Should Postmastectomy Radiotherapy to the Chest Wall and Regional Lymph Nodes Be Standard for Patients with 1–3 Positive Lymph Nodes?

The indication for adjuvant postmastectomy radiotherapy (PMRT) in breast cancer patients with small tumors and 1-3 macrometastases in the axilla remains a controversial issue, despite the recommendation that PMRT should be applied in these patients in the most recent overview by the Early Breast Cancer Trialists' Collaborative Group. In this report, we discuss the available data on the benefit from PMRT in patients diagnosed with N1 breast cancer. Based on this, we recommend adjuvant PMRT to the chest wall and regional lymph nodes in patients diagnosed with early node-positive breast cancer.     

Is Interstitial Pneumonia in Patients with Collagen Diseases a Contraindication to Lung Cancer Surgery?

Purpose

Lung cancer surgery can be dangerous in patients with interstitial pneumonia (IP) as acute exacerbation of the IP may prove fatal. It remains unclear if patients with collagen diseases (CD), who often suffer from IP, are also at increased risk during lung cancer surgery.

Methods

We retrospectively examined 17 (3.1%) patients with CD among 545 patients who underwent surgery for lung cancer at our institution.

Results

Nine patients with rheumatoid arthritis, five with systemic sclerosis, two with Sjögren's disease, and one with systemic lupus erythematosus were enrolled in this study. Eleven patients (65%) were taking corticosteroids at the time of surgery. Fourteen patients underwent lobectomy and lymph node dissection, and three patients with pStage IA lung cancer underwent pulmonary wedge resection. Pathologically, 11 (65%) patients had IP with various inflammatory cellular infiltrations, and three (18%) had honeycombing of the lung. Postoperatively, none of the patients suffered acute exacerbation of their IP.

Conclusions

Despite the high incidence of IP in patients with lung cancer and CD, our results suggest that CD is not a contraindication to the surgical resection of lung cancer.

     

What Is the Minimum Number of Examined Lymph Nodes After Neoadjuvant Therapy in Rectal Cancer?

Background

To date, no guidelines have standardized the number of examined lymph nodes (eLNs) after neoadjuvant treatment. This study investigated the minimum number of eLNs required for patients with rectal cancer (RC) who received neoadjuvant treatment.

Material and Methods

This study was based on data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. We included 2173 patients with RC who received neoadjuvant therapy. Restricted cubic spline was used to analyze the association between eLNs and lymph node metastasis (LNM).

Results

The number of eLNs was an independent predictive factor for the presence of LNM (odds ratio 1.033; 95% confidence interval 1.020–1.046; P?<?0.001). When the number of eLN?≤?16, 10 and 11 eLNs had the highest rates of positive LNM. Analysis of the restricted cubic spline method found that when number of eLNs was <?10, the LNM rate increased rapidly, but this increase was not so obviously when there were >?10 eLNs.

Conclusions

Among RC patients who receive neoadjuvant therapy, the minimum number of eLNs may be 10 to ensure pathological quality.

     

Axillary Lymph Nodes in Breast Cancer: Is Size Related to Metastatic Involvement?

Usually when using imaging procedures, such as axillary mammography or ultrasonography, a cutoff level of 5 mm for lymph node size is postulated to be not only the limit of lymph node visibility but also a sign of metastatic involvement. The aim of this study was to evaluate whether this assumption, used as a basic hypothesis in many reports, is true. A series of 72 axillary specimens from 71 breast carcinoma patients operated at the university hospital of Vienna were analyzed. A comparison of histologically noninvolved axillary specimens with those showing metastatic involvement revealed that the two groups did not differ significantly according to the number or size of lymph nodes per axilla. For lymph nodes <5 mm the probability of being metastatically involved was still 10%. Enlarged lymph nodes (5–20 mm) had a slightly higher risk of being malignant (20%). In contrast, the probability of metastatic involvement for lymph nodes >20 mm was only 40%. We suggest that many reports dealing with the prediction of malignancy in axillary lymph nodes may have used misleading basic assumptions, so the results of these studies must be viewed critically.     

