Potentially curable recurrent disease after surgically managed non-metastatic renal cell carcinoma in low-, intermediate- and high-risk patients

Purpose

Guidelines recommend risk-adapted follow-up (FU) strategies after (partial) nephrectomy in non-metastatic renal cell carcinoma (RCC). Since current systemic therapy does not cure metastatic RCC, only timely detected recurrence accessible for local therapy is potentially curable. This study analyzed the rate and management of potentially curable recurrences per risk group.

Methods

This is a retrospective study including non-metastatic RCC patients who underwent (partial) nephrectomy from 2004 to 2011, with a minimum follow-up of 4 years. Risk stratification was by Leibovich score (clear cell subtype) and UICC/AJCC grading (other subtypes). Recurrence, time to recurrence, symptoms and detection method were documented. Isolated local recurrence, solitary- and oligometastases (≤3 lesions, single site) were considered potentially curable.

Results

Among 234 patients, followed during a median of 61.9 months, 68 patients (29.1 %) developed a recurrence of which 28 (41.2 %) were considered potentially curable. The 5-year risk of recurrence for low-, intermediate- and high-risk patients was 7.8, 26.3 and 59.1 % of which 71.4, 52.2 and 23.1 % were considered potentially curable, respectively. In high-risk patients, incurable recurrence was detected after a median of 7.9 (3.7–17.2) months versus 13.9 (6–41.3) months for potentially curable lesions. Only 13 of potentially curable lesions (46 %) received local therapy.

Conclusion

FU protocols should be adapted to the recurrence pattern of potentially curable disease. Most of the benefit may be achieved in intermediate-risk and high-risk-patients free of recurrence 1 year after surgery. Despite frequent imaging, only 13 patients (5.6 % of all patients followed) were managed with local therapy of whom only 4 remained free of disease.

     

Needle localization of occult breast lesions

Excision of mammographically demonstrated breast lesions that are clinically occult remains a surgical challenge. Eighteen lesions were preoperatively localized (all but 1 with the Frank hooked wire technique). Eleven lesions were evaluated with specimen radiography. Three lesions proved to be malignant at biopsy and 15 were benign. We found hooked wire needle placement to be extremely accurate, enabling rapid excision of the suspicious mass with excision of rather small areas of the breast with no significant cosmetic defect. Mean anesthetic time for breast biopsy alone was slightly less than time for biopsy with needle localization, which was less than that when specimen radiography was employed. In the absence of a discrete lesion, specimen radiography is a useful adjunct. Needle localization is simple, accurate, rapid, and requires no special apparatus. Its widespread use should lead to the identification of more breast carcinomas in a potentially curable state.     

Prognosis in patients with obstructing colorectal carcinoma

Over a 30 year interval (1950 to 1979), 1,061 patients with colorectal carcinoma were seen; 148 presented with bowel obstruction and in this retrospective study were compared with those having nonobstructive tumors. The age and sex distribution did not differ between the groups. The curability rate was 53 percent, versus 72 percent for nonobstructed patients; the 5 year survival rate was 16 percent overall and 31 percent in curable cases, versus 37 and 50 percent for elective patients, respectively. Survival within tumor stages did not differ between the groups; the difference in outcome was mainly a result of obstructed patients having fewer stage A and more stage C lesions. Most right-sided growths were primarily resected, while the left-sided growths were mainly treated with staged resection. Operative mortality for curable patients was 8 percent, not different from the 7 percent rate in elective patients. The 5 year survival rate was 19 percent after primary and 35 percent after staged resection. It was concluded that patients with bowel obstruction secondary to colorectal carcinoma have low curability and survival rates, primarily because of advanced disease at the time of diagnosis and treatment.     

Primary carcinoma of the gallbladder.

The records of patients with primary carcinoma of the gallbladder treated at Charity Hospital, New Orleans, Louisiana, from 1965 through 1978 were reviewed. Eighty patients had histologically proven primary carcinoma of the gallbladder. Sixty-nine patients had sufficient data available for evaluation. Only one patient (1.4%) was clinically free of disease at five years. Surgical procedures were performed in 45 of the 69 patients. The remainder of the patients had their disease proved at autopsy. Thirty-five patients had widespread metastatic disease at the time of operation. None of these patients survived more than one year. Only 10 patients had potentially curable lesions. The diagnosis of carcinoma of the gallbladder was not made at operation in eight of these patients. The only five-year survivor was in this subgroup. This patient had papillary adenocarcinoma confined to the mucosa and muscularis, and had a cholecystectomy alone. This report reinforces the difficulty in diagnosis and the dismal prognosis for patients with primary carcinoma of the gallbladder. Intraoperative examination of the gallbladder, earlier operation for documented gallbladder disease, and more aggressive surgical therapy should improve survival figures.     

