Inaccuracies in assignment of clinical stage for localized prostate cancer

BACKGROUND:

Recent data have suggested that clinical T stage is not independently associated with biochemical recurrence of localized prostate cancer after radical prostatectomy. One explanation for this lack of predictive power may be the inaccurate application of staging criteria.

METHODS:

Data from men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database with localized prostate cancer (clinical T1‐T2) were analyzed. Correct stage was determined by digital rectal examination (DRE) and transrectal ultrasound (TRUS) findings and was compared with the clinical stage reported directly by the practitioner. DRE/TRUS findings and biopsy results were evaluated to determine factors influencing staging errors. The ability of corrected stage to predict biochemical disease recurrence after prostatectomy was assessed using multivariable analysis.

RESULTS:

Clinical stage was assigned incorrectly in 1370 of 3875 men (35.4%). Errors more commonly resulted in patient downstaging than upstaging (55.1% vs 44.9%; P < .001). Patients with TRUS lesions were more likely to be staged incorrectly than those with abnormal DRE findings (65.8% vs 38.2%; P < .001). Biopsy laterality was found to strongly influence stage assignment. Even after correction of staging errors, there was no association noted between clinical stage and biochemical disease recurrence after radical prostatectomy.

CONCLUSIONS:

Errors in applying clinical staging criteria for localized prostate cancer are common. TRUS findings are frequently disregarded, and practitioners incorrectly incorporate biopsy results when assigning stage. However, staging errors do not appear to account for the inconsistent reliability of clinical stage in predicting prostate cancer outcomes. These findings further challenge the utility of a DRE‐based and/or TRUS‐based staging system for risk assessment of localized prostate cancer.Cancer 2011. © 2010 American Cancer Society.     

Utility of paired box gene 8 (PAX8) expression in fluid and fine‐needle aspiration cytology

BACKGROUND:

Metastases from ovarian neoplasms are commonly encountered in peritoneal fluids. In addition, reactive mesothelial cells in effusion specimens can mimic ovarian serous carcinoma, making the diagnosis difficult. Calretinin has been recognized as a reliable immunohistochemical marker for mesothelial cells, whereas WT1 has proven useful in the diagnosis of ovarian serous carcinoma. This can present a diagnostic pitfall in effusion cytology, because mesothelial cells can demonstrate immunoreactivity for WT1. Recently, paired box gene 8 (PAX8) has been used in distinguishing ovarian from mammary carcinoma. To the authors' knowledge, no studies using PAX8 have been performed on peritoneal cytology specimens to date, and its expression in metastatic ovarian serous carcinoma has not been studied.

METHODS:

These markers, along with BerEP4 and MOC‐31, were evaluated in cytology cell block preparations from 30 fluid cytology specimens and 11 fine‐needle aspiration specimens.

RESULTS:

PAX8 was found to be positive in 37 of 41 (90%) ovarian carcinoma cases studied, and was a sensitive (90%) and specific (100%) marker for the detection of metastatic ovarian carcinoma. In addition, calretinin was found to be useful for identifying mesothelial cells in fluid cytology. Furthermore, although PAX8 and WT1 have demonstrated comparable sensitivity (90% and 93%, respectively) in diagnosing metastatic ovarian carcinoma, PAX8 appears to have superior specificity because staining is not observed in mesothelial cells. BerEP4 and MOC‐31 were found to have a lower sensitivity and specificity compared with PAX8.

CONCLUSIONS:

PAX8‐positive, calretinin‐negative staining appears to be highly specific and sensitive for detecting metastatic ovarian serous carcinoma in cytologic preparations and can be useful in distinguishing it from mesothelial cells in fluid cytology. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

Fine‐needle aspiration biopsy of high‐grade sarcoma

BACKGROUND.

To the authors' knowledge, few studies exist demonstrating the reliability of fine‐needle aspiration (FNA) biopsy for high‐grade sarcoma (HGS).

METHODS.

In the current study, the authors reviewed their cytopathology database (March 2001 through January 2007) and identified all FNA cases diagnosed as HGS. They also searched their tissue database for all HGS cases that had prior FNA biopsy findings.

RESULTS.

