Malignant mesothelioma: current status and perspective in Japan and the world

Malignant pleural mesothelioma (MPM) is associated with a poor prognosis; and to make things worse, its incidence is increasing throughout the world. Surgical management of MPM is comprised of two aspects: diagnosis and resection. Surgical biopsy with thoracoscopy provides a higher yield but a higher rate of tumor cell seeding than blind biopsy. In some surgical cases, extended surgical staging with mediastinoscopy, laparoscopy, and contralateral thoracoscopy is required for the preoperative evaluation for resectablity. There are two types of surgical resection for MPM. Pleurectomy/decortication (P/D) involves removal of as much of the visceral, parietal, and pericardial pleura and the tumor as possible without removing the underlying lung. Because P/D is less radical but less invasive compared to extrapleural pneumonectomy (EPP), it can be tolerated by poor-risk patients. EPP comprises en bloc resection of visceral, parietal, and pericardial pleura and adjacent components such as ipsilateral lung, pericardium, and diaphragm, without opening the pleural cavity. EPP was considered a highly dangerous procedure with a surgical mortality of more than 30% decades ago, but its current operative mortality/morbidity rates are 4%-9% and 60%, respectively. As macroscopic complete resection is the primary goal of surgery for MPM because of its diffuse intrapleural growth, surgical resection alone is associated with poor survival. In this context, combination therapy with surgery plus chemotherapy and/or radiotherapy is currently considered the standard treatment for patients with respectable MPM. A national survey of EPP was conducted recently in Japan, and a few multicenter clinical trials will start soon.     

Survey of surgical treatment of malignant pleural mesothelioma in Japan

Surgical results of patients with malignant pleural mesothelioma (MPM) in Japan was surveyed from the results of a questionnaire sent to members of the Japan Lung Cancer Society. and a total of 132 surgical cases of MPM from 1997 to 2002 were analyzed. They consisted of 112 males and 20 females. By histological type, 87 cases had epithelial type, 10 had sarcomatous type, 26 had mixed type and 2 had uncommon type of MPM (the histology of 7 cases was not indicated). As to the surgical mode, extrapleural pneumonectomy (EPP) was performed in 73 cases, and limited surgery such as decortication and tumorectomy was performed in 59 cases. The tumor was potentially completely resected in 83 cases. Postoperative adjuvant therapy was performed in 56 cases. The 1-, 2- and 3-year survival rates of the present cases were 54, 33 and 21%, respectively, and the perioperative mortality rate was 5%. These survival and mortality rates in the present series were almost similar to those of the MPM cases in the previously reported series from 1987 to 1996 by Takagi et al. According to Cox regression analysis, prognostic factors for survival included postoperative adjuvant therapy (p=0.003) and complete resection (p=0.037) significantly, and International Mesothelioma Interest Group (IMIG) stage (p=0.051) and performance status (p=0.086) with a marginal significance, indicating that complete surgical resection of the tumor and perioperative adjuvant therapy could be effective treatment for MPM in Japan. Thus, the development of multimodality therapy including surgical treatment for this disease may be required to improve surgical results of MPM patients.     

Treatment of Malignant Mesothelioma

Malignant pleural mesothelioma (MPM) is a rare tumor that predominantly afflicts men over 50 years of age. Nearly 3000 MPMs are reported annually in the United States with the incidence expected to rise into the new millenium. Over the past 40 years, MPM has been unequivocally linked to asbestos exposure worldwide. Recently, however, a new theory on the carcinogenesis of this tumor has been proposed with the isolation of a simian virus (SV 40)-like gene sequence in mesothelioma tumor cells. The clinical presentation of MPM is variable, although most patients typically present with dyspnea, chest pain, or pleural effusion. Obtaining a diagnosis of MPM has been greatly assisted by video-assisted surgery and the use of immunohistochemistry and electron microscopic techniques, which help distinguish MPM from other tumor pathologies such as adenocarcinoma. Computed tomography and magnetic resonance imaging have been also useful for determining tumor burden and resectability. Traditionally, strategies for the treatment of MPM have included supportive care, surgery, radiotherapy, and chemotherapy. Survival with supportive care alone ranges between 4 and 12 months. Single-modality therapy using traditional approaches (surgery, radiotherapy, chemotherapy) alone has failed to improve patient survival significantly. Recently, results using a multimodality approach have been favorable. In particular, cytoreductive surgery (pleuropneumonectomy) followed by sequential chemotherapy and radiotherapy have demonstrated improved survival, especially for patients with epithelial histology, negative resection margins, and no metastases to extrapleural lymph nodes. Innovative therapies such as the use of photodynamic, targeted cytokines and gene therapy are currently being investigated for management of MPM.     