Pancreatic tuberculosis: still a histopathological diagnosis

BACKGROUND: Pancreatic tuberculosis is usually unsuspected as it can present in various forms. Though an uncommon disease, once diagnosed it is potentially curable. PATIENTS AND METHODS: Retrospective review of the records of 9 patients with histologically proven tuberculosis of the pancreas. RESULTS: In none of the 9 patients was a preoperative diagnosis of tuberculosis possible. The diagnoses considered included: pancreatic cancer (n = 5); acute pseudocyst (n = 1); pancreatic abscess (n = 1); chronic pancreatitis with pancreatic head mass (n = 1), and carcinoma of the colon causing massive lower gastrointestinal bleeding (n = 1). All the patients underwent surgery. The diagnosis of tuberculosis was confirmed by histopathological examination of biopsy specimens obtained at the time of laparotomy. One patient died, the remaining patients received antitubercular therapy and are doing well at a median follow-up period of 26 months. CONCLUSION: In view of the nonspecific and variable clinical presentation and atypical radiological signs, a clinical diagnosis of pancreatic tuberculosis is usually not possible. Therefore there should be a high index of suspicion for this disease in young patients residing in endemic areas. Our experience highlights the importance of performing biopsy in apparently inoperable pancreatic mass lesions.     

Laparoscopic vs. open intraoperative ultrasound examination of the liver: A controlled study

A prospective study was undertaken to determine whether the use of laparoscopy plus laparoscopic ultrasound examination can avoid unnecessary laparotomy, without missing potentially curable disease, in patients scheduled for curative liver surgery. Thirty-one consecutive patients who underwent surgery for planned curative liver surgery were prospectively evaluated by means of both laparoscopy plus laparoscopic ultrasound and laparotomy with intraoperative ultrasound. Laparoscopic ultrasound examination of the liver could not be performed in two patients, and in two other patients only partial examinations were possible because of dense adhesions. All patients underwent laparotomy with intraoperative ultrasound. A total of 50 malignant at laparotomy with intraoperative ultrasound, that is, there were no false positive results. An additional four malignant lesions in four patients were not seen at laparoscopic ultrasound examination but were identified at laparotomy with intraoperative ultrasound (sensitivity 93%, specificity 100%, positive predictive value 100%, negative predictive value 85%). Based on the laparoscopic ultrasound findings, nontherapeutic laparotomy could have been avoided in 10% of our patients. Laparoscopy with laparoscopic ultrasound is a promising technology that may allow some patients to avoid a nontherapeutic laparotomy without significant risk of missing potentially curable disease. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Excisional breast biopsy and roentgenographic examination for mammographically detected microcalcification

Sixty-two women had excisional breast biopsy for areas of microcalcification detected by mammography with no associated palpable mass. Carcinoma was discovered in 20 patients (32 percent). These cancers ranged in size from 0.6 to 14 mm in greatest diameter. Six patients had multicentric carcinoma, including one synchronous bilateral lobular carcinoma. Axillary metastasis was present in three patients (15 percent), each with multicentric lesions. Chronic cystic mastopathy (55 percent) was the most common finding associated with microcalcification. In six patients (30 percent) with carcinoma, the microcalcification was present only in adjacent tissue and ducts. Generous excisional biopsy, verification of excision of the site of microcalcification by roentgenographic examination of the specimen, and thorough histologic examination by paraffin section are mandatory to detect these early and potentially curable breast carcinomas.     

Carcinoma of the breast in women 80 years of age and older: still a lethal disease

Cancer of the breast is a frequent and potentially lethal problem in women 80 years of age and older. In our experience, many present with advanced disease which indicates the continuing need for patient and doctor education concerning the significance of a breast lump in the elderly. Although many of these patients have other diseases, only a small number, if thoughtfully managed, will not be fit for appropriate standard methods of treatment. In the majority of patients who died, death was due to the breast cancer and many who did die from other causes had the added misery of persisting or metastatic breast cancer. In those patients with potentially curable cancer, we recommend either wide local excision, axillary node dissection and irradiation, or modified radical mastectomy. When simple mastectomy alone is used, there is a very high local recurrence rate. Although the patients studied were treated before the era of tamoxifen therapy, it is noteworthy that hormone manipulation would be of value in many of these patients and in selected cases, chemotherapy should also be considered.     