A total of 107 FNA samples from 98 patients (age range, 13–90 years, with a male:female ratio of 1:1) had an FNA diagnosis of HGS, or had HGS and a prior FNA diagnosis of another entity. Ten cases were nondiagnostic. Of the 97 remaining samples, 6 were diagnosed as something other than HGS (sensitivity of 94%). The positive predictive value of an FNA diagnosis of HGS was 97% (88 of 91 cases). Fifty‐four cases were diagnosed as HGS, not otherwise specified, 8 as myxofibrosarcoma, 8 as osteosarcoma, 5 as malignant peripheral nerve sheath tumor, 5 as leiomyosarcoma, 4 as Ewing sarcoma, 4 as liposarcoma, 2 as epithelioid sarcoma, and 1 as angiosarcoma. Approximately 71% of patients presented with a primary tumor, 23% with disease recurrence, and 7% with metastasis. Sites of disease included the lower extremity (59%), upper extremity (19%), trunk (15%), groin (4%), and head and neck (4%). FNA diagnosis was confirmed histologically in 88% of cases, clinically in 7% of cases, and cytogenetically in 1% of cases; 3% of cases had false‐positive results and 1 patient was lost to follow‐up. Sixteen of 19 patients received neoadjuvant chemotherapy based on the FNA diagnosis alone.

CONCLUSIONS.

A cytopathologic diagnosis of HGS was found to be accurate in 88 of 97 cases (91%) with follow‐up. A FNA biopsy diagnosis of HGS appears to be clinically reliable in a high percentage of cases when used in close conjunction with the orthopedic team. Cancer (Cancer Cytopathol) 2007. © 2007 American Cancer Society.     

The rationale for and long-term outcome of incomplete axillary staging in elderly women with primary breast cancer

Background

The proportion of elderly women diagnosed with breast cancer is rising. Standard treatment, including axillary staging, is often not given to these patients. This study aimed to investigate reasons to omit any surgical axillary staging or to refrain from completion axillary lymph node dissection (cALND) after positive-sentinel lymph node biopsy (SLNB); so-called “incomplete staging”. Furthermore, the impact of incomplete staging on regional control and survival in patients aged 75 or older was evaluated.

Durable oncologic outcomes after radiofrequency ablation

BACKGROUND:

Long‐term oncologic outcomes for renal thermal ablation are limited. The authors of this report present their experience with radiofrequency ablation (RFA) therapy for 243 small renal masses (SRMs) over the past 7.5 years.

METHODS:

The authors' institutional, prospectively maintained RFA database was reviewed to determine intermediate and long‐term oncologic outcomes for patients with SRMs (generally <4 cm) who underwent RFA. Particular attention was placed on patients who had a minimum 3 years of follow‐up. Patients were excluded from the analysis if they had received previous treatment for renal cell carcinoma (RCC) on the ipsilateral kidney or if they did not have at least 1 imaging study available for follow‐up.

RESULTS:

Two hundred eight patients (with 243 SRMs) who had no evidence of previous ipsilateral renal cancer treatment underwent RFA and had follow‐up imaging studies available for review. Overall, tumor size averaged 2.4 cm, and follow‐up ranged from 1.5 months to 90 months (mean, 27 months). Of the 227 tumors (93%) that underwent preablation biopsy, RCC was confirmed in 79%. The initial treatment success rate was 97%, and the overall 5‐year recurrence‐free survival rate was 93% (90% for 160 patients who had biopsy‐proven RCC). During follow‐up, 3 patients developed metastatic disease, and 1 patient died of RCC, yielding 5‐year actuarial metastasis‐free and cancer‐specific survival rates of 95% and 99%, respectively.

CONCLUSIONS:

RFA provided successful treatment of SRMs and produced a low rate of recurrence as well as prolonged metastasis‐free and cancer‐specific survival rates at 5 years after treatment. Although longer term follow‐up of RFA will be required to determine late recurrence rates, the current results indicated a minimal risk of disease recurrence in patients who are >3 years removed from RFA. Cancer 2010. © 2010 American Cancer Society.     

Surgical staging and prognosis in serous borderline ovarian tumours (BOT): A subanalysis of the AGO ROBOT study

Background:

Incomplete surgical staging is a negative prognostic factor for patients with borderline ovarian tumours (BOT). However, little is known about the prognostic impact of each individual staging procedure.

Methods:

Clinical parameters of 950 patients with BOT (confirmed by central reference pathology) treated between 1998 and 2008 at 24 German AGO centres were analysed. In 559 patients with serous BOT and adequate ovarian surgery, further recommended staging procedures (omentectomy, peritoneal biopsies, cytology) were evaluated applying Cox regression models with respect to progression-free survival (PFS).

