Management of recurrent locoregional breast cancer: oncologist survey

Locoregional recurrence (LRR) after therapy for early breast cancer is common. A questionnaire was used to assess consensus between breast oncologists about the definition, prognosis and management of patients with LRR. The questionnaire was mailed to surgical, radiation and medical oncologists in Canada, the UK and the USA. Of 495 questionnaires, 322 (65%) were returned. Most clinicians sampled agree that disease in the skin of the chest wall, surgical scar, axilla, ipsilateral breast tumor recurrence (IBTR), infraclavicular lymph nodes, supraclavicular fossa lymph nodes and internal mammary lymph nodes constitute sites of LRR. The sites that were felt to be curable by the majority of respondents were: IBTR, surgical scar, axilla or chest wall. It was for these disease sites that local therapy was generally recommended. Irrespective of the site of recurrence, most respondents surveyed recommend initiation of a new systemic therapy at the time of LRR. While the results of this survey show general agreement regarding the definition of sites of LRR, treatment recommendations vary among oncologists. Due to the variation in sites of recurrence, time since initial diagnosis and prior therapy, the exact prognosis and optimal management of LRR remain undefined. In the absence of randomized prospective trial data, recommendations for local and systemic therapy of LRR will continue to mimic those offered at the time of initial presentation of breast cancer.     

Survival following locoregional recurrence after breast conservation therapy for cancer.

We postulated that locoregional recurrence after limited surgery and radiotherapy for breast cancer might be associated with an additional survival hazard, similar to that of a second primary tumor with the same extent of local and regional disease. Using this hypothesis we examined the likely resultant effect on survival. Our calculations indicated that no statistically significant survival deficit due to such recurrence would be detectable until a randomized controlled trial comparing breast conservation with mastectomy had monitored more than 10,000 patients for more than 10 years. A simple mathematical model predicted 5-year survival rates in a cohort of patients treated with breast conservation of 75%, compared to 83% in those without locoregional recurrence. From the date of locoregional recurrence, a 61% 5-year survival rate was predicted, compared to 83% if no hazard was associated with locoregional recurrence. These predictions were compared with the actuarial survival rates of 499 patients with unilateral breast cancer, 49 of whom had developed locoregional recurrence. From the date of initial treatment, the 5-year survival rate of those whose disease recurred was 79%, compared to 88% for those without locoregional recurrence (p = 0.19). The actuarial 5-year survival rate from the date of locoregional recurrence was 63%. The similarity between the patient data and the predictions of the mathematical model indicates that locoregional failure after breast conservation therapy may result in reduced survival. The lack of a significant survival deficit in our cohort or in controlled trials comparing breast conservation therapy with mastectomy is compatible to the small size of the overall effect.     

Survival after palliative surgery for advanced intraabdominal cancer.

The clinical course of 300 patients with known intraabdominal neoplasm requiring surgical exploration was analyzed. The most common primary tumor sites were the gastrointestinal tract (60 per cent), female reproductive organs (17 per cent), and urinary tract (6 per cent). Gastrointestinal and extrahepatic biliary obstruction, gastrointestinal bleeding, and peritonitis were the most common indications for surgery. The overall operative mortality was 26 per cent, and the mean survival time was 6.6 months. Small bowel fistulas, intraabdominal abscesses, and cardiopulmonary and renal failure were the leading causes of death. Palliative procedures in patients less than sixty years old with single site of obstruction or with tumor of gastrointestinal origin were associated with a low operative mortality and prolonged survival. On the other hand, surgical intervention in patients more than seventy years old undergoing chemotherapy, with multiple sites of obstruction, peritonitis, or primary tumor originating outside the gastrointestinal tract, was associated with high operative mortality and seldom benefited from palliative intervention. Surgical intervention to relieve a distressing symptom in a patient with advanced neoplasm is a well established procedure, but the risks and benefits of such intervention should be carefully weighed against the expected mortality and the quality of survival.     

Prognostic factors for survival after salvage surgery for locoregional recurrence of colon cancer

Background

Although locoregional recurrence after rectal cancer resection has been extensively investigated, studies of salvage surgery for locoregionally recurrent colon cancer are scarce. This study aimed to determine the predictors of postsalvage survival for locoregionally recurrent colon cancer.

Methods

We studied 45 consecutive patients who underwent macroscopically complete resection of locoregionally recurrent colon cancer between April 1988 and December 2007. The primary end point was cancer-specific survival, and 20 clinical variables were analyzed for their prognostic significance.

Results

Cancer-specific 5-year survival for the entire cohort of 45 patients was 46%. Multivariate survival analysis showed that margin status (P = .0311), number of locoregional recurrent tumors (P = .0002), pathological grade (P = .0416), largest tumor diameter (P = .0247), and distant metastasis (P = .0006) were independently associated with cancer-specific survival.