Detecting curable disease following hepatectomy for colorectal metastases

INTRODUCTION: Although resection may be curative for patients with hepatic colorectal metastases, recurrence occurs in the majority. Recurrence is occasionally amenable to repeated resection. The aim of the present study was to evaluate which modalities, at what intervals, detected potentially curable resection. METHODS: The records of patients undergoing hepatectomy for colorectal metastases over 10 years in one centre were retrospectively reviewed to determine when and how recurrence was diagnosed. Specific attention was paid to the detection of potentially curable disease. RESULTS: Of 41 recurrences, 22 occurred in the first year postoperatively, 21 of which were suitable for palliative treatment only. Ten of 19 recurrences occurring after 1 year underwent potentially curative intervention, 10 were diagnosed by computed tomography (CT). Carcinoembryonic antigen did not diagnose any curable recurrence. CONCLUSIONS: A follow-up protocol is proposed, based on annual CT.     

Surgery for intramedullary tuberculoma of the spinal cord: report of 2 cases

BACKGROUND: Intramedullary tuberculomas are rare. With the widespread availability of MRI and the increasing incidence of HIV and HIV-related tuberculous infections, the incidence of these lesions is likely to increase worldwide. The role of medical and surgical treatment of these relatively rare lesions remains to be defined. We report 2 patients who presented with intramedullary tuberculomas and discuss the importance of early surgery in this condition. CASE DESCRIPTION: Two female patients presented with insidious onset of myelopathy. The first patient had seizures due to imaging-documented intracranial tuberculomata and progressive paraparesis due to an intramedullary tuberculoma. The second patient had also had insidious onset of myelopathy and evidence of an intramedullary tuberculoma in MRI. She was also found to have abdominal and pulmonary tuberculosis. In view of the presence of tuberculosis elsewhere in the body in both the patients and the classical imaging features of intramedullary tuberculoma, they were treated initially with antituberculous chemotherapy. However, despite chemotherapy, both patients did not show improvement. Subsequently, both patients underwent microsurgical removal of the intramedullary lesions. The first patient who was neurologically well preserved at the time of surgery improved, whereas the second patient who was paraplegic with sphincter disturbances did not show any improvement. CONCLUSIONS: These case reports are presented to highlight the role of early surgery in patients with profound neurological deficits and intramedullary tuberculoma even if the radiological appearance of the lesion is characteristic. Even in lesions that are potentially curable by chemotherapy, early surgery has an important role in the treatment.     

Aldosteronoma in a child with localization by adrenal vein aldosterone: collective review of the literature.

Hyperaldosteronism due to aldosteronoma is a rare but potentially curable form of pediatric hypertension. We have presented a patient who had symptoms of enuresis and fatigue, and in whom the diagnosis was suggested by low serum potassium and persistent hypertension. Diagnosis was confirmed by increased plasma and urinary aldosterone and decreased plasma renin. The tumor was localized with the aid of adrenal venography and catheterization, which showed greatly increased plasma aldosterone levels in the right adrenal vein. The pathologic findings were totally reversed by right adrenalectomy. The clinical picture and results following surgical removal of aldosterone-producing tumors in six children are reviewed.     

Esophageal carcinoma. The value of staging in long-term survival.

A three-stage study of 177 patients in Puerto Rico who had esophageal carcinoma is presented. Those surviving five or more years over a twenty-one-year period were located. Next, the experience at the San Juan City Hospital from 1968 to 1973 was examined. The information obtained from those two groups led to the last stage, a prospective study in which treatment was based on objective staging of the extent of the disease. Only 27% of these patients are really potentially curable upon admission to the hospital, and they should have aggressive therapy. Adequate palliation can be obtained with radiotherapy and chemotherapy in the remainder. The findings that nearly half of the five-year survivors had metastases or tumor extension and that some patients survived for prolonged periods without treatment emphasize the need for individualized treatment and research in tumor immunology.     

Cranial-epidural tuberculosis presenting as a scalp swelling

BACKGROUND: Unlike the brain tuberculoma, tubercular osteomyelitis of the skull is very rare and not sufficiently described in the literature. Awareness of this entity makes diagnosis possible. CASE DESCRIPTIONS: Two unique cases of cranial and epidural tuberculosis (TB) with absence of intradural and brain involvement are presented. Both patients presented with scalp swellings but extending through the calvarium into the epidural space. Histologic/bacteriologic confirmation of tuberculosis was obtained from biopsy specimens. Magnetic resonance imaging (MRI) findings of this rare lesion are described for the first time. CONCLUSIONS: Inflammatory scalp lesions with skull involvement and epidural extension should be investigated for tuberculous etiology. With early diagnosis and a combination of surgical and medical management, all cases of skull tuberculosis are potentially curable.     