Results:

For patients with one missing staging procedure, the hazard ratio (HR) for recurrence was 1.25 (95%-CI 0.66–2.39; P=0.497). This risk increased with each additional procedure skipped reaching statistical significance in case of two (HR 1.95; 95%-CI 1.06–3.58; P=0.031) and three missing steps (HR 2.37; 95%-CI 1.22–4.64; P=0.011). The most crucial procedure was omentectomy which retained a statistically significant impact on PFS in multiple analysis (HR 1.91; 95%-CI 1.15–3.19; P=0.013) adjusting for previously established prognostic factors as FIGO stage, tumour residuals, and fertility preservation.

Conclusion:

Individual surgical staging procedures contribute to the prognosis for patients with serous BOT. In this analysis, recurrence risk increased with each skipped surgical step. This should be considered when re-staging procedures following incomplete primary surgery are discussed.     

Endoscopic ultrasound-guided paracentesis of ascitic fluid: a morphologic study with ultrasonographic correlation

BACKGROUND:

Endoscopic ultrasound (EUS)‐guided fine needle aspiration (FNA) has been widely used for the diagnosis of primary and metastatic gastrointestinal (GI) and non‐GI malignancies. Few studies have been published to evaluate the accuracy and the cytologic features of EUS‐guided paracentesis in the diagnosis and staging of malignant neoplasms.

METHODS:

All EUS‐guided paracenteses of ascitic fluid performed at the University of California Irvine Medical Center (UCIMC) from January 2003 to February 2006 were retrospectively retrieved. Corresponding EUS findings, cytology and histology slides, and follow‐up information were reviewed.

RESULTS:

One hundred one (101) cases were found. Two smears were submitted in 11 cases because of the scanty amount of fluid aspirated. In the remaining cases, 5 mL or less of fluid were aspirated in 56 patients, and, of 9 who had prior computed tomography (CT), ascitic fluid was not seen in 6. The cytologic diagnoses were as follows: 17 were positive for adenocarcinoma, 1 positive for metastatic small‐cell carcinoma of the lung, 1 positive for diffuse large‐cell lymphoma, 3 suspicious for adenocarcinoma, 1 suspicious for plasmacytoma, 4 atypical epithelial cells, and 74 negative. Cell block was available in 80 cases and immunohistochemical stains were performed in 71 cases to confirm the diagnosis. Six patients had peritoneal biopsy. The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 80%, 100%, 100%, 95%, and 96%, respectively.

CONCLUSIONS:

EUS‐guided paracentesis is a valuable aid in the cytologic diagnosis of malignant ascites. It is particularly useful when no abnormality is identified by CT. Cancer (Cancer Cytopathol) 2010;. © 2010 American Cancer Society.     

Prognosis and prognostic factors of the micropapillary pattern in patients treated for stage II and III serous borderline tumors of the ovary

Background.

To determine the prognosis of a micropapillary (MP) pattern in patients with stage II and stage III serous borderline tumor of the ovary (SBOT).

Methods.

Review of patients with stage II and stage III SBOT treated or referred to our institution with characterization of an MP pattern and its clinical impact.

Results.

In 1969–2006, 168 patients were reviewed. Fifty-six patients had SBOT-MP. The rate of conservative surgery was lower in the SBOT-MP group than in the typical SBOT group, but the rate of patients with more than three peritoneal sites with implants was higher in the SBOT-MP group. The rate of invasive implants was not statistically different between the two groups. Eighteen recurrences were observed (six of them in the form of invasive disease) in the SBOT-MP group. Only one death was observed. The overall survival times and recurrence-free intervals were similar in both groups. The only prognostic factor for recurrence in the SBOT-MP group was the use of conservative surgery.

Conclusions.

In the present series, an MP pattern doesn''t appear to signify a poor prognosis. The only prognostic factor for recurrence in SBOT-MP was the use of conservative surgery. Further studies on the MP pattern are needed to evaluate prognosis and the results of conservative surgery.     

Platinum/taxane‐based chemotherapy with or without radiation therapy favorably impacts survival outcomes in stage I uterine papillary serous carcinoma

BACKGROUND:

A study was undertaken to determine recurrence patterns and survival outcomes of stage I uterine papillary serous carcinoma (UPSC) patients.

