetaxel 60 mg/m² every 21 days for unfit patients or (2) docetaxel 75 mg/m² every 21 days for fit patients.

Results

Median number of docetaxel cycles was three. Overall disease control rate was 18 %. Of the 22 patients, no patient achieved complete or partial response and four patients had stable disease. Median progression-free survival was 1.67 months and median overall survival was 3.12 months. Neutropenia was the most common adverse event.

Conclusions

This study identifies that docetaxel as second-line chemotherapy has low activity and was associated with significant toxicity.

     

Are patients with cancer receiving adequate treatment for thrombosis? Results from FRONTLINE

The current practice of clinicians worldwide in the treatment of venous thromboembolism was assessed via responses to the FRONTLINE survey. Significant regional differences in practice were noted. Use of low-molecular-weight heparin was reported as the most common initial treatment for venous thromboembolism, although, in North America, unfractionated heparin was widely used to treat surgical cancer patients after a thrombotic episode. Oral anticoagulants were favoured for long-term treatment of venous thromboembolism, particularly in Western Europe and North America. Case study reports from the survey revealed that a substantial proportion of patients with cancer had been perceived to be at low risk of thrombosis, had consequently not received thromboprophylaxis and developed VTE.     

Which biomarker predicts benefit from EGFR-TKI treatment for patients with lung cancer?

Subsets of patients with non-small cell lung cancer respond remarkably well to small molecule tyrosine kinase inhibitors (TKI) specific for epidermal growth factor receptor (EGFR) such as gefitinib or erlotinib. In 2004, it was found that EGFR mutations occurring in the kinase domain are strongly associated with EGFR-TKI sensitivity. However, subsequent studies revealed that this relationship was not perfect and various predictive markers have been reported. These include EGFR gene copy numbers, status of ligands for EGFR, changes in other HER family genes or molecules downstream to EGFR including KRAS or AKT. In this review, we would like to review current knowledge of predictive factors for EGFR-TKI. As all but one phase III trials failed to show a survival advantage of the treatment arm involving EGFR-TKIs, it is necessary to select patients by these biomarkers in future clinical trials. Through these efforts, it would be possible to individualise EGFR-TKI treatment for patients suffering from lung cancer.     

Do patients with pN0 gastric cancer benefit from prophylactic extended lymphadenectomy?

PurposeTo investigate the impact of prophylactic extended lymphadenectomy on survival for patients with node-negative (pN0) advanced gastric cancer according to the extent of lymph node dissection.MethodsThis study retrospectively investigated the clinicopathological characteristics and prognostic outcomes of 458 patients who had pN0 advanced gastric cancer between 1995 and 2001. Postoperative survival was compared in patients who underwent different extents of prophylactic lymphadenectomy.ResultsThe overall 5-year and 10-year survival rates were 62.01% (284/458) and 40.83% (187/458), respectively. The survival rates differed significantly in patients who underwent a different extent of prophylactic lymphadenectomy (≤D1+ versus D2 versus D3 versus ≥D3) (X² = 8.59, P = 0.035). Survival in patients who received less than D1+ dissection, however, were not significantly better than patients who received D2 dissection (X² = 0.907, P = 0.341). Survival in patients who received D2 dissection was significantly better than survival in patients who received D3 dissection (X² = 5.685, P = 0.017). No differences in postoperative survival rates were observed between patients who received D3 dissection and those received more than D3 dissection (X² = 2.468, P = 0.116). Patients who were older than 60 years and receive more than D2 dissection experienced significantly worse postoperative survival than those who received less than D2 dissection (X² = 14.885, P = 0.001). The extent of prophylactic lymphadenectomy did not significantly affect local tumor recurrence in patients with node-negative advanced gastric cancer (X² = 0.458, P = 0.928).ConclusionsD2 prophylactic lymphadenectomy is appropriate for pN0 patients who were less than 60 years old, and less than D2 dissection was suitable for the older cases.     

Cryopreservation of sperm from patients with leukemia: is it worth the effort?

BACKGROUND: Intracytoplasmic sperm injection (ICSI) allows pregnancies to be established with a single sperm, improving the chances for men with severely impaired sperm quality to cause a pregnancy. Men with leukemia typically are of reproductive age and their fertility is threatened by initially impaired semen quality and cytotoxic chemotherapy. The authors examined the feasibility of sperm cryopreservation in men with leukemia before treatment and whether the type of leukemia is related to prefreeze or postthaw semen quality. METHODS: Records of 25 patients with acute (n=13) or chronic (n=12) leukemia who banked their sperm were reviewed. Semen characteristics were compared with those of normal donors (n=50) and between the 2 patient groups before and after cryopreservation. Motile sperm count (MSC), motility, curvilinear velocity (VCL), linearity, and amplitude of lateral head movement were compared between patients and healthy donors. No patient had undergone chemotherapy before sperm banking. The nitrogen vapor technique was used for sperm cryopreservation. RESULTS: Patients with leukemia had significantly lower prefreeze and postthaw MSC (P=0.0001), motility (P<0.05), and VCL (P<0.05) compared with healthy donors. The percentage change from prefreeze to postthaw in MSC and motility (P<0.05) was significantly greater in patients than in healthy donors. The effect of cryopreservation on semen quality was similar in patients with both acute and chronic leukemia. CONCLUSIONS: Patients with leukemia have poor prefreeze and postthaw semen quality compared with healthy donors. In this study the type of leukemia did not appear to affect prefreeze or postthaw semen quality and the postthaw MSC was sufficient for use with ICSI. Sperm cryopreservation should be offered to all men of reproductive age before the initiation of therapy for leukemia.