Follow-up care of patients with breast cancer

In the US, over 200,000 new cases of invasive breast cancer are diagnosed each year, with an additional 60,000 cases of ductal carcinoma in situ. The majority of these women will never experience a recurrence of their disease, and most will survive more than 5 years. Follow-up care for these women is focused on addressing long-term complications of therapy, and early detection of new primary cancers and locoregional recurrences. There is no evidence that early detection of distant metastases will lead to an increase in survival, and currently routine imaging studies are not recommended. With the growing number of breast cancer survivors, further studies should be undertaken to study the cost-effectiveness of surveillance strategies.     

Follow-up abdominal CT is not necessary in low-grade splenic injury

Nonoperative management of splenic injury has become the standard of care in the hemodynamically stable patient. The time period of observation and the utility of follow-up scanning remain an area of debate. This study examined the utility of follow-up abdominal CT for detection of delayed vascular injury in patients with low-grade splenic injury. A retrospective review of all patients with low-grade splenic injuries undergoing nonoperative management from June 2000 to June 2004 was performed. Patients underwent follow-up abdominal CT 48 to 72 hours after admission to rule out delayed vascular injury and were discharged if the results were negative. Charts were reviewed for demographic data, abdominal CT results, and splenic salvage. A total of 472 patients underwent nonoperative management for splenic injury, with 140 patients treated with simple observation during this protocol. All patients were successfully managed with simple observation with no nonoperative failures; there were two instances of delayed vascular injury on follow-up CT. Both patients with progression of injury had decreasing hematocrit levels during admission prior to follow-up abdominal CT scan. Overall, the injury severity score was 22 points and the American Association for the Surgery of Trauma (AAST) splenic injury severity score was 1.8 points. Length of hospital stay was 2.8 days for patients with predominately splenic injury and 10 days for the overall cohort. Follow-up abdominal CT confers no benefit in patients with low-grade splenic injury, and a stable hematocrit level and abdominal exam.     

Triple assessment is not necessary in most young women referred with breast symptoms

IntroductionA palpable lesion in the breast is usually subjected to triple assessment (clinical examination [CE], imaging and core biopsy [CB] or fine needle aspiration [FNA]) to minimise the risk of missing breast cancer. However, breast cancer is rare in young women, and triple assessment (especially CB) is invasive and expensive. Our aim was to see whether CB/FNA could be avoided in young women with benign findings on CE and imaging.MethodsThis study analysed data from a prospectively entered database on female patients aged under 25 years who attended a rapid diagnosis breast clinic over a 68-month period.ResultsAmong 10,301 patients seen, 955 females (9.3%) were aged <25 years. The most common presenting complaint was a lump, followed by pain and nipple discharge. CE was normal or revealed benign findings in all except 15 patients, in whom it was indeterminate. Ultrasonography was performed in 692 patients (72%) and was normal (n=289) or benign (n=382) in all except 21 patients, in whom it was indeterminate. In six patients, both were indeterminate. A total of 317 patients (35%) had triple assessment: FNA in 106, CB in 239 and both in 9 cases. No cancers were diagnosed.ConclusionsIt would appear safe to omit FNA/CB in patients aged under 25 years when clinical and ultrasonography findings are normal or benign. This approach would have avoided needle biopsies in all but 30 patients (3%) in the study.     

Aspiration of breast cysts

One hundred and sixty nine women with 220 breast cysts were treated by needle aspiration between 1950 and 1980. Mean follow up was seven years. One hundred and twenty two (72%) patients were aged from 40 to 49 years. The majority (61%) of cysts occurred in the left breast. In 147 patients 174 (79%) of 220 cysts were aspirated once and did not recur at that site. One hundred and eleven (66%) patients presented with a single cyst and had no recurrence in either breast after aspiration. Two patients developed carcinoma of the opposite breast at 8 and 12 years after cyst aspiration. Needle aspiration of the breast is regarded as a safe, simple and economic diagnostic and therapeutic modality in women presenting with single breast lumps.     

