Are we jumping the gun with pharmaconutrition (immunonutrition) in gastrointestinal onoclogical surgery?

Over the last 20 years there has been considerable research into the use of immunonutrition,also referred to as pharmaconutrition,in the management of patients undergoing and recovering from elective gastrointestinal surgery for malignancy.In this group of patients,the use of pharmaconutrition seems to confer superior outcomes to standard nutrition formulations with regards to postoperative infective complications and length of hospital stay.It is therefore frequently recommended for use in elective gastrointestinal oncological surgical populations.However,it remains unclear whether the data supporting these recommendation is robust.Studies reporting improved outcomes with pharmaconutrition frequently compare this intervention with non-equivalent control groups,do not report on the actual nutritional provision received by study participants,overlook the potential impact of industry funding on the conduct of research and do not adopt amulti-disciplinary approach to the research undertaken.For these reasons,an urgent critical re-appraisal of the use and recommendations of pharmaconutrition in this group of patients is warranted to resolve some of the above mentioned issues.     

Can we predict local recurrence in breast conserving surgery after neoadjuvant chemotherapy?

Background

One of the benefits of neoadjuvant chemotherapy (NAC) is its ability to convert patients ineligible for breast conservative treatment (BCT) to be candidates for this treatment, although questions have been raised regarding the effectiveness of BCT in terms of loco-regional recurrence (LRR). The objective of this study is to evaluate LRR in this group and the influence of tumor characteristics in recurrence.

Material and Methods

Between 1996 and 2007, 137 patients were treated with BCT after NAC at our Service. After completion of NAC a multidisciplinary team evaluated the cases eligible for BCT. All patients treated with BCT had negative margins and received radiation therapy. Risk factors associated with local recurrence were analyzed using Kaplan–Meier survival curves and long-rang test.

Results

Information was obtained in 121 patients. Median age was 54 years old (SD: 12 years). At a median follow-up of 35 months (range, 18–87 months), 6 (4.95%) patients developed an LRR, with an accumulative incidence at 5 years of 7.3% (95% CI: 0.4–14.1%) and at 10 years of 11.5% (95% CI: 2.8–20.1%). Overall survival at 5 and 10 years was 94.8% (95% CI: 90.9–98.6%) and 82.3% (95% CI: 67.3–97.2%) respectively. Tumor size (T3) (p < 0.001) and pathological stage (Stage III) (p = 0.001) after surgery were strongly associated with LRR.

Conclusions

The results of this study confirm that BCT is an effective treatment in patients with NAC. Tumor size and pathological stage after systemic treatment influence loco-regional recurrence in patients with BCT.     

Are cellular polarisation and mitotic frequency prognostic factors for local recurrence in patients with ductal carcinoma in situ of the breast?

There is still no generally accepted histopathological classification system for ductal carcinoma in situ (DCIS) of the breast. Nuclear grade, with or without other histopathological parameters (i.e. comedo-type necrosis and cellular polarisation), has been demonstrated to yield prognostic information. A detailed method for the evaluation of the mitotic frequency in DCIS, based on an approach by Contesso, was used in this study. We also investigated if cellular polarisation and mitotic frequency were important for the ipsilateral local recurrence-free interval (IL-RFI) in 121 DCIS patients who had been operated upon with breast-conserving treatment (BCT) without radiotherapy. Both cellular polarisation and the mitotic frequency were associated with histopathological and cellular biological factors (in previous evaluations), and were of borderline significance for IL-RFI in the univariate analyses. However, when nuclear grade was included in the multivariate analyses (with or without the growth pattern), neither cellular polarisation nor the mitotic frequency were of any independent prognostic value.     

Will we be able to care for cancer patients in the future?

The number of cancer patients and cancer survivors continues to increase rapidly amid predictions of a shortfall in physicians to care for them. In addition, newer cancer therapies have become increasingly complex and resource-intensive, compounding the impending workforce shortage. Simultaneously, the growing understanding of the biologic heterogeneity of cancer and the development of pharmacogenomics have opened up the possibility of personalized approaches to cancer diagnosis and treatment. Such personalization has been promulgated as a means of decreasing the cost of drug development, improving the efficacy of treatments, and reducing treatment toxicity. Although there have been notable successes, the fulfillment of these promises has been inconsistent. Providing care for future cancer patients will require the development of innovative delivery models. Moreover, new approaches to clinical research design, to the assessment of therapeutic value, and to the approval of and reimbursement for diagnostics and treatments are needed.