METHODS:

A retrospective, multi‐institutional study of stage I UPSC patients diagnosed from 1993 to 2006 was performed. Patients underwent comprehensive surgical staging; postoperative treatment included observation (OBS); radiotherapy alone (RT); or platinum/taxane–based chemotherapy (CT) ± RT.

RESULTS:

The authors identified 142 patients with a median follow‐up of 37 months (range, 7‐144 months). Thirty‐three patients were observed, 20 received RT alone, and 89 received CT ± RT. Twenty‐five recurrences (17.6%) were diagnosed, and 60% were extrapelvic. Chemotherapy‐treated patients experienced significantly fewer recurrences than those treated without chemotherapy (P = .013). Specifically, CT ± RT patients had a lower risk of recurrence (11.2%) compared with patients who received RT alone (25%, P = .146) or OBS (30.3%, P = .016). This effect was most pronounced in stage IB/IC (P = .007). CT‐ and CT + RT–treated patients experienced similar recurrence. After multivariate analysis, treatment with chemotherapy was associated with a decreased risk of recurrence (P = .047). The majority of recurrences (88%) were not salvageable. Progression‐free survival (PFS) and cause‐specific survival (CSS) for chemotherapy‐treated patients were more favorable than for those who did not receive chemotherapy (P = .013 and .081). Five‐year PFS and CSS rates were 81.5% and 87.6% in CT ± RT, 64.1% and 59.5% in RT alone, and 64.7% and 70.2% for OBS.

CONCLUSIONS:

Stage I UPSC patients have significant risk for extrapelvic recurrence and poor survival. Recurrence and survival outcomes are improved in well‐staged patients treated with platinum/taxane–based chemotherapy. This multi‐institutional study is the largest to support systemic therapy for early stage UPSC patients. Cancer 2009. © 2009 American Cancer Society.     

Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer

BACKGROUND:

Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes.

METHODS:

A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local‐regional recurrence, distant disease‐free survival (DDFS), and overall survival were evaluated.

RESULTS:

We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow‐up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03‐2.6; P = .04) but not local‐regional recurrence or overall survival.

CONCLUSIONS:

IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy. Cancer 2012. © 2012 American Cancer Society.     

Sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy

BACKGROUND:

Sentinel lymph node biopsy (SLNB) is a widely used staging method for patients with early breast cancer. Neoadjuvant chemotherapy modifies the anatomical conditions in the breast and axilla, and thus SLNB remains controversial in patients treated preoperatively. The aim of this study was to demonstrate the reliability and accuracy of this procedure in this particular group of patients.

METHODS:

The retrospective study analyzed medical records of patients diagnosed with primary breast cancer between the years 2005 and 2009. Of the patients treated by neoadjuvant therapy, 343 underwent lymphatic mapping to identify sentinel lymph nodes, and these were included in the analysis.

RESULTS:

The overall detection rate of sentinel lymph nodes was 80.8%. It was strongly influenced by clinical lymph node status (significantly higher success rate in lymph node‐negative patients); higher detection rates were also associated with age <50 years, estrogen receptor positivity, lower proliferation index, and absent lymphovascular space invasion. The false‐negative rate was 19.5% and was only marginally significantly dependent on lymphovascular space invasion. The overall accuracy of the method was 91.5%.

CONCLUSIONS:

By using the present technique, sentinel lymph node biopsy cannot be recommended as a reliable predictor of axillary lymph node status when performed at the authors' institution after neoadjuvant chemotherapy. Infrequent use of blue dye for lymphatic mapping, low number of resected sentinel lymph nodes, and absence of any selection among patients included in the study could be the main factors responsible for the low detection rate and high false‐negative rate. Cancer 2011;. © 2011 American Cancer Society.     

The current status of surgical staging of ovarian serous borderline tumors

BACKGROUND: The purpose of the current study was to evaluate the current practice of surgical staging of ovarian serous borderline tumors. METHODS: Women with a diagnosis of ovarian serous borderline tumors whose pathology slides were sent to the M. D. Anderson Cancer Center for second-opinion diagnostic consultation between 1990-1996 were identified. The original pathology reports and M. D. Anderson Cancer Center consultation reports of 255 cases were reviewed for the frequencies of frozen-section analyses and staging biopsies, biopsy results, the specialty of the surgeon, and hospital type. RESULTS: The majority (78%) of ovarian borderline tumors primarily were encountered and staged by general obstetrician-gynecologists. Overall, 66% of patients had at least 1 staging biopsy performed. Approximately 12% of subjects underwent complete surgical staging, defined as having biopsy samples taken from pelvic and abdominal peritoneum, omentum, and retroperitoneal lymph nodes. Gynecologic oncologists performed complete staging in 50% of cases, obstetrician-gynecologists performed complete staging in 9% of cases, and general surgeons performed complete staging in 0% cases. The overall frequency of a positive staging biopsy was 37%. Approximately 47% (80 of 169) of patients who underwent biopsies were upstaged as a result of positive biopsies, - with 41% (70 of 169) having extrapelvic spread. CONCLUSIONS: Currently, surgical staging for women with ovarian serous borderline tumors remains inadequate, although a significant proportion of patients who undergo staging are noted to have extrapelvic spread.     

Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer

BACKGROUND:

Preoperative chemoradiation is becoming the standard treatment for patients with locally advanced rectal cancer. However, since the introduction of total mesorectal excision (TME), local recurrence rates have been reduced significantly, and some patients can be spared from potentially toxic over treatment. The current study was designed to assess the factors that predict recurrence in an institutional series of patients with rectal cancer who had clinical T2 lymph node‐positive (cT2N+) tumors or cT3N0/N+ tumors and underwent radical surgery without receiving preoperative chemoradiation.

METHODS:

Between November 1997 and November 2008, the authors' multidisciplinary group preoperatively staged 398 patients with rectal cancer by using endorectal ultrasonography and/or magnetic resonance imaging. The analysis included 152 consecutive patients with cT2N+, cT3N0, or cT3N+ rectal cancer who underwent TME without receiving preoperative chemoradiation. Macroscopic assessment of the mesorectal excision and circumferential resection margins were determined. Factors potentially related to local recurrence (LR), disease‐free survival (DFS) and cancer‐specific survival (CSS) were analyzed.

RESULTS:

After a median follow‐up of 39 months, the 5‐year actuarial LR, DFS, and CSS rates were 9.5%, 65.4%, and 77.8%, respectively, for the whole group. Threatened mesorectal fascia at preoperative staging was the only independent preoperative factor that predicted a higher risk for LR (P = .007), shorter DFS (P = .007), and shorter CSS (P = .05). In particular, the 5‐year LR rates for patients with and without preoperative threatened circumferential resection margins were 19.4% and 5.4%, respectively.

CONCLUSIONS:

The current results suggested that patients with rectal cancer clinically staged as T3N0/N+ or T2N+ with a free margin >2 mm from mesorectal fascia may undergo TME alone, avoiding over treatment with preoperative chemoradiation. Cancer 2011. © 2011 American Cancer Society.     

Early stage squamous cell cancer of the oral tongue--clinicopathologic features affecting outcome

BACKGROUND:

The objective of this study was to report the authors' experience in the management of patients with early stage squamous cell cancer (SCC) of the oral tongue and determine clinicopathologic factors predictive of outcome.

METHODS:

Two hundred sixteen patients with early stage (cT1T2N0) SCC of the oral tongue were identified from a pre‐existing database of patients with oral cancer who were treated at Memorial Sloan‐Kettering Cancer Center from 1985 to 2005. Patient, tumor, and treatment characteristics were recorded. Overall survival (OS), disease‐specific survival (DSS), and recurrence free survival (RFS) were calculated using the Kaplan‐Meier method. Predictors of outcome were identified using multivariate analysis.

RESULTS:

With a median follow‐up of 80 months (range, 1‐186 months), the 5‐year DSS, OS, and RFS rates were 86%, 79%,and 70%, respectively. Local, neck, and distant recurrences occurred in 24 patients (11%), 40 patients (18%), and 5 patients (2%), respectively. Multivariate analysis identified occult neck metastases as the main independent predictor of OS, DSS, and RFS; patients who had occult metastases had a 5‐fold increased risk of dying of disease compared with patients who did not have occult metastases (5‐year DSS, 85.5% vs 48.5%; P = .001). A positive surgical margin was the main independent predictor for local RFS (91% vs 66% for a negative surgical margin; P = .0004), and depth of invasion was the main predictor for neck RFS (91% vs 73% for depth of invasion <2 mm and >2 mm, respectively; P = .02).

CONCLUSIONS:

In the authors' experience, patients with early stage oral tongue cancer have excellent outcomes. In the current study, the presence of occult metastases was the main predictor of survival outcome. Cancer 2012;. © 2011 American Cancer Society.     