Routine preoperative 123I-MIBG scintigraphy for patients with phaeochromocytoma is not necessary

BACKGROUND: Functional imaging using (123)I-meta-iodo-benzyl-guanetidine (MIBG) scintigraphy has alleged 100% specificity for phaeochromocytoma (PHAEO). Its benefit in patients with biochemical diagnosis of PHAEO is arguable when cross-sectional radiology can demonstrate the side-size of the adrenal tumours. MATERIALS AND METHODS: This is a retrospective review of clinical notes of patients undergoing adrenalectomy for PHAEO in a University centre. RESULTS: Between January 2000 and December 2007, adrenalectomy for PHAEO was performed on 66 patients (28 M and 38 F, aged 24-82 years). Diagnosis was demonstrated by raised 24-h urine catecholamines (n = 14) or metanephrines (n = 52). The side and size of adrenal tumours were demonstrated on computed tomography (n = 58) and/or magnetic resonance imaging (n = 20) scans. MIBG scans were performed in 38 patients. Four of these patients were found to have non-adrenal pathology (haemangioblastomas, haemangioma, a bronchogenic cyst and an angiomyolipoma); hence, the positive predictive value of MIBG scan was 90%. In a further five patients, MIBG raised the suspicion of local metastatic disease but this was not confirmed on operative findings and no recurrence was detected in these patients during 6-92-month follow-up. This led to an overall rate of false-positive rate of 23%. CONCLUSION: MIBG scintigraphy adds little to the routine preoperative management of patients with suspected PHAEO. Its use should be limited to the small minority of patients with negative cross-sectional imaging and those with recurrent or metastatic disease.     

Follow-up of patients with localized breast cancer and first indicators of advanced breast cancer recurrence: A retrospective study

We conducted a retrospective study to assess the follow-up of patients with localized breast cancer and the first indicators of advanced breast cancer recurrence.All patients with advanced breast cancer recurrence treated between January 2010 and June 2016 in our institution were registered. Among these patients, 303 patients initially treated for early breast cancer with curative intent were identified.After initial curative treatment, follow-up involved the oncologist, the general practitioner and the gynecologist in 68.0%, 48.9% and 19.1% of cases, respectively. The median DFI was 4 years for luminal A, 3.8 years for luminal B, 3.7 years for HER2-positive and 1.5 years for TNBC (p = 0.07). Breast cancer tumor marker was prescribed for 164 patients (54.1%). No difference in terms of follow-up was observed according to the molecular subtype. Symptoms were the primary indicator of relapse for 143 patients (47.2%). Breast cancer recurrence was discovered by CA 15.3 elevation in 57 patients (18.8%) and by CAE elevation in 3 patients (1%). The rate of relapse diagnosed by elevation of CA 15.3 or CAE was not statistically associated with the molecular subtype (p = 0.65). Luminal A cases showed a significantly higher rate of bone metastases (p = 0.0003). TNBC cases showed a significantly higher rate of local recurrence (p = 0.002) and a borderline statistical significant higher rate of lung/pleural metastases (p = 0.07).Follow-up recommendations could be adapted in clinical practice according to the molecular subtype. General practitioners should be more involved by the specialists in breast cancer follow-up.     

Association of breast cysts and breast cancer

A review of 915 consecutive patients with breast cancer and 812 with breast cysts showed that an association between the two is uncommon--5% of breast cancers were associated with cysts and 4% of cysts were associated with breast cancer. Four types of association were identified: (a) cystic cancers--easily diagnosed because of the characteristic features of the aspirate, failure of the mass to disappear and early recurrence in a patient whose age and menstrual status were not usually associated with cysts; (b) cancers occurring simultaneously with breast cysts--recognized because they did not contain cyst fluid; (c) cysts occurring after breast cancer--diagnosed by aspiration of the mass in premenopausal women; (d) cancers in patients who have had breast cysts--usually occurring many years after the cyst aspiration when menses had ceased. These associations were not sufficiently frequent to justify specific follow-up, but all suspected cysts should be successfully aspirated to confirm the clinical diagnosis.     