Is Sentinel Node Biopsy of the Internal Mammary Lymph Nodes Relevant in the Management of Breast Cancer?

The aim of this study was to review the outcomes of a series of breast cancer patients who underwent sentinel node biopsy inclusive of lymphoscintigraphy, and to assess the incidence of internal mammary node (IMN) metastatic positivity at exploration and whether these findings influenced treatment. Between April 2001 and December 2012, 581 breast cancer patients at Princess Alexandra Hospital underwent preoperative lymphoscintigraphy in the course of the performance of sentinel node biopsy. Analysis was performed of those patients who demonstrated radio‐isotope uptake to the IMN chain, and who had sentinel node biopsy of the IMN's and were found to have metastatic involvement. Assessment was made to determine whether the finding of IMN metastases changed the adjuvant systemic management of these patients, and to review complication rates. 95 of 581 (16.4%) patients with preoperative breast lymphoscintigraphy had lymphatic mapping to the IMN chain. 51 (54%) of these patients had IMN chain surgically explored and IMN nodes were found in 35 of these patients (success rate of 69%). Of these, three patients (3/35 = 8.6%) had metastatic involvement of the IMN sentinel node group. All three IMN positive patients received adjuvant breast radiotherapy, chemotherapy, and hormonal therapy. In four patients (7.8%) IMN surgical exploration was complicated by pneumothorax. Only a small proportion of breast cancer patients were found to have metastasic involvement of the IMN chain and which did not significantly change their adjuvant therapy management. These findings suggest that the benefits of exploration of the IMN chain in breast cancer patients are limited and may be outweighed by the risk of complications.     

Is Routine Intraoperative Frozen-Section Examination of Sentinel Lymph Nodes in Breast Cancer Worthwhile?

Background: Routine intraoperative frozen section (FS) of sentinel lymph nodes (SLN) can detect metastatic disease, allowing immediate axillary dissection and avoiding the need for reoperation. Routine FS is also costly, increases operative time, and is subject to false-negative results. We examined the benefit of routine intraoperative FS among the first 1000 patients at Memorial Sloan Kettering Cancer Center who had SLN biopsy for breast cancer.Methods: We performed SLN biopsy with intraoperative FS in 890 consecutive breast cancer patients, none of whom had a back-up axillary dissection planned in advance. Serial sections and immunohistochemical staining for cytokeratins were performed on all SLN that proved negative on FS. The sensitivity of FS was determined as a function of (1) tumor size and (2) volume of metastatic disease in the SLN, and the benefit of FS was defined as the avoidance of a reoperative axillary dissection.Results: The sensitivity of FS ranged from 40% for patients with T1a to 76% for patients with T2 cancers. The volume of SLN metastasis was highly correlated with tumor size, and FS was far more effective in detecting macrometastatic disease (sensitivity 92%) than micrometastases (sensitivity 17%). The benefit of FS in avoiding reoperative axillary dissection ranged from 4% for T1a (6 of 143) to 38% for T2 (45 of 119) cancers.Conclusions: In breast cancer patients having SLN biopsy, the failure of routine intraoperative FS is largely the failure to detect micrometastatic disease. The benefit of routine intraoperative FS increases with tumor size. Routine FS may not be indicated in patients with the smallest invasive cancers.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, March 16–19, 2000, New Orleans     

Definition of T3/4 and Regional Lymph Nodes in Gallbladder Cancer: Which Is More Valid, the UICC or the Japanese Staging System?

Background

The Union for International Cancer Control (UICC) and Japanese Society of Biliary Surgery (JSBS) staging systems differ in their staging of gallbladder cancer: they define hepatic invasion with or without invasion of another organ as T3 and either T3 or T4, respectively, and posterosuperior pancreatic lymph node (PSPLN) metastases as M1 and N2, respectively.