Multimodality therapy for diffuse malignant pleural mesothelioma

Despite the rising incidence of diffuse malignant pleural mesothelioma (MPM), there is still no standard treatment for this disease, and the prognosis for patients remains poor. Recently, long-term survival has been reported when multimodality therapy is used, combining extrapleural pneumonectomy with perioperative chemotherapy and/or radiotherapy in highly selected patients. We report a case of a patient who presented with MPM, accompanied by a large malignant pleural effusion and pneumothorax, who was successfully treated with combination therapy. After being diagnosed with epithelial type MPM using thoracoscopic surgery, the patient underwent extrapleural pneumonectomy. Examination of the surgical specimen revealed invasion of the chest wall muscle and fat, as well as several positive mediastinal lymph nodes. The patient received 2 courses of postoperative chemotherapy using cisplatin and gemcitabine. He is currently alive and has been disease-free for 2 years.     

Oncolytic Vaccinia Virus as an Adjuvant Treatment to Cytoreductive Surgery for Malignant Peritoneal Mesothelioma

Background

Malignant peritoneal mesothelioma (MPM) is an aggressive cancer with a dismal prognosis. Oncolytic viruses are a promising new therapy for cancer because of their ability to kill tumor cells with minimal toxicity to normal tissues. This experimental study aimed to examine the potential of modified vaccinia virus (VV) to treat MPM when administered alone or as an adjuvant treatment to surgery.

Methods

Two aggressive murine mesothelioma cell lines (AC29, AB12), were used. Cell viability and viral cytopathic effects were assessed using MTS and crystal violet assays. Immunocompetent mice were injected intraperitoneally with MPM cells and treated with intraperitoneal VV. Tumor-bearing mice also underwent cytoreductive surgery (CRS) followed by VV (or control) therapy.

Results

The cytotoxic effects of VV on MPM cell lines was significantly increased compared with the control non-cancer cell line. In both orthotopic models, VV induced tumor regression, prolonging median and long-term survival. VV treatment after incomplete CRS was not superior to VV alone; however, when mice with microscopic disease were treated with VV, further prolongation of median and long-term survivals was observed.

Conclusions

VV selectively kills MPM cells in vitro and leads to improved survival and cures in immunocompetent murine models. Higher efficacy of the virus in the microscopic disease context suggests the use of the virus as an adjuvant treatment to complete surgical resection. These promising results justify further studies of VV in humans as a novel treatment for MPM.     

Regionale Versorgung des malignen Pleuramesothelioms

Introduction

Malignant pleural mesothelioma (MPM) is an aggressive, malignant tumor of the pleural surface and is strongly associated with asbestos exposure. Incidence of MPM will reach its peak over the coming years. Most patients present with advanced tumor stages and therefore surgical options are limited.

Patients and methods

Retrospective analysis of all patients with MPM reported to the tumor centre Regensburg between January 1998 and August 2011.

Results

A total of 118 patients (85 % male) with cytologically or histologically confirmed MPM were reported. The mean age at diagnosis was 67 years (range 45–84 years) and 65 % of patients had a history of asbestos exposure. The incidence of MPM at the tumor centre Regensburg was 0.8/100,000 inhabitants with obvious regional differences depending on asbestos exposure. Staging was completed in 81 patients (67 %): stage I 9 %, stage II 22 %, stage III 23 % and stage IV 46 %. Of the patients 87 (74 %) underwent at least one surgical procedure: diagnostic thoracoscopy with biopsy (n?=?37, 43 %), debulking surgery or talcum pleurodesis (n?=?33, 38 %) and potentially curative resection (n?=?17, 19 %). After a mean follow-up of 20 months the overall median survival was 14 months (1 year survival rate 62 %, 3 year survival rate 15 %). Patients had a significantly better median survival of 18 months after curative resection.

Conclusions

The distribution of MPM varies according to regional and industrial asbestos exposure. Screening and diagnostics should concentrate on locations with higher incidence of MPM to facilitate surgical therapy in a multimodal treatment regime.     