Factors predicting peritoneal recurrence in advanced gastric cancer: implication for adjuvant intraperitoneal chemotherapy

Background

Despite adjuvant chemotherapy, patients with advanced gastric cancer (AGC) often develop recurrence, and the peritoneum is the most common site of recurrence. Therefore, intraperitoneal chemotherapy (IPC) has been proposed as a treatment option. The aim of this study was to select the eligible patients for application of IPC.

Methods

A total of 805 patients with AGC who underwent curative D2 gastrectomy between May 2003 and December 2009 were included in this study. Risk factors for peritoneal recurrence were analyzed.

Results

Recurrence developed in 245 patients (30.4 %). The first site of recurrence was the peritoneum in 144 patients (58.8 %), and the 5-year peritoneal recurrence-free survival was 79.3 %. Depth of tumor invasion ≥T3, extensive lymph node metastasis (N3), Bormann type 4, infiltrative type (Ming’s classification), and venous invasion were independent risk factors for peritoneal recurrence. In subgroup analysis with patients who had received adjuvant chemotherapy (n = 481), depth of tumor invasion ≥T3, Bormann type 4, infiltrative type (Ming’s classification), and venous invasion were independent risk factors for peritoneal recurrence. When a peritoneal recurrence risk index was made with each risk factor assigned 1 point (2 points for T4 stage), peritoneal recurrence rates with 0, 1, 2, 3, 4, or 5 points were 0 %, 3.9 %, 13.1 %, 33.3 %, 44.0 %, and 72.0 %, respectively, in those patients.

Conclusions

Patients at higher risk for peritoneal recurrence can be identified from the findings of this study. Further prospective studies are required to evaluate the usefulness of IPC for these patients.     

Intravenous methotrexate as central nervous system (CNS) prophylaxis is associated with a low risk of CNS recurrence in high‐risk patients with diffuse large B‐cell lymphoma

BACKGROUND:

The outcome of patients with systemic diffuse large B‐cell lymphoma (DLBCL) had improved over the past decade with the addition of monoclonal antibody therapy. Unfortunately, approximately 5% of these patients still developed a secondary central nervous system (CNS) recurrence followed invariably by rapid death. This rate is substantially increased in patients with certain high‐risk features. Although prophylaxis against CNS recurrence with either intrathecal or intravenous methotrexate is commonly used for such patients, to the authors' knowledge, there is no standard of care. Retrospectively evaluated was the role of high‐dose systemic methotrexate combined with standard cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab (R‐CHOP) chemotherapy to decrease CNS recurrence in high‐risk patients.

METHODS:

A total of 65 patients with DLBCL and CNS risk factors were identified at the study institution between 2000 and 2008 who received intravenous methotrexate as CNS prophylaxis concurrent with standard systemic therapy with curative intent. CNS recurrence rate, progression‐free survival, and overall survival were calculated.

RESULTS:

Patients received a median of 3 cycles of methotrexate at a dose of 3.5 gm/m² with leucovorin rescue. The complete response rate was 86%, with 6% partial responses. At a median follow‐up of 33 months, there were only 2 CNS recurrences (3%) in this high‐risk population. The 3‐year progression‐free and overall survival rates were 76% and 78%, respectively. Complications associated with methotrexate therapy included transient renal dysfunction in 7 patients and a delay in systemic chemotherapy in 8 patients.

CONCLUSIONS:

Intravenous methotrexate can be safely administered concurrently with R‐CHOP and is associated with a low risk of CNS recurrence in high‐risk patients. Cancer 2010. © 2010 American Cancer Society.     

Diagnostic yield of percutaneous image-guided tissue biopsy of focal hepatic lesions in cancer patients: ten percent are not metastases from the primary malignancy

BACKGROUND:

The diagnostic yield was evaluated of percutaneous image‐guided tissue biopsy of hepatic lesions identified on computed tomography performed for staging of a primary malignancy, and it was determined how often the biopsy result was unexpectedly negative, benign, or secondary to a second unknown malignancy.

METHODS:

In a retrospective investigation from 1998 through 2008, 580 patients with primary malignancies had indeterminate focal hepatic lesions and underwent percutaneous image‐guided biopsy; 369 patients had lesions in their liver at first cross‐sectional imaging, performed for staging; 211 patients had a negative liver imaging study, followed by the subsequent appearance of at least 1 indeterminate suspicious lesion. The results of percutaneous image‐guided tissue biopsies were compared with the histology of the primary malignancy.