Methods

We retrospectively evaluated the survival of 224 patients who had undergone macroscopically curative resection for gallbladder cancer and assessed the influence of the differences between the two staging systems on survival.

Results

JSBS staging stratified the survival curves better for stages III or IV. Fifty-seven patients were classified as UICC-T3 but JSBS-T4. These patients had better survival than did 43 patients with UICC-T4/JSBS-T4 and comparable survival to 17 patients with UICC-T3/JSBS-T3. UICC stage IIIB is composed of two subgroups: U-T2N1 (18 patients) and U-T3N1 (21 patients). Their 5-year survivals were 85 and 41?%, respectively (P?=?0.01). The latter was comparable to that of 28 T3N0 patients (35?%, P?=?0.93). The survival of the UICC-M1 patients with disease restricted to PSPLNs was significantly better than that of those with involvement beyond PSPLNs (5-year survival 35 vs. 17?%; P?=?0.04).

Conclusions

Although UICC staging more accurately defines the T category, JSBS staging better stratifies the prognosis of patients with gallbladder cancer, mainly because UICC stage IIIB includes T1/2N1M0, which is associated with significantly better survival than T3N0M0. It would be appropriate to classify PSPLNs as regional lymph nodes.     

Is Blue Dye Indicated for Sentinel Lymph Node Biopsy in Breast Cancer Patients With a Positive Lymphoscintigram?

Background The use of isosulfan blue dye in sentinel node biopsy for breast cancer has been questioned because of its risk of allergic reaction. We hypothesized that blue dye could be safely omitted in the subgroup of patients who have evidence of successful sentinel node localization by lymphoscintigraphy.Methods A retrospective review of patients with breast cancer and sentinel node biopsy was conducted. Information was collected on lymphoscintigraphy results, use of blue dye, and intraoperative and pathologic findings of sentinel nodes.Results We identified 475 patients with breast cancer who underwent 478 sentinel node biopsies. Both dye and isotope were given in 418 cases, of which 380 had a positive lymphoscintigram. In 5 of the 380 cases with a positive lymphoscintigram, the sentinel nodes obtained were blue but not hot, for a 1.3% marginal benefit of dye in the technical success of the procedure. Sentinel nodes positive for metastasis were found in 102 of 380 cases; in 3 cases, the only positive sentinel node was blue but not hot. Omission of the blue dye tracer would have increased the false-negative rate of the sentinel node procedure by approximately 2.5%.Conclusions Even in sentinel node biopsy cases with a positive lymphoscintigram, the use of blue dye is beneficial for both improving the technical success of the procedure and reducing the false-negative rate of the procedure. Because the marginal benefits of dye justify its routine use, strategies to minimize the toxicity of blue dye are warranted.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

Is Axillary Lymph Node Dissection Necessary After Sentinel Lymph Node Biopsy in Patients with Mastectomy and Pathological N1 Breast Cancer?

Background

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial reported that axillary lymph node dissection (ALND) did not change the recurrence and overall survival (OS) rates in patients with lumpectomy and one to two positive nodes detected by sentinel lymph node biopsy (SLNB). The aim of this study was to determine whether patients with mastectomy and pathological N1 disease found by SLNB could forego ALND.

Materials and Methods

This is a retrospective study of 214 patients diagnosed with primary invasive breast cancer who were treated by mastectomy and lymph node staging surgery (SLNB or ALND) at the Revlon/UCLA Breast Center between January 2002 and December 2010. Patients with pathological N1 disease were separated by their first nodal surgery into SLNB (subgroups: observation, radiation, and additional ALND with or without radiation) and ALND groups (subgroups: ALND with or without radiation).

Results

After a median follow-up of 43.6 months, the OS and systemic relapse-free survival (RFS) rate of the radiation group and additional ALND group were significantly better than the observation group (p = 0.031 and 0.046, respectively). Human epidermal growth factor receptor 2 (HER2) expression was found to predict OS and patients’ age, histological grade and HER2 expression predicted systemic recurrence. Compared with the SLNB group, pain (p = 0.021) and lymphedema (p = 0.043) occurred more frequently in the ALND group.