Follow-up of patients with contrast-induced nephropathy

In this chapter, we review the approach to following the patient after contrast is administered. We first discuss the clinical importance of renal injury for if there were no clinically significant consequences of this renal injury, we would have far less concern for the adequacy of follow-up. We next look at markers of renal injury and what tests are used in clinical practice to define contrast-induced nephropathy (CIN). Finally, we discuss the steps that should be taken in those who do develop CIN to limit the impact of the injury and protect them from future adverse events.     

Follow-up of patients with colorectal cancer

In our follow-up study of 65 patients after curative surgery for colorectal cancer, tests other than history and physical examination detected only two cases of potentially curable recurrent colorectal cancer. As a routine follow-up test, carcinoembryonic antigen determination is preferable to computerized tomographic scanning, since the sensitivity and specificity of carcinoembryonic antigen and computerized tomographic scanning were found to be equivalent and carcinoembryonic antigen is much less expensive. There was no benefit to the routine use of liver function tests or chest roentgenograms during follow-up. Since barium enema contributed little to what colonoscopy accomplished with greater comfort to the patient, barium enemas should be used only when colonoscopy is not totally successful in reaching the cecum. The most beneficial aspect of the follow-up of these patients is probably the elimination of future metachronous lesions by removal of small, benign polyps.     

Follow-up of adult patients with myelomeningocele

The adult outcome of spina bifida patients is fraught with multiple problems reflecting the multisystemic nature of the disease. These problems result in both mortality, actually caused in most cases by the shunt, and morbidity, mostly affecting locomotion and sphincter control. These patients can thus lose ambulation and suffer from worsening incontinence and kidney function. The result in the vast majority of cases is a poor functional and socioprofessional outcome. The patients’ demands regarding their occupational and affective lives, as well as procreation, must be heard. This requires a multidisciplinary approach, andpediatric and adult, as well as patient education and financial support for maintaining the patient's autonomy and medical acts allowing the viability of continued medical care.     

Follow-up study of patients with colostomies

A series of twenty patients who had had colostomies or ileostomies for over eighteen months because of disease of the large bowel were studied to assess their psychologic adjustment to the disability. Eleven were thought to show some maladjustment, which was regarded as at least partially disabling in six. These six patients were significantly more depressed than the remainder as measured on a semiobjective rating scale. Their symptoms mainly consisted of excessive attention to the stoma, protracted washing and cleanliness routines designed to remove any supposed odor, and a variably severe withdrawal from social activities to avoid giving offense by smelling. No consistent personality type was found to occur. It is concluded that the treatment of such psychologic symptoms might best be with tricyclic antidepressive drugs, and that the presence of such symptoms indicates that the surgical success of the operation is incomplete.     

Follow-up study of benign breast diseases

Follow-up study after surgery of the benign breast disease revealed that rates of the recurrence were 50%, 6%, 4%, 3.5% in those who had phyllodes tumor, duct ectasia, intraductal papillary lesion, and multiple fibroadenoma, respectively. Incidences of the subsequent breast cancer development were 14.3% after ADH, 11.7% after ALH, 1.5% after PDWA, respectively. However no difference was found statistically among those diseases(X2 = 2.89). The longest interval between time of the first surgery and time of detection of subsequently developing cancer was 68 months. Accordingly, checks at three times of postoperative third, fifth and eighth year were required for early detection of such subsequent breast cancer, using image diagnostic methods.     

Follow-up of patients with resected thoracic malignancies

The authors have systematically performed a literature search using 8 databases identifying established guidelines for follow-up after resected thoracic malignancies. Seven different societies' (found to have published recommendations for non-small cell lung cancer, esophageal cancer, thymoma, or mesothelioma) guidelines are reviewed in this article. High-quality evidence leading to consistent, strong recommendations among societies has not been found. With the subsequent advancements in surgical treatment and other curative modalities, the ability to detect and intervene with curative therapy at earlier stages of disease in a growing portion of the current patient population will benefit from higher-quality evidence.