Endovascular treatment of TransAtlantic Inter-Society Consensus D aortoiliac occlusive disease using unibody bifurcated endografts

Objective

Aortobifemoral bypass has been the gold standard treatment for extensive aortoiliac occlusive disease. Endovascular therapy and stenting of aortic and iliac occlusive lesions has proven to be efficacious, especially when dealing with short segment lesions. Endovascular treatment of TransAtlantic Inter-Society Consensus II (TASC) D aortoiliac occlusive lesions remains a challenge, but a valuable treatment option in poor surgical candidates. We present our operative technique and midterm results in treating TASC D aortoiliac occlusive disease using unibody bifurcated endografts.

CRANIOTOMY AND THORACOTOMY FOR NON-SMALL CELL CARCINOMA OF THE LUNG WITH CEREBRAL METASTASIS

Twenty patients with non-small cell carcinoma of the lung who had cerebral metastasis, were treated by craniotomy and thoracotomy. Eighteen of these patients had a solitary metastasis and all were treated as curable. Ten patients presented with synchronous lung and brain disease. Of the remaining 10, nine initially presented with the lung tumour, which was treated first. There was a zero operative mortality rate and median survival was 12 months with reasonable quality of life for this time.     

The critical role of patient follow-up after receiving a diagnosis of prostatic intraepithelial neoplasia

With the increasing incidence of prostatic intraepithelial neoplasia being found at the time of prostate biopsy and the association of prostatic intraepithelial neoplasia to coexisting prostate cancer and/or the future development of prostate cancer, patient compliance in following post-biopsy follow-up instructions for re-biopsy is becoming more significant in the detection of prostate cancer at an earlier and, therefore, potentially curable stage. During a 3-y period, we reviewed the charts of 130 patients who received an initial diagnosis of prostatic intraepithelial neoplasia after undergoing transrectal ultrasound of the prostate with biopsy. It is our policy to inform the patient of their diagnosis of prostatic intraepithelial neoplasia at the time of the initial biopsy and to recommend a repeat biopsy in 6-12 months. Patients are informed of the diagnosis of prostatic intraepithelial neoplasia verbally and in writing. In addition, a letter is sent to their referring physician with the re-biopsy recommendation. Thirty-nine of 130 patients (30%) were seen for re-biopsy within the specified time. An additional 36 patients (27.69%) were re-biopsied between 12 and 18 months after the initial diagnosis of prostatic intraepithelial neoplasia. An additional 11 patients (7%) were re-biopsied more than 18 months after their initial diagnosis. Forty-four patients failed to return for re-biopsy. Overall, patient follow-up within the desired protocol was poor and must be improved upon to prevent any delays in the diagnosis of prostate cancer. Prostate Cancer and Prostatic Diseases (2001) 4, 63-66     

Changing trends in the surgical treatment of coarctation of the aorta

From 1974 through 1983, 107 patients 4 days to 27 years old underwent 115 operations for treatment of coarctation of the aorta. Thirty-two patients were infants (1 year old or younger), and 28 of them were newborns. All newborns were seen with congestive heart failure. Seventy-one patients were seen with hypertension. Associated anomalies were present in 72 patients (67%). Resection was performed in 48 patients, patch aortoplasty in 16, bypass of the coarcted segment in 15, and left subclavian artery flap angioplasty (LSAFA) in 36. Ligation of a patent ductus arteriosus was simultaneously performed in 28 patients and pulmonary artery banding, in 4. Follow-up was 6 months to 9.2 years. There was a significant difference in aortic cross-clamp time between 26 patients who had resection (37.9 +/- 12.9 minutes) (mean +/- standard deviation) and 32 patients who had LSAFA (22.9 +/- 7.7 minutes) (p less than 0.05). Six patients died within thirty days after operation; 5 of them had resection, and 1 had bypass. Major postoperative complications included bleeding requiring exploration in 3 patients (2 after resection and 1 after LSAFA) and paraplegia in 1 patient after reoperation (resection) for recurrent coarctation 3 years after patch aortoplasty. Paradoxical hypertension was observed in 13 patients, and sustained systemic postoperative hypertension developed in 11 after effective repair of coarctation. There was no significant difference in early postoperative arm-leg pressure gradients between the types of operation or the various age groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Improved survival in small pancreatic cancer