Conclusions

Salvage surgery for locoregional recurrence of colon cancer can provide a chance for long-term survival in selected patients.     

Primary lung cancer surgery after curative chemoradiotherapy for esophageal cancer patients

The safety and perioperative problems of primary lung cancer surgery after curative chemoradiotherapy (CRT) for thoracic esophageal cancer (EC) are controversial. We retrospectively evaluated six patients who had received curative CRT for EC from 2003 to 2009, in whom the lung nodule was identified as a primary lung cancer and who subsequently underwent pulmonary resection. The treatment for EC consisted of chemotherapy with cisplatin and 5-fluorouracil with concurrent curative thoracic radiotherapy (60 Gy). The median age at the surgery was 75 years (range 69-80 years). The median time from radiation to pulmonary resection was 26 months (range 7-70 months). All patients had a predicted postoperative forced expiratory volume in 1 s (FEV(1))% of >40% before lung surgery. The surgical difficulty involves mediastinal lymph node dissection following tissue fibrotic changes after thoracic radiation. Postoperative complications occurred in two patients, and included arrhythmia and empyema. The patient who developed empyema had a massive pericardial effusion after CRT and underwent pericardial fenestration at the time of pulmonary resection. There was no operative mortality. Lung cancer surgery after curative CRT for EC is feasible in carefully evaluated and selected patients.     

Correlation between plasma or blood transfusion and survival after curative surgery for colorectal cancer.

Out of 473 patients operated radically for colon or rectal cancer different survival curves have been calculated according to whether they had received or not blood or plasma transfusions during their hospital stay. The non-transfused patients have a better 5-year survival rate and the difference is statistically significant both including and not including Duke's C stage cases. Anemia on hospital admission, on the contrary, does not seem to influence patients survival. Immune depression after blood or plasma transfusion is a very well known phenomenon in transplant surgery and actually depends on the infusion of leucocytes. Is not yet clearly demonstrated that in cancer surgery immune depression may lead to a poorer survival of transfused patients but several papers, including ours, suggest that this effect is very likely. At present in cancer patients it is preferable to limit transfusions to the minimum. If they are absolutely necessary leucocyte poor or, better still, leucocyte free preparations should be administered.     

Laparoscopic palliative gastrojejunostomy for advanced recurrent gastric cancer after Billroth I resection

Palliative surgery for advanced gastric cancer has equivocal results. Laparoscopy is likely to provide some advantage compared to open procedures. We present a case of laparoscopic gastrojejunostomy for advanced gastric cancer, which recurred after Billroth I resection. Reproducing the results of the early experiences so far reported in the literature, laparoscopy provided us with the accurate staging of the disease along with the opportunity, at the same time, to perform a palliative procedure, avoiding laparotomy. Operative results were good, vomiting was relieved, and the patient was able to cope with his disease until death eventually occurred after 6 months.     

Colon cancer: survival after curative surgery

Several new aspects have evolved during the past years concerning factors that influence survival in surgically and medically treated colon cancer patients that are relevant to the treating team for the treatment strategy and patients choice. The 5-year-survival rates dependent on UICC stages/substages (I: 68%–100%, II: 58%–90%, III: 33%–76%, IV: <5%–9%) show remarkable variations between published reports, surgical hospital units, individual surgeons, and continents (USA vs Europe). Those variations may be due to surgical techniques, training status, hospital and individual case volume, and, also, referral patterns and statistical evaluation methods. Survival times and cure rates are significantly improved by adjuvant chemotherapy in UICC III and in substages of UICC II (e.g. UICC II B) by 5%–12%, when compared with surgical controls. In three recently published trials standard adjuvant chemotherapy was further improved by increased survival rates, e.g. from 59% to 71% in stage III and IIB patients. Molecular and genetic factors, such as thymidylate synthase (TS), microsatellite instability (MSI) or loss of chromosome 18q/DCC might have an independent impact on prognosis in the spontaneous course, and TS could help to better select patients for adjuvant chemotherapy.     

Clinico-pathological study on recurrent gastric cancer after curative resection

Among 675 patients who had undergone curative resection of gastric cancer during last 13 years, 113 died of cancer recurrence. One hundred and forty-five patients who had survived longer than 5 years were used as controls. In the recurrence group, the primary lesion was larger and the lymph node metastasis more common as compared with the surviving controls. Moreover, these lesions were often located at the upper third of the stomach and exhibited Borrmann 3 or 4 type. Prognostic serosal invasion was positive in 75 per cent of the recurrence group and negative in 84 per cent of the surviving controls. The most frequent mode of recurrence was hematogenous metastasis in negative prognostic serosal invasion (54%) and peritoneal disseminated metastasis in positive prognostic serosal invasion (52%). There were no differences in the distribution of gross and histological types of cancer in the modes of recurrence. It was found that peritoneal dissemination and/or local recurrence dominated as the mode of recurrence (51%), followed by hematogenous metastasis (34%), but that lymph node recurrence was uncommon (15%). In peritoneal disseminated cases, long-term survival following reoperation should not be expected. It was suggested that in order to improve the prognosis in the case of hematogenous metastasis, postoperative immunochemotherapy should be applied.     

