Patterns of lymph node spread and its influence on outcome in resectable parotid cancer

Aim

To assess the metastatic topography of intraparotideal and neck lymph nodes in parotid cancer and its influence on tumour recurrence and survival.

Methods

The lymph node spread of 142 patients with primary parotid carcinoma treated from 1986 to 2006 was analysed. Disease-free survival (DFS) and overall survival (OS) were calculated. The role of the metastatic pattern as prognostic factors were univariately and multivariately analysed.

Results

A lateral, total or radical parotidectomy was performed in 19, 80 and 43 patients, respectively. A radical/radical-modified or selective neck dissection was performed in 68 and 74 patients, respectively. Eighty-seven neck dissection specimens were negative (pN0). Twelve patients had intraparotideal and cervical lymph node involvement (pPar+/pN+). In 24 patients only intraparotideal metastases were detected (pPar+/pN0). 19 patients only had cervical nodal involvement (pPar−/pN+). Twenty-five patients had occult locoregional lymph metastases (cN0/pN+). The median follow-up was 24.4 months. The disease-free survival rate was 81% at 5 years, and 62% at 10 years. By univariate analysis, R+ (p = 0.001), pT (p = 0.019), lymphangiosis carcinomatosa (p = 0.019), pN+ (p = 0.042), and extracapsular spread (p = 0.046) were prognostic for disease-free survival. Multivariate analysis revealed R+ as independent risk factor (p = 0.046). In pN+ patients, involvement of parotid lymph nodes (p = 0.013), nodes in neck level I (p < 0.0001) and IV (p = 0.005) were univariate risk factors. Multivariate analysis showed lymph node metastases in level I as independent risk factor (p = 0.022).

Conclusion

Total parotidectomy and radical-modified neck dissection is recommended as surgical treatment of parotid cancer and should be analysed in a prospective trial.     

Utility of FDG PET in patients with squamous cell carcinomas of the oral cavity

Background

The utility of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in oral cavity cancer has received little attention in a clinician's perspective. We systematically evaluated the clinical roles of FDG PET in patients with oral cavity squamous cell carcinomas (SCCs).

Methods

Between August 2001 and February 2005, 82 new patients with resectable oral cavity SCCs underwent CT/MRI and FDG PET at initial staging and follow-up. The sensitivity and specificity of CT/MRI and FDG PET for neck metastases were compared with histopathologic reference of 67 patients who underwent neck dissection. The relationships between the maximal standardized uptake value (SUV) of primary tumors and clinicopathologic parameters, such as gender, age, tumor thickness, local invasiveness, T and N categories, tumor-node-metastasis stage, and histological grade, as well as with disease-free survival (DFS), were assessed.

Results

FDG PET was more sensitive than CT/MRI for detecting cervical metastases on a level-by-level basis (38/43 vs. 28/43; P = 0.002). Age, T and N categories, tumor thickness (>8 mm) and SUV (>5.0) were also significant variables of 3-year DFS in univariate analysis. T category was an independent determinant of DFS in multivariate analysis (P < 0.05). During a mean follow-up of 36 months, FDG PET correctly diagnosed locoregional recurrences in 20 patients, distant metastases in six and second cancers in five.

Conclusion

FDG PET may have potential roles in initial staging, survival prediction, and the detection of recurrences and second cancers.     

Management of the clinically negative neck (N0) of supraglottic laryngeal carcinoma: A systematic review

Aim

The most effective therapeutic approach for patients with supraglottic laryngeal carcinoma (SGLC) and clinically negative neck (cN0) remains a subject of much debate. The purpose of this systematic review was to answer the following question: among patients with SGLC and cN0 neck, are the survival and occurrence of neck metastases significantly different between patients that received neck dissection and those that had another therapeutic treatment (radiotherapy, combined therapy, ‘wait and see’ policy)?

Materials and methods

An electronic literature search was performed in MEDLINE, EMBASE, Cochrane Library and CENTRAL databases, followed by extensive hand-searching for the identification of relevant studies.The following inclusion criteria were established: the study should (a) include a comparison of neck dissection with one of the other therapeutic procedures for cN0 of SGLC; (b) report the therapy for the initial supraglottic cancer; and (c) use time-to-event analysis of its results.Six studies were eventually identified and systematically reviewed.

Results

All studies included in the systematic review were retrospective (n = 792 patients). The survival (overall, disease-specific and neck disease-free) and the site of neck recurrence of the patients with N0 supraglottic cancer were not significantly different between patients