BACKGROUND: Although the incidence of pancreatic cancer is relatively low compared with other tumors (2.4%), the death rate is high. Tumor detection and treatment at an early stage is necessary to improve the poor prognosis of patients, as is demonstrated by some reports showing a 5-year survival rate varying between 19 and 41% for patients undergoing radical pancreatectomy with the highest survival in patients with small tumors. METHODS: In our study we retrospectively reviewed the histologic and demographic data of 596 patients who were admitted to the surgical units of the Careggi Hospital (University of Florence-AOC of Florence) between 1988 and 1994 with the incoming diagnosis of pancreatic cancer. RESULTS: Results are reported as the mean +/- standard deviation. The postoperative survival rate was calculated by the Kaplan-Meier method and statistical analysis was performed by the log rank test (significance p < 0.05). 247 patients had surgery, 110 with a curative intent. Postoperative mortality was 5.45%. The crude 5-year survival rate for patients who underwent curative surgery was 16.36% (18 patients), but for patients with small lesions confined to the pancreas (T1N0M0, 29 patients) this was even 31.03% (9 patients; p < 0.01, chi2 test). CONCLUSIONS: Our results indicate that it seems reasonable to consider these cancers as 'small', with survival reported in literature from 35 to 41%, so they probably represent the only curable condition at the present time.     

Role of Tc-99m MIBI in the evaluation of single pulmonary nodules: a preliminary report

BACKGROUND: Survival in bronchial carcinoma is closely related to the stage of the disease at the time of diagnosis and a single pulmonary nodule represents a potentially curable stage. This study was conducted to assess the feasibility of using Tc-99m labelled 2-methoxy isobutyl isonitrile (MIBI) to differentiate benign from malignant single pulmonary nodules. METHODS: A prospective study was conducted in the outpatient pulmonary clinic at the Cleveland Clinic Foundation. Twenty five patients with single pulmonary nodules considered indeterminate by their physicians and undergoing a procedure for tissue diagnosis were evaluated by Tc-99m MIBI SPECT scanning prior to definitive testing. Assessment of MIBI uptake was done qualitatively (subjectively) and quantitatively and correlated with the histopathology and nodule size. RESULTS: Of the 21 patients with malignant lesions, 18 had increased uptake of MIBI corresponding to the location of the nodule and were considered positive. The predominant tumour types were large cell (n = 5) and adenocarcinoma (n = 10). All four patients with benign lesions had negative MIBI scans. For malignancy the overall specificity was 100%, sensitivity was 85.7%, positive predictive value was 100%, and negative predictive value was 57%. Quantitative uptake of MIBI correlated with the diameter of the nodule with a correlation coefficient of 0.61 by Spearman's rank sum test. This relationship was statistically significant (p = 0.02). CONCLUSION: This preliminary study suggests that Tc-99m MIBI has a very high specificity and positive predictive value for malignant single pulmonary nodules and might be a useful non-invasive diagnostic modality in their management.     

Complex hepatic surgery aided by a 1.5-tesla moveable magnetic resonance imaging system

BACKGROUND: Resection represents the best treatment for potentially curable liver tumors; radiofrequency ablation (RFA) is an alternative. The curative potential of RFA may be hampered because the extent of burn is difficult to estimate by ultrasound. We postulated that intraoperative MRI (iMRI) would enable a more accurate assessment of ablation completeness. METHODS: We performed open hepatic surgery in an operating room equipped with a unique, retractable 1.5-T magnet. Patients were selected because it was anticipated that RFA (with or instead of resection) was likelihood and that iMRI might be helpful in making intraoperative decisions. After baseline MRI, lesions were further assessed by ultrasound at the time of open surgery. Lesions were resected and/or ablated, and further imaging confirmed the margins of the procedure. RESULTS: Nine patients underwent the procedure: 1 with metastatic carcinoid, 4 with hepatocellular carcinoma, and 4 with colorectal liver metastases. In 4 patients, iMRI had an effect on decision-making. In 5 individuals, there were nonlocal recurrences, and 1 patient who was never disease-free had a local recurrence. COMMENTS: Intraoperative MRI could potentially impact operative decision-making when ablating extensive disease. Its ability to prevent local recurrences must be determined. Moreover, the role of this technology in the overall treatment armamentarium must be defined.