Conclusion

Radiation was as effective as ALND in patients with mastectomy and N1 disease for OS and RFS rates, yet radiation after SLNB had fewer side effects than ALND. SLNB followed by radiation could replace ALND in patients with mastectomy and pathological N1 breast cancer identified by SLNB.     

Is Overweight Related to the Prognosis of Octogenarians with Lung Cancer?

Background

This study aimed to determine outcomes and prognostic factors associated with octogenarians who underwent pulmonary resection for lung cancer.

Methods

From 2009 to 2018, 76 octogenarians who underwent pulmonary surgery for lung cancer were enrolled in this study. We divided them into two groups, namely overweight and non-overweight, and investigated their clinicopathological characteristics and outcomes. Disease-specific survival (DSS) rates were determined using Kaplan–Meier curves. Univariate and multivariate analyses were performed to identify prognostic factors.

Results

Although perioperative morbidity and mortality in octogenarians were not significantly different between the two groups, the long-term prognosis of the overweight group was significantly worse than that of the non-overweight group. The 3-year DSS rate was 56.5%. The median observation period after surgery was 37.5 (8.9–112.3) months for the entire cohort postoperatively. Kaplan–Meier curves showed that being overweight (body mass index ≥ 25) was associated with worse survival rates in all pathological stages (0 to III) and stage 0/I (DSS, p = 0.036 and p = 0.003, respectively). Multivariate analysis identified overweight as an unfavorable prognostic factor for DSS in patients with stage 0/I lung cancer (hazard ratio 2.240, 95% confidence intervals 1.052–4.564, p = 0.037).

Conclusions

Overweight is an independent risk factor, especially in pathological stage 0/I lung cancer. Indications for surgery should be carefully considered in elderly patients with obesity. However, owing to the limitations of this retrospective single-center study, future studies involving multiple institutions are required to confirm our findings.

     

Adjuvant Postoperative Radiotherapy to the Cervical Lymph Nodes in Cutaneous Melanoma: Is There Any Benefit for High-Risk Patients?

Background  The use of adjuvant radiotherapy after lymph node dissection for metastatic melanoma remains controversial. This study examined the effectiveness of adjuvant radiotherapy in controlling regional disease in high-risk patients. Methods  A total of 716 patients were identified from a large prospective database who underwent cervical lymph node surgery between 1990 and 2004. Patients with high-risk disease were offered radiotherapy (n = 129), and this group was compared with the group of patients who did not receive radiotherapy (n = 587) in the same period. Results  Radiotherapy did not improve regional control in patients who had metastatic melanoma of the cervical lymph nodes (P = .2). There were 10% fewer regional recurrences in patients with extracapsular spread who received adjuvant radiotherapy, although this was not statistically significant (P = .34). Adjuvant radiotherapy conferred no overall survival benefit to patients with nodal metastases (P = .39). There was a statistically significant trend for worse survival with increasing nodal tumor burden that remained unchanged with adjuvant radiotherapy. Conclusion  This large, nonrandomized retrospective study found no evidence to support the use of adjuvant radiotherapy for high-risk melanoma. A multicenter randomized, controlled trial investigating this important clinical dilemma is advocated.     

Is There a Role for Palliative Gastrectomy in Patients with Stage IV Gastric Cancer?

