The Role of Radiotherapy for Patients with Ductal Carcinoma In Situ

Abstract: Some patients with ductal carcinoma in situ (those with small low-to moderate-grade tumors excised with wide margins) appear to be good candidates for treatment with surgery alone. There is no agreement on the exact features defining this subgroup, however. Radiotherapy will reduce the risk of recurrence further even in this subgroup. Other patients with uninvolved microscopic resection margins have a low risk of failure when treated with surgery and radiotherapy. Patients with involved margins may be at increased risk of recurrence even after irradiation, although data on this point are contradictory. Since salvage therapy for patients with local failure after initial breast conserving therapy is not perfect at preventing subsequent local-regional or distant recurrences, such patients might be more appropriately treated with mastectomy. The ultimate risk of dying of breast cancer is small for patients with DCIS, regardless of the initial treatment approach. Each patient's preferences must be accorded great weight in making treatment decisions. It is the duty of her physicians to inform her of the potential risks and benefits of all treatment options.     

Twenty-Year Outcomes after Breast-Conserving Surgery and Definitive Radiotherapy for Mammographically Detected Ductal Carcinoma In Situ

Background

Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT).

Methods

Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86?% of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4?Gy to the lumpectomy cavity.

Results

A total of 129 cases were evaluated; the median follow-up was 19.3?years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2?% of which were invasive (n?=?16). Fourteen recurrences (66?%) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women <45?years of age (20?%/24?% vs. 5.1?%/8?%) at 10 and 20?years (p?=?0.02). The 5-, 10-, 15-, and 20-year actuarial rates of IBTR for this cohort were 8.7, 10.4, 12.1, and 16.3?% (IBTR), while overall survival at 5, 10, and 20 years was 97.6, 96.8, and 96.8?%, respectively.

Conclusions

Mammographically detected DCIS remains a clinically distinct subset of noninvasive breast cancer. With 20?year follow-up, local control and overall survival are excellent after BCT.     

乳腺导管原位癌的治疗现状与进展

目的总结乳腺导管原位癌的治疗现状与进展。方法查阅近年来关于乳腺导管原位癌治疗现状与进展的文献资料,并作综述。结果随着乳腺导管原位癌发病率的增加,其治疗方法也在不断演变。外科治疗包括全乳切除术和保乳术（BCS）。保乳术联合放疗被认为是标准的减少局部肿瘤复发的方法。内分泌治疗也在临床上得到了重视及应用。结论保乳术与综合治疗已成为乳腺导管原位癌治疗的主要方法,需要通过进一步的研究来确定何种乳腺导管原位癌亚组只需行BCS术而不需要其他的辅助治疗。微创治疗将是乳腺导管原位癌治疗的一个发展方向。     

The Results of Conservative Surgery and Radiation for Mammographically Detected Ductal Carcinoma In Situ

Abstract: Approximately 85% of all ductal carcinoma in situ (DCIS) are now detected by mammographic screening. For the most part, the literature that reported the results of conservative surgery and radiation for DCIS reflected outcomes in a heterogeneous patient population that frequently included patients with clinically evident DCIS (palpable mass or bloody nipple discharge). There are limited data regarding outcome in patients with mammographically detected DCIS treated with conservative surgery and radiation. The 10-year breast recurrence rate ranges from 4% to 7% for patients with negative margins of resection with a 10-year cause-specific survival of 96–100%. Factors that have been associated with an increased risk of breast recurrence include the failure to remove all malignant appearing calcifications prior to radiation and positive margins of resection. The influence of young age and positive family history on breast recurrence rates requires further study. To date there has been little correlation with the pathologic features of DCIS (architectural pattern, necrosis, nuclear grade) and breast recurrence rates in patients receiving radiation. Comedo or high nuclear grade DCIS tends to recur at a shorter median interval than noncomedo or low nuclear grade DCIS. Approximately 50% of the recurrences are invasive and salvage mastectomy has resulted in long-term control in 100% of the noninvasive recurrences and approximately 80% of the invasive recurrences.     

Breast-Conserving Therapy for Ductal Carcinoma in Situ: The Van Nuys Experience with Excision Plus Radiation Therapy

Abstract: The incidence of ductal carcinoma in situ (DCIS) of the breast has increased significantly in the last 15 years paralleling increases in the use of screening mammography. During that time, breast-conserving therapy for DCIS has become an established treatment option for patients with DCIS. 185 patients with pure DCIS treated with excision and radiation therapy were studied. The risk of local recurrence increased as nuclear grade or the diameter of the primary tumor increased. It decreased as margin width increased. Tumors containing predominantly comedo histology had an increased local recurrence rate when compared with noncomedo lesions. There was no difference in local recurrence rates for patients treated 4 or 5 days per week. The median time to local recurrence was 53 months. At 12 years, the actuarial local recurrence rate was 24% for all patients. The breast-cancer specific mortality over the same 12 year period was 3%. The increasing incidence of DCIS necessitates that current treatment options undergo continuous re-evaluation. Although it is likely that selected subsets of low-risk patients can be adequately treated with excision and observation, it is equally likely that patients at high risk for local recurrence will require radiation therapy as part of their management if breast preservation is chosen. Our data suggests that histologic factors such as large tumor size, narrow margin width, high nuclear grade, and comedo architecture may aid in selecting which patients require the addition of radiation therapy to their treatment regimen and which patients do not if breast preservation is chosen.     

The Use of Oncoplastic Reduction Techniques to Reconstruct Partial Mastectomy Defects in Women with Ductal Carcinoma In Situ

Abstract: The application of oncoplastic techniques to breast conservation therapy (BCT) is thought to improve cosmetic results with some documented oncologic advantages in certain patients. Although present data highlight the oncologic safety of this approach, the role of oncoplastic surgery specific to ductal carcinoma in situ (DCIS) has not been elucidated. In this study, all women in the Emory Healthcare system between January 1991 and June 2006 with biopsy‐proven DCIS who underwent lumpectomies combined with simultaneous reduction mammaplasties or mastopexies were identified. Medical records, including office notes, operative and pathology reports were analyzed. Parameters included age, BMI, histologic grade (low, intermediate, high) and type (comedo versus non‐comedo) of DCIS, margin status, locoregional recurrence, specimen weight, postoperative complications, and overall outcomes. Pedicle design and contralateral breast pathology were also analyzed. Twenty‐eight women were included in the study with an average age of 47. Therapeutic mammaplasty was the definitive procedure for 18 (64%) of these patients. Ten patients (36%) required reoperations: nine for positive margins and one for residual microcalcifications (stereo biopsy DCIS). Overall, seven patients (25%) required completion mastectomy with reconstruction (transverse rectus abdominus myocutaneous flap: n = 3, latissimus flap: n = 4), whereas three patients (11%) underwent re‐excisions with confirmation of negative margins. All ten women who required completion mastectomy or re‐excisions exhibited either intermediate or high‐grade, comedo DCIS. Overall, 50% (6/12) of women diagnosed with high‐grade comedo DCIS required completion mastectomy with reconstruction after initial therapeutic mammaplasty. The final positive‐margin rate for women diagnosed with intermediate‐grade, comedo necrosis was 43% (3/7). The women in this failed group that required reoperations were overall younger (mean: 45.6; median: 43) than those in which oncoplastic surgery was the definitive procedure (mean: 57.8; median: 57). There were no significant differences between the failed and successful groups in terms of biopsy weight (failed: 253 g, successful: 237 g), type of excision (e.g., wire‐localized), location of tumor, reduction type (e.g., superior medial), or postoperative complications. There was one case of locoregional recurrence of DCIS 7 months after the initial operation. All 28 patients had no evidence of disease at an average follow‐up of 2.7 years. This study suggests that although oncoplastic reduction techniques are a reasonable approach for women with DCIS, stricter patient selection and improved confirmation of negative margins will minimize the need for either re‐excisions or completion mastectomy and reconstruction.     

Using Patient Demographics and Statistical Modeling to Predict Knee Tibia Component Sizing in Total Knee Arthroplasty

Background

Preoperative planning is important to achieve successful implantation in primary total knee arthroplasty (TKA). However, traditional TKA templating techniques are not accurate enough to predict the component size to a very close range.

Radiographic and Histologic Response to Neoadjuvant Radiotherapy in Patients With Soft Tissue Sarcoma

Background  

Limited data exist regarding the radiographic and histologic response of soft tissue sarcoma (STS) to neoadjuvant radiotherapy (RT).     

Gender-Related Differences in Repopulation and Early Tumor Response to Preoperative Radiotherapy in Rectal Cancer Patients

Purpose  

Inhibition of tumor proliferation rate based on bromodeoxyuridine labelling index (BrdUrdLI), S-phase fraction (SPF) and MIB-1 labelling index (MIB-1 LI) as an early rectal cancer response to preoperative radiotherapy (RT).     

Use of the Twelve-Gene Recurrence Score for Ductal Carcinoma in Situ and Its Influence on Receipt of Adjuvant Radiation and Hormonal Therapy

Annals of Surgical Oncology - Tumor genomic prognostic assays estimate 10-year local recurrence risk in ductal carcinoma in situ (DCIS) and can guide treatment decisions. This study aimed to...     

Allograft Necrosis in Liver Biopsy Is Predictive for Organ Outcome and Patient Survival

AimTo evaluate if any association existed between the extent of allograft necrosis in liver biopsy and patient survival.MethodsSixty-nine patients who had 70 liver transplantations with allograft necrosis were included in the study. Correlations of necrosis, the Model for End-Stage Liver Disease (MELD) score, and allograft survival were analyzed.ResultsAllograft failure rate within 1 month after index biopsy was worse in patients with a higher extent of necrosis (2.5%, 12.5%, 25%, and 40% in groups with allograft necrosis of 1-25%, 26-50%, 51-75%, and >75%, respectively). Adequate biopsy with more than 50% necrosis is associated with significant allograft failure (P < .001). The MELD scores did not always accurately predict fatality that was caused by massive necrosis. In the absence of substantial clinical changes, repetition of allograft biopsy within a short period of time did not provide additional value. Among patients with more than 75% allograft necrosis, one who received an immediate second transplantation survived and 3 out of 9 patients who had not received those deceased within 1 month.ConclusionsAllograft necrosis demonstrates strong predictive power in organ and patient survival. Additionally, biopsy-proven allograft necrosis unequivocally pinpoints ischemia as the direct cause of allograft failure, which facilitates clinical management. Immediate retransplantation is crucial for patients with substantial allograft necrosis.     

APACHE III Score Is Superior to King's College Hospital Criteria,MELD score and APACHE II Score to Predict Outcomes After Liver Transplantation for Acute Liver Failure

Objectives

The Model for End–Stage Liver Disease score and king's College Hospital (KCH) criteria are accepted prognostic models acute liver failure (ALF), while the use of (APACHE) scores predict to outcomes of emergency liver transplantation is rare.

Materials and Methods

The present study included 87 patients with ALF who underwent liver transplantation. We calculated (KCH) criteria, as well as MELD, APACHE II, and APACHE III scores at the listing date for comparison with 3-month outcomes.

Results

According to the Youden-Index, the best cut-off value for the APACHE II score was 8.5 with 100% sensitivity, 49% specificity, 24% positive predictive value (PPV), and 100% negative predictive value (NPV). Patients with <8.5 points had a significantly higher survival rate (P < .05). The proposed APACHE III cut-off was 80. The APACHE III score demonstrated the highest specificity and PPV (90% specificity, 50% PPV). The NPV was 92%. With a 90-point threshold the specificity increased to 98% with 75% PPV and 89% NPV. Only 1 of 4 patients with a score >90 survived transplantation (P = .001). MELD score and KCH criteria were not significant (P > .05). According to the Hosmer-Lemeshow test, only the APACHE III score adequately describe the data.

Conclusions

The APACHE III score was superior to KCH criteria, MELD score, and APACHE II score to predict outcomes after transplantation for ALF. It is a valuable parameter for pretransplantation patient selection.     

The Response to Repeated Nitric Oxide Inhalation Is Inconsistent in Patients with Acute Respiratory Distress Syndrome

Background: Nitric oxide (NO) is administered frequently in patients with acute respiratory distress syndrome (ARDS) and pulmonary hypertension. The efficacy of this therapy over several days is not well known. The authors first determined the consistency of the response to repeated administration of NO and then the baseline variables that were associated with improvement in patients with severe ARDS.

Methods: In a prospective trial, 32 mechanically ventilated patients with severe ARDS received 10 parts per million NO by inhalation. In 22 of these patients, its effect was tested repeatedly (up to four times) in several days. Improvement was defined as an increase > 10% in the ratio of pressure of oxygen in arterial blood (PaO sub 2) to the inspiratory pressure of oxygen (FIO2) from baseline. Patients showing such an improvement were maintained on NO inhalation.

Results: Twelve of the 22 patients (54%) showed a clinically significant and reproducible increase in the PaO2 /FIO2 ratio with NO, from 74 +/- 30 mmHg (mean +/- SD) to 95 +/- 41 mmHg (P <0.001). In three patients (14%), PaO2 did not improve, even with multiple exposures. In seven patients (32%), an inconsistent response was seen on different days. Mean pulmonary artery pressure decreased for the entire group from 34 +/- 10 mmHg to 29 +/- 9 mmHg (P < 0.01), but this decrease did not correlate with the increase in PaO2 in individual patients. The baseline PaO2 /FIO2 ratio and mixed venous oxygenation (PvO2) were significantly lower, and the venous admixture was greater in patients showing beneficial effects of NO inhalation on PaO2.