Multimodality approach in management of malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is a solid, locally aggressive tumor, which has been closely linked to asbestos exposure. The survival rate without treatment ranges from 4 to 12 months. Response to chemotherapy and radiation is poor, and surgery is the most effective therapy. There are currently 3000 new MPM cases per year in the United States, with the peak incidence in the United States and Europe expected to occur in the year 2020. The prognosis depends on the stage of the tumor at the time of diagnosis, its histological type, lymph node status, and resection margins. While the diagnosis is often delayed, earlier intervention may improve life expectancy. Single-modality therapy has not been effective in changing the natural history of MPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy have been initiated. Multiple modality approach has demonstrated favorable outcome, particularly in patients with epithelial histology, negative resection margins and presence of no metastases to extrapleural lymph nodes. Cisplatin and mitomycin have demonstrated modest efficacy in management of distant tumor recurrence. Cisplatin and gemcitabine regimen as well as cisplatin/pemetrexed followed by 54 Gy of adjuvant hemithorax radiation have been reported to improve the outcome.     

Peritoneal mesothelioma in a case of inguinal hernia. A review of the literature

The peritoneal mesothelioma (PM) is a rare, benign or malignant, primary tumour, arising from the peritoneal membrane. The most frequent histological form is the malignant one with an incidence of 2-2.6 new cases per million per year. The symptomatology is insidious and poses difficult problems in the diagnosis and the treatment. Instrumental diagnostic investigations are useful only in the diagnostic orientation. Only the pathologic examination allows to distinguish a peritoneal carcinomatosis from PM. The prognosis of MPM is pour. An intense multimodal therapy, combining surgery with CT and RT, increases the survival rates in the patients with MPM. It has been proposed that hernia of abdominal wall play a role in the pathogenesis of this tumor. We believe that hypothesis seems unlikely considering the enormous discrepancy between the incidence of hernial pathology and PM.     

Prospective trial for the treatment of malignant peritoneal mesothelioma

Malignant peritoneal mesothelioma (MPM) is a rare and often rapidly fatal disease with median survival of 5 to 12 months for untreated cases and 16 months reported after multimodality treatment. We report a prospective clinical treatment study using cytoreductive surgery combined with intraoperative intraperitoneal heated chemotherapy (IPHC) perfusion using mitomycin C for MPM. Twelve patients (11 male with a mean age 51 years) were treated. Seven patients presented with bulky disease and seven with ascites. All underwent exploratory laparotomy with histologically confirmed diagnosis of MPM. Surgical debulking as feasible was performed. Complete gross tumor removal was possible in only one patient. Cytoreduction was followed by a 2-hour closed low-volume IPHC using mitomycin C. One patient died 50 days postoperatively from complications relating to small bowel perforation. Hematologic toxicity of the procedure was minimal. Ascites was controlled in all patients and permanently in 86 per cent of patients presenting with ascites. To date median survival is 34.2 months with median follow-up of 45.2 months. One patient was re-explored for ventral hernia 2 years post-IPHC, had negative peritoneal biopsies, and remains disease-free at 5 years. Given the dismal prognosis associated with MPM the results of treatment with cytoreductive surgery combined with IPHC perfusion are encouraging. The rarity of MPM makes appropriately powered prospective randomized trials unlikely. Therefore, we now offer this approach off protocol; however, further study of this combined modality therapy is warranted.     

Current Trends in the Management of Malignant Peritoneal Mesothelioma

Background

Historically, malignant peritoneal mesothelioma (MPM) has been considered an aggressive and lethal neoplasm. However, contemporary series have demonstrated improved outcomes following a combination of cytoreductive surgery and intraperitoneal chemotherapy. We sought to assess the trends in management and survival of patients with MPM in the United States.

Methods

The Surveillance, Epidemiology, and End Results database was used to identify all patients diagnosed with malignant peritoneal mesothelioma from 1973 to 2010. Overall survival (OS) was studied with Kaplan–Meier curves and Cox regression analyses.