Patients with metastatic gastric cancer are currently not considered operative candidates and are most often offered systemic therapy. Palliative resection of the primary tumor has been considered irrelevant to the outcome and has been recommended only for palliation of symptoms. We have examined the role of palliative gastrectomy and its impact on survival in patients with stage IV gastric cancer at initial diagnosis between 1990 and 2000. A total of 105 patients with stage IV disease were identified during this period; 81 of them (77.1%) had no resection, and 24 (22.9%) underwent palliative gastric resection. Mean survival in those without resection who received chemotherapy (with or without radiation) treatment was 5.9 months (95% confidence interval 4.2–7.6). For those with resection and adjuvant therapy, mean survival time was 16.3 months (95% confidence interval 4.3–28.8 months). Kaplan-Meier survival analysis showed significantly better survival in those with resection and adjuvant therapy (log-rank test, P = 0.01). Mortality and morbidity rates associated with palliative resection were 8.7% and 33.3%, respectively, which did not differ statistically from the 3.7% and 25.3% in patients who underwent curative gastrectomy during same period of time. However, the length of hospitalization (22 versus 16 days) was significantly higher compared with those without stage IV disease. These data suggest that palliative resection combined with adjuvant therapy may improve survival in a selected group of patients with stage IV gastric cancer. Palliative gastrectomy plus systemic therapy should be compared with systemic therapy alone in a randomized trial.     

Is Hypoalbuminemia an Independent Prognostic Factor in Patients with Gastric Cancer?

Background  

Studies have indicated that hypoalbuminemia is associated with decreased survival of patients with gastric cancer. However, the prognostic value of albumin may be secondary to an ongoing systemic inflammatory response. The aim of the study was to assess the relation between hypoalbuminemia, the systemic inflammatory response, and survival in patients with gastric cancer.     

Secondary Carina and Lobar Bronchi Stenting in Patients with Advanced Lung Cancer: Is It Worth the Effort? A Clinical Experience

Background: The lobar airway stenting remains an endoscopic procedure not well standardized in patients with locally advanced lung cancer disease. The goal of this study was to evaluate technical feasibility, clinical outcome, and complications of different stents in patients with malignant lesions involving lobar bronchi, primary and secondary carina.Methods: Between November 2008 and October 2013, we retrospectively analyzed 146 patients with benign and malignant tracheobronchial stenosis who underwent airway stent insertion below main carina and main bronchi.Results: In all, 170 airway stenting procedures were performed on 146 patients. In all, 51 of them with malignant peripheral airway stenosis underwent stents placement below main carina. In all but one patient, the deployment of stents was successful with improvement of symptoms. The chest radiograph after the procedure detected the lung re-expansion in 29 of 51 patients. The mean follow-up duration was 123 days ± 157. Complications observed included stent migration, tumor overgrowth, infections, granulation tissue formation, and obstruction due to tenacious secretions. Longer survival was observed in patients who received additional treatment after airway stenting compared to those who did not (p <0.01).Conclusions: Stenting of lobar bronchi and primary or secondary carina is technically feasible, effective, and acceptably safe.     

Is Perioperative Systemic Inflammation the Result of Insufficient Cortisol Production in Patients with Colorectal Cancer?

Background

Patients with colorectal cancer who have a raised systemic inflammatory response before surgery have been shown to have poorer long-term and short-term outcomes. The presence of an ongoing systemic inflammatory response in these patients may be due to impaired cortisol production. The aim of the present study was to examine the relationship between the perioperative systemic inflammatory response and endogenous cortisol production.

Methods

A prospective study was performed to incorporate the assessment of adrenocortical function using synthetic adrenocorticotrophic hormone, a short Synacthen test, as part of the preoperative assessment of patients undergoing resection for colorectal cancer.

Results

A total of 80 patients underwent short Synacthen testing. There were no significant associations between the baseline, 30 min, or change (both relative and absolute) in cortisol and age (all p > 0.10), sex (all p > 0.10), site (all p > 0.10), TNM stage (all p > 0.10), modified Glasgow prognostic score (all p > 0.10), NLR (all p > 0.10), white cell count (all p > 0.10) or postoperative C-reactive protein concentrations (all p > 0.10).

Conclusions

Impaired cortisol production was uncommon in patients with potentially curable colorectal cancer. The presence of a perioperative systemic inflammatory response was not significantly associated with impaired cortisol production.