RESULTS:

Liver biopsies were performed in 580 patients (288 men and 292 women; age, 25‐92 years; mean age, 61 years). The most common primary malignancies were pancreatic (n = 96), breast (n = 85), melanoma (n = 57), esophageal (n = 51), lung (n = 47), colorectal (n = 37), and urothelial tumors (n = 26). Biopsy results were positive for malignancy in 528 (91%) cases. Among the positive biopsies, 29 (5%) cases had pathology results different from the primary tumor. Of the 52 biopsies negative for malignancy, 20 yielded a specific benign diagnosis, and 32 were nondiagnostic.

CONCLUSIONS:

If all liver lesions had been assumed to be metastases, as expected secondary to the known primary tumor, then the true or presumed alternate diagnosis would have been missed in 60 (10.3%) of the 580 cases. The authors did not attempt to determine whether actual clinical management changed based on these 60 liver biopsy results, so this number is an upper bound on management change. On the basis of these results, and given the minimal complication rate of liver biopsy, the authors suggest that liver biopsy should still be performed in the types of cases studied here, despite the finding that the vast majority of biopsies produced the expected result and presumably did not change patient management. Cancer 2011;. © 2011 American Cancer Society.     

Association between initial diagnostic procedure and hysteroscopy and abnormal peritoneal washings in patients with endometrial carcinoma

BACKGROUND: Hysteroscopy has been implicated in the finding of positive peritoneal washings (PW) in patients with endometrial carcinoma in several case reports. The current study was designed to evaluate whether there was an increased incidence rate of positive peritoneal washings in patients after hysteroscopy compared with patients who did not undergo hysteroscopy. METHODS. Two hundred eighty-four women with endometrial carcinoma were treated by hysterectomy with intraoperative PW at the Memorial Sloan-Kettering Cancer Center between 1995-1998. They were diagnosed by either endometrial biopsy (EMB) or dilatation and curretage (D & C) with or without hysteroscopy during the same period. RESULTS. Of 173 patients diagnosed by EMB, 16 had abnormal PW (9.2%). Of 111 patients diagnosed by D & C, 11 had abnormal PW (9.9%). There was no significant difference between the two groups (P = 0.85). Of 23 patients who were diagnosed by D & C with hysteroscopy, 3 had abnormal PW (13.0%). Of 177 patients who did not undergo hysteroscopy, 17 had abnormal PW (9.6%). Of 84 patients for whom information regarding hysteroscopy was not available, 7 had abnormal PW (8.3%). The incidence rates among the three groups were not significantly different (P = 0.79). CONCLUSIONS. The initial diagnostic procedure, including hysteroscopy, does not appear to be associated with a high incidence rate of abnormal PW in patients with endometrial carcinoma.     

Fertility sparing surgery in early stage epithelial ovarian cancer

Objective

Fertility sparing surgery (FSS) is a strategy often considered in young patients with early epithelial ovarian cancer. We investigated the role and the outcomes of FSS in eEOC patients who underwent comprehensive surgery.

Methods

From January 2003 to January 2011, 24 patients underwent fertility sparing surgery. Eighteen were one-to-one matched and balanced for stage, histologic type and grading with a group of patients who underwent radical comprehensive staging (n=18). Demographics, surgical procedures, morbidities, pathologic findings, recurrence-rate, pregnancy-rate and correlations with disease-free survival were assessed.

Results

A total of 36 patients had a complete surgical staging including lymphadenectomy and were therefore analyzed. Seven patients experienced a recurrence: four (22%) in the fertility sparing surgery group and three (16%) in the control group (p=not significant). Sites of recurrence were: residual ovary (two), abdominal wall and peritoneal carcinomatosis in the fertility sparing surgery group; pelvic (two) and abdominal wall in the control group. Recurrences in the fertility sparing surgery group appeared earlier (mean, 10.3 months) than in radical comprehensive staging group (mean, 53.3 months) p<0.001. Disease-free survival were comparable between the two groups (p=0.422). No deaths were reported. All the patients in fertility sparing surgery group recovered a regular period. Thirteen out of 18 (72.2%) attempted to have a pregnancy. Five (38%) achieved a spontaneous pregnancy with a full term delivery.

Conclusion

Fertility sparing surgery in early epithelial ovarian cancer submitted to a comprehensive surgical staging could be considered safe with oncological results comparable to radical surgery group.