Results

We identified 1,591 patients with MPM. Median age at diagnosis was 64 years (IQR 53–74 years) with the majority of patients presenting with metastatic disease (n = 962, 60.5 %). A total of 980 patients (61.6 %) did not receive surgical therapy. Receipt of radical cytoreduction for patients with metastatic MPM demonstrated a significant improvement in OS compared with patients not receiving surgery (20 vs. 4 months, p < 0.01). A temporal increase was observed in OS for patients receiving surgery (1991–1995: 15 vs. 2006–2010: 38 months, p = 0.1). In multivariate models, limited (HR 0.55; 95 % CI 0.48–0.63; p < 0.01) and radical (HR 0.66; 95 % CI 0.54–0.80; p < 0.01) surgery were independently associated with improved survival.

Conclusions

In the current era, approximately three of every five patients do not receive surgery when diagnosed with MPM, although a significant survival benefit is noted in select patients. The opportunity to improve patient survival with surgical therapy is lost in a significant number of MPM patients.     

胰十二指肠切除术中静脉切除重建的研究现状

胰腺癌是一种恶性肿瘤，可接受治愈性手术的患者较少，静脉切除是获取切缘阴性与扩大手术人群的有效方式。外科医师主要通过术前影像学检查与患者特征决定是否在胰十二指肠切除术(pancreaticoduodenectomy，PD)中同时行相关静脉的切除及重建。切除肿瘤侵犯的静脉重建方式有多种选择，主要由肿瘤与静脉间的关系与手术医师的选择有关。PD合并静脉切除重建后可能会带来切缘阳性增多、并发症发生率升高等新的问题。辅助治疗已经成为胰腺癌的标准治疗方案，新辅助治疗在静脉受侵犯时的作用也受到认可。基因组学与信息化技术可能会为未来的手术及术后综合治疗提供新的诊疗方式。     

FDG PET/CT is useful for detecting infiltration to the port site in patients with malignant pleural mesothelioma

Objective

One reason for the poor outcomes of multimodality therapies, including macroscopic complete resection, in patients with malignant pleural mesothelioma (MPM) is the difficulty of correctly staging the disease, which can result in incomplete resection. The purpose of this study was to investigate the aspects of tumor infiltration to the port site and the usefulness of preoperative FDG PET/CT for diagnosing MPM.

Methods

Between June 2007 and May 2013, 21 patients who underwent surgical treatment with curative intent for MPM that had been previously diagnosed on a video-assisted thoracic surgery (VATS) biopsy were included in this study.

Results

There were 17 males and four females, with a mean age of 63 years. The accumulation of FDG at the port site was observed in all nine patients with tumor infiltration to the port site, whereas this feature was not noted in 15 patients without tumor extension to the port site. There were more positive lymph node cases in the infiltration group than in the non-infiltration group (p = 0.02). No significant differences in survival were observed between the patients with and without tumor infiltration to the port site.

Conclusions

FDG PET/CT is useful for detecting tumor infiltration of MPM to the port site and may help to prevent local recurrence, especially port site relapse, following macroscopic complete resection. However, this condition is related to tumor aggressiveness; therefore, performing careful staging and determining the appropriate treatment strategy are required in such patients.     

Cytoreductive Surgery Combined With Intraoperative Hyperthermic Intrathoracic Chemotherapy for Stage I Malignant Pleural Mesothelioma

Background:Malignant pleural mesothelioma (MPM) is a disease mostly confined to the thoracic cavity. Untreated, the median survival is <1 year. Cytoreductive surgery combined with intraoperative hyperthermic intrathoracic chemotherapy is used to kill residual tumor cells on the surface of the thoracic cavity while having limited systemic side effects.Methods:From August 1998 to August 2001, 22 patients with stage I MPM were included in this study. Two patients were irresectable at operation because of extrathoracic tumor growth. Twenty procedures were performed. After cytoreduction, a perfusion was performed with cisplatin and doxorubicin at 40°C to 41°C for 90 minutes. Adjuvant radiotherapy was given to surgical scars and drainage tracts.Results:There was no perioperative mortality, but significant morbidity was seen in 13 patients (65%), including bronchopleural fistula, diaphragm rupture, wound dehiscence, persistent air leakage, and chylous effusion. No hair loss or leucopenia was noticed. The median follow-up was 14 months. The median survival (Kaplan-Meier) was 11 months, with a 1-year survival of 42%. A favorable pharmacokinetic ratio was observed for both cisplatin and doxorubicin.Conclusions:Cytoreductive surgery combined with hyperthermic intrathoracic chemotherapy for stage I MPM is feasible. However, this treatment is accompanied by considerable morbidity. Survival data were less encouraging.     

The changing landscape of surgery for Crohn's disease

The incidence of Crohn's disease is increasing world-wide and the disease location and behavior is changing towards more colonic as well as inflammatory behavior. As previous data have spoken towards ileal disease and structuring and penetrating disease to be the indications most in need of surgery, one could expect the surgical load to decrease. As these changes are relative, the absolute numbers of surgical interventions are less affected. There are also data showing an increasing complexity among patients at time of surgery. Finally, a new role for surgery as initial therapy to induce remission instead of biologic therapy in ileal or ileocaecal disease has been suggested. In order to improve the care for patients with Crohn's disease in general, and the peri‑operative phase in particular, the use of multidisciplinary team discussions is essential. In conclusion, the role of surgery is changing. Fewer patients need surgery, but when they do they have more complex disease. In the future, ileocaecal resection may be used increasingly as initial therapy to induce remission in a true top-down approach.     

Malignant pleural mesothelioma: clinicopathologic and survival characteristics in a consecutive series of 394 patients.

OBJECTIVE: Treatment of malignant pleural mesothelioma (MPM) remains disappointing, although recent reports suggest that multimodality therapy including surgery may provide a significant survival benefit. The aims of this single institution study were: to investigate clinicopathologic characteristics and potential prognostic factors in MPM patients, and to ascertain whether surgery followed by adjuvant therapy had an independent prognostic role. METHODS: Retrospective review of a prospectively compiled computerized database of all patients with MPM evaluated between 1989 and 2003. Kaplan-Meier method, log-rank test, and Cox model were used in the statistical analysis. RESULTS: There were 394 patients: 270 men (68.5%), 124 women, median age 64 (range 28-93). Twenty-seven patients (6.8%) underwent surgical resection (extrapleural pneumonectomy 15, pleurectomy/decortication 12), followed by adjuvant therapy. As of March 2006, 381 patients (96.7%) had died (median survival, 11.7 months; range 0.03-117.9). Median follow-up of 13 surviving patients (3.3%) was 45.2 months (range 28.7-126.5). Overall survival at 2 years was 18.8%. Multimodality therapy including surgery yielded a median survival of 14.5 months and a 2-year survival rate of 29.6%. Using univariate analysis, age (p=0.009), chest pain (p=0.01), weight loss (p=0.001), performance status (p=0.0001), platelet count (p=0.008), histology (p=0.0001), macroscopic appearance of pleural surface (non-specific inflammation, tumor-like thickening, or nodules; p=0.0001), visceral pleura involvement (p=0.0001), degree of involvement of pleural cavity (less than or more than one third of the cavity; p=0.0001), and multimodality therapy (p<0.01) were found to be significant prognostic factors. At multivariate analysis, performance status, platelet count, histology, and degree of involvement of pleural cavity remained independently associated with survival, whereas multimodality therapy failed to enter the model. CONCLUSIONS: Significant predictors of survival include performance status, platelet count, histology, and degree of involvement of pleural cavity. Within the confines of this retrospective study and the small number of patients undergoing multimodality therapy, the role of surgery in the treatment of MPM remains unclear. Further investigation is warranted to determine the optimal treatment strategy in this disease.     

How should we treat malignant pleural mesothelioma (MPM)?

MPM is an occupational disease with increasing incidence. From 1986 to 1998 we operated 59 patients for MPM: in 11 cases only biopsy or exploration, 23 (stage T1a and T1b) Pleurectomy/Decortication, 22 (stage T2/3) extended pleuropneumonectomy (PPE) with resection of pericardium and diaphragm. In 3 cases we did additionally a chestwall resection. One patient in the PPE-group died postoperatively. Median survival time in the diagnosis/exploration group is 6 months. In the pleurectomy group (earlier stages) 14 months, in the PPE-group 16 months. One patient in the PPE-group survived 68 months, in the pleurectomy group the longest survival was 39 months. Up today 20 patients in the PPE-group died, 12 without any evidence local recurrency. Despite the fact that patients in the pleurectomy group are operated in earlier tumor stages they do not have a longer median survival time. In more than 50 percent only local disease control can be achieved by ePPE. Therefore in my opinion the first operative step must be followed by a second therapeutic step as immune- or gene therapy.     

