Outcomes of Screening-Detected Ductal Carcinoma In Situ Treated with Wide Excision Alone

Background  

Ductal carcinoma in situ (DCIS) is commonly identified on screening mammography. Standard treatment for localized DCIS is wide local excision (WLE) and adjuvant radiotherapy. This approach represents overtreatment in many cases, where the DCIS would never have become clinically significant, or where less intensive treatment would have been satisfactory. We reviewed the medium-term outcome of a cohort of screen detected DCIS patients treated mainly with WLE without radiotherapy.     

Patients’ Preferences on Information and Involvement in Decision Making for Gastrointestinal Surgery

Background

The relationship between physicians and patients has undergone important changes, and the current emancipation of patients has led to a real partnership in medical decision making. The present study aimed to assess patients’ preferences on different aspects of decision making during treatment and potential complications, as well as the amount and type of preoperative information wanted before visceral surgery.

Methods

This was a prospective non-randomized study based on a questionnaire given to 253 consecutive patients scheduled for elective gastrointestinal surgery.

Results

In considering surgical complications or treatment in the intensive care unit, 64 % of patients wished to take an active role in any medical decisions. The respective figures for cardiac resuscitation and treatment limitations were 89 and 60 %. As for information, 73, 77, and 47 % of patients wish detailed information, information on a potential ICU hospitalization, and knowledge of cardiac resuscitation, respectively. Elderly and low-educated patients were significantly less interested in shared medical decision making (p = 0.003 and 0.015), and in receiving information (p = 0.03 and 0.05). Similarly, involvement of the family in decision making was significantly less important to elderly and male patients (p = 0.05 and 0.03, respectively). Neither the type of operation (minor or major) nor the severity of disease (malignancies versus non-malignancies) was a significant factor for shared decision making, information, or family involvement.

Conclusions

The vast majority of surgical patients clearly want to get adequate preoperative information about their disease and the planned treatment. They also consider it crucial to be involved in any kind of decision making for treatment and complications. For most patients, the family role is limited to supporting the treating physicians if the patient is unable to participate in decision making.     

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

Background

The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy.

Methods

The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years.

Results

Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1–2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1–2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005).

Conclusions

Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.     

Postoperative Radiation Therapy in 26 Patients with Invasive Transitional Cell Carcinoma of the Upper Urinary Tract: No Impact on Survival?

Purpose

To evaluate the role of adjuvant radiation therapy in invasive transitional cell carcinoma of the upper urinary tract, we retrospectively reviewed a series of 26 patients who underwent radical surgery plus postoperative prophylactic irradiation for such a tumor.

Materials and Methods

Between February 1980 and October 1993, 18 men and 8 women (mean age 65 plus/minus 9 years, standard deviation) were treated for an invasive transitional cell carcinoma of the upper urinary tract. Tumor location was the renal pelvis in 15 patients (58 percent). The tumor was pathological stage B in 11 patients (42 percent) and stage C in 15 (58 percent). Tumor grade was 2 in 10 patients, 3 in 15 and unknown in 1. One patient had epidermoid metaplasia of urothelial cancer and 9 had node involvement. All patients underwent surgery followed by radiation therapy to a total dose of 45 Gy. to the tumor bed²³ and/or regional nodes¹⁸.

Results

After a mean followup of 45 months 13 patients (50 percent) were alive and 11 were disease-free at analysis. Local tumor relapse, nodal recurrence and metastasis were noted in 1, 4 (15 percent) and 14 (54 percent) patients, respectively. All patients with nodal recurrence had metastasis. A secondary location was noted frequently (6 bladder, 1 contralateral renal pelvis and 1 urethral tumors). Overall 5-year survival rate and 5-year survival rate with no evidence of disease were 49 percent and 30 percent, respectively. Overall 5-year survival rates were 60 percent for stage B and 19 percent for stage C disease (p = 0.07), 49 percent for node-negative versus 15 percent for node-positive cancer (p = 0.04), and 90 percent for grade 2 and 0 percent for grade 3 tumors (p less than 0.01).

Conclusions

In our trial using a radio-surgical approach, local control of disease and survival rates were similar to those reported previously in surgical series. Prophylactic postoperative radiation therapy is not recommended except in prospective randomized studies.     

Cancer-specific Survival After Metastasis Following Primary Radical Prostatectomy Compared with Radiation Therapy in Prostate Cancer Patients: Results of a Population-based,Propensity Score–Matched Analysis

BackgroundData regarding the difference in the clinical course from metastasis to prostate cancer–specific mortality (PCSM) following radical prostatectomy (RP) compared with radiation therapy (RT) are lacking.ObjectiveTo examine the association between primary treatment modality and prostate cancer–specific survival (PCSS) after metastasis.Design, setting, and participantsWe used the Surveillance Epidemiology and End Results–Medicare linked database from 1994 to 2007 for patients diagnosed with localized prostate cancer (PCa). We used cancer stage and Gleason score to stratify patients into low and intermediate–high risks.InterventionRadical prostatectomy or radiation therapy.Outcome measurements and statistical analysisOur outcome is time from onset of metastases to PCSM. Propensity score matching and Cox regression were used to analyze the PCSM hazard for the RP group compared with the RT group.Results and limitationsOur study consisted of 66 492 men diagnosed with PCa, 51 337 men receiving RT, and 15 155 men undergoing RP within 1 yr of cancer diagnosis. During the study period, 2802 men were diagnosed as having metastatic disease. A total of 916 men with metastases were included in the propensity-matched cohort; of these men, 186 died from PCa. During the follow-up, for the low-risk patients, the adjusted PCSS after metastasis was 86.2% and 79.3% in the RP and RT groups, respectively; for the intermediate–high-risk patients, the PCSS after metastasis was 76.3% and 63.3% in the RP and RT groups, respectively. The hazard ratios estimating the risk of PCSM between the RP and RT groups were 0.64 (95% confidence interval [CI], 0.36–1.16) and 0.55 (95% CI, 0.39–0.77) for the low- and intermediate–high-risk groups, respectively. Because of the nature of observational studies, the results may be affected by residual confounders and treatment indication.ConclusionsFollowing the development of metastases, men who received primary RP have a longer PCSS than men who received primary RT. Our results may have implications for the timing and nature of local PCa treatment.     