Prediction of distant metastases after curative surgery for rectal cancer

BACKGROUND: This study was performed to define selection criteria for adjuvant therapy in rectal cancer. MATERIALS AND METHODS: An immunohistochemical analysis using nine monoclonal antibodies against CEA, CD15s, CD44v6, DCC, E-cadherin, EGF-R, NM23, PAI-1, and P53 was performed on paraffin sections of two matched (age, gender, UICC stage [I-III], year of operation [1982-1991]) groups of patients (n = 2 x 64) with rectal carcinoma curatively treated by surgery alone. The two groups differed only with regard to metachronous distant metastatic spread. In order to exclude the influence of surgery, all patients had to meet the selection criterion "free of locoregional disease." Follow-up was prospective (median 80 months). Conventional staining procedures and immunohistochemical evaluation were used. Tumor grading and lymphatic and extramural venous invasion were also investigated. Analysis was performed with Fisher's exact test and Kaplan-Meier estimates of disease-free survival (log rank). The Cox model was used for multivariate analysis. RESULTS: In univariate analysis only grading (P < 0.001) and extramural venous invasion (P < 0.001) correlated significantly with metachronous metastases. In multivariate analysis, beside grading (P = 0.010) and extramural venous invasion (P = 0.011), CD15s (P = 0.042) was also of significance. All other immunohistochemical markers failed. CONCLUSIONS: The histopathological parameters grading and extramural venous invasion appear to be acceptable predictors of metachronous distant spread in curatively resected rectal cancer. In contrast to the immunohistochemical markers, grading seems to better reflect the individual tumor phenotype and its behavior.     

Locally recurrent breast cancer after conservation therapy

BACKGROUND: Today, the majority of small invasive and noninvasive breast cancers are treated with breast conservation therapy (BCT). The incidence of local-regional recurrence (LRR) after BCT for stage 0, I, and II patients ranges between 5% and 22%. METHODS: A literature search for BCT, local recurrence, and regional recurrence was performed. Data from over 50 articles pertaining to the characteristics, risk factors, detection, management, and prognosis of these patients with LRR after BCT were collected and analyzed. RESULTS: Positive margins, high-grade ductal carcinoma in situ (DCIS), young age, and the absence of radiation therapy after BCT increase the risk for LRR. Prognosis at LRR is impacted by invasive versus noninvasive histology, size and stage, method of detection, and involvement of skin and/or axillary lymph nodes. The standard treatment is salvage mastectomy. CONCLUSIONS: The prognosis for LRR after BCT is favorable compared with patients with postmastectomy chest wall recurrence.     

Long-term results of palliative stenting or surgery for incurable obstructing colon cancer

Objective  Self-expanding metal stents are an effective means of relieving left-sided malignant colonic obstruction, and in the setting of incurable disease may provide palliation while allowing the patients to avoid surgery altogether. With modern chemotherapy regimes, patients may have a long-life expectancy, even in the presence of metastases. The purpose of this study was to investigate the long-term results of palliative stent placement, compared with patients undergoing palliative surgery.
Method  This is a retrospective study of 55 consecutive patients who underwent colonic stenting or palliative surgery for incurable, obstructing adenocarcinoma of the left colon.
Results  Twenty-nine patients underwent colonic stenting, and 26 had surgery during the study period. Survival was similar in the two groups (14 months in the stent group, 11 months in the surgery group). Median hospital stay was shorter in the stent group (4 vs 13.5 days), and fewer patients in the stent group had complications (2 vs 14). Only four patients in the stent group went on to require later surgery. The median time to failure of the stents was 14 months.
Conclusion  Colonic stenting provides effective and durable palliation for patients with incurable, obstructing adenocarcinomas of the left colon. It can be performed with less morbidity than palliative surgery, and offers similar long-term survival.     

Outcomes of outpatient breast cancer surgery at a private breast clinic

Advances in surgical and anesthetic techniques have allowed for outpatient treatment of breast cancer. We evaluated the feasibility, safety, efficacy, and surgical outcomes of outpatient surgery in 370 patients with breast cancer who underwent breast‐conserving surgery (BCS)/axillar lymph node (ALN) management. There were no deaths or severe intraoperative complications, but 41 complications were observed and disease recurrence occurred in 18 patients. The cumulative overall survival rate was 95.2%. Outpatient surgery was well tolerated, feasible, and safe in patients receiving BCS/ALN management.