Chirurgische Therapieoptionen bei malignen Knochentumoren

Beside the susceptibility to a (neo-) adjuvant therapy, the surgical margin is the most important prognostic factor in the treatment of primary malignant bone tumors. If adjuvant therapy is not possible, the outcome of the disease depends on the selected surgical treatment.Limb salvage has proven to be a safe procedure for local tumor control and provides good functional results.The surgeon has to consider the best surgical option depending on the site and size of the tumor but also depending on the patient's age and the overall prognosis.Surgical techniques and possible complications of the most common procedures in tumor surgery are described.     

Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is associated with a very poor prognosis. Unlike other solid tumors, any type of planned surgery for MPM would be cytoreductive rather than radical. There are two types of surgery for MPM. Extrapleural pneumonectomy (EPP) involves en bloc resection of the lung, pleura, pericardium, and diaphragm. Pleurectomy/decortication (P/D) is a lung-sparing surgery that removes only parietal/visceral pleura. In comparison with EPP, P/D is theoretically less radical but is associated with less perioperative mortality/morbidity and less postoperative deterioration of cardiopulmonary function. It still remains unclear which surgical technique is superior in terms of the risk/benefit ratio. In this context, selection between EPP and P/D has been a matter to debate.     

The management of malignant pleural mesothelioma; single centre experience in 10 years.

BACKGROUND AND OBJECTIVES: Malignant pleural mesothelioma (MPM) is an asbestos-related disease of the pleura with a survival time without treatment ranging from 4 to 12 months. The objective of this study is to review our experience in selection of MPM patients for various modalities of treatment. METHODS: Between 1989 and 1998, 302 patients with MPM have been referred to our Centre for assessment. Majority (191 patients, 61%) of them received no specific treatment. Forty-seven patients were treated by decortication/pleurectomy and 64 had a radical extra-pleural pneumonectomy (EPP). Intrapleural chemotherapy and systemic post-operative chemotherapy was employed only in the last 51 patients following radical surgery. RESULTS: The average survival was 8.9 months for those treated by palliative care only. The average survival was 13 and 14 months for patients treated by radical surgery only or by decortication/pleurectomy, respectively. However, survival has improved to a mean of 35 months for patients treated by radical surgery followed by systemic post-operative chemotherapy. In this group, the survival prevalence was 90 and 70% for T1 patients and 85 and 36% for T2 patients at 1 and 3 years, respectively (P=0.002). Survival was surprisingly, not affected by lymph node involvement (P=0.08) or pathological type of MPM (P=0.07). The operative mortality was 9% for EPP and 0% for decortication/pleurectomy. CONCLUSION: In selected patients with MPM, complete surgical resection by EPP represents an important initial step in their management. Systemic chemotherapy improves survival in surgically treated patients. Further trials are needed to improve on the adjuvant treatment regimes.     

Aromatase inhibitors as solely treatment in postmenopausal breast cancer patients

Several studies evaluating the clinical effectiveness of endocrine therapy alone in breast cancer patients aged 70 years or older reported comparable survival rates to conventional surgical therapy, although the incidence of local recurrences was higher. Primary endocrine therapy is therefore only recommended as an alternative approach in elderly woman with estrogen receptor positive tumors who are deemed inoperable or who refuse surgery. We report our experience with aromatase inhibitors as primary endocrine therapy for estrogen receptor positive breast cancer in postmenopausal woman who are impaired by other diseases, refuse surgery or are of old age. Fifty-six patients with fifty-seven ER+ operable breast cancers who refused surgery, were judged ineligible for surgery because of comorbidity, or were of old age were treated with endocrine therapy using aromatase inhibitors only. Digital mammography and high-end breast ultrasound were used to assess tumor sizes. The mean age of the patients was 74 years (range 52-102 years). All patients suffered from breast cancer. The mean follow-up interval was 40 months (range 5-92 months). Seven patients (12%) achieved complete clinical remission, 31 (57%) partial response giving an overall objective response rate of 69%. In addition, seven (12%) patients showed stable disease, giving a clinical benefit rate (complete remission + partial response + stable disease rate) of 81%. Eleven patients (19%) progressed after an initial partial response or stable disease. Only one patient (2%) progressed on endocrine therapy within the first months. Eventually, 22 (39%) patients underwent surgery after informed consent to achieve better local tumor control. Primary endocrine therapy with aromatase inhibitors may offer an effective and safe alternative to surgery giving a high local control rate in postmenopausal women who refuse surgery, who are judged ineligible for surgery, or are of old age.