The Results of Chemotherapy with Two Variants of Intravenous CMF in Patients with Early Stage Breast Carcinoma; Does Dose Density Matter?

No direct comparisons can be made in early stages of breast cancer, between the intravenous combinations of: cyclophosphamide, methotrexate, and fluorouracil; named modified versions of CMF with the classical oral version of CMF. Since these modifications have different dose intensities and densities, the outcomes for their subsequent treatments may be varied, and not produce the same results. Despite that, classical CMF has been commonly replaced with intravenous modifications. This study aimed to assess the results of treatment with two common intravenous modification of CMF chemotherapy; to represent the most effective and successful substitute of classical CMF. Five hundred patients in two groups were eligible to take part in the experiment. For two hundred and twenty‐nine patients in the group CMF 1&8, chemotherapy was administered intravenously on days 1 and 8 every 28 days for six cycles consisting of: cyclophosphamide 600 mg/m², methotrexate 40 mg/m², fluorouracil 600 mg/m². In the group CMF 1 which consisted of 271 patients, chemotherapy was administered with all the same drugs and doses, however, it was only administered on day 1 and repeated at 21‐day intervals for six cycles. Overall survival (OS), disease‐free survival (DFS), the prognostic factors and other probable interventional factors were then compared between the two groups. The 5‐year OS rate of 87.5% and 10‐year OS rate of 82% in the group CMF 1&8 were statistically significantly better than 5‐year OS of 84% and 10‐year OS of 61.5% in the group CMF 1 (p = 0.01). The 5‐year and 10‐year DFS rates were 76% and 60% respectively, in the group CMF 1&8 compared with 77% and 54% respectively in the group CMF 1 (p = 0.8). Two groups were comparable regarding their distribution of different prognostic factors and other probable interventional factors. Considering 30% higher dose density of drugs in the protocol of CMF 1&8, the improving outcome can be related to the efficacy of dose‐dense chemotherapy. Therefore, this intravenous modification is the better substitute of classical CMF.     

The impact of evolving V.A.C ® Therapy technology on outcomes in wound care. Prologue

In May 2011, an international panel of wound care experts from multiple disciplines convened to develop this document to summarise the evolution of negative pressure wound therapy (NPWT) technology devices over the past 15 years, specifically concentrating on the V.A.C.(?) Therapy (KCI USA, Inc., San Antonio, TX) family of products. The aim of this document, which will be comprised of six articles, is to describe appropriate use of current technology options across a variety of wound types. The articles will include literature reviews, initiation criteria, treatment outcomes, technical pearls and clinical cases that will show the enhanced outcomes and potential economic value of the various NPWT technologies in use today.     

Investigations on the Subclinical and Clinical Nephrotoxicity of Interferon α-2B in Patients with Myeloproliferative Syndromes

Since the introduction of interferon α-2b (IFN α-2b) into clinical oncology there have been several reports dealing with acute renal failure during therapy with this new type of anticancer drug. We investigated 58 patients (pts) with myeloproliferative syndromes (56 pts with chronic myelogenous leukemia, 2 pts with essential thrombocythemia) who were treated with 4 × 10⁶ IU IFN α-2b each day subcutaneously. In order to assess the nephrotoxic potential we used the following noninvasive methods: 1. Analysis of the excretion of 4 urinary enzymes (LDH, LAP, GGT, NAG), 2. Determination of the excretion of protein, albumin, α-1-microglobulin immunoglobulin G (Ig G), 3. serum creatinine. The investigations were done every 2 weeks and took 70 weeks. We found an increase in the excretion of all 4 enzymes which remained stable during the whole observation period, protein excretion was pathological in about 20% of all pts and reached values of up to 9.07 g/L α-1-microglobulin was excreted in pathological amounts in about 20% of all pts during the whole observation period, albumin was found in pathological quantities in about 15% of all pts and Ig G was pathologically increased in the urine in about 10% of the pts. Serum creatinine rose in 5–10% of the pts up to 1.5 mg/dL. In conclusion, IFN α-2b is capable of inducing combined glomerular and tubular damage. Therefore, avoiding additional nephrotoxic insults is desirable.     

Society of Surgical Oncology–American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer

Purpose

Controversy exists regarding the optimal margin width in breast-conserving surgery for invasive breast cancer.

Methods

A multidisciplinary consensus panel used a meta-analysis of margin width and ipsilateral breast tumor recurrence (IBTR) from a systematic review of 33 studies including 28,162 patients as the primary evidence base for consensus.

Results

Positive margins (ink on invasive carcinoma or ductal carcinoma in situ) are associated with a two-fold increase in the risk of IBTR compared with negative margins. This increased risk is not mitigated by favorable biology, endocrine therapy, or a radiation boost. More widely clear margins than no ink on tumor do not significantly decrease the rate of IBTR compared with no ink on tumor. There is no evidence that more widely clear margins reduce IBTR for young patients or for those with unfavorable biology, lobular cancers, or cancers with an extensive intraductal component.

Conclusion

The use of no ink on tumor as the standard for an adequate margin in invasive cancer in the era of multidisciplinary therapy is associated with low rates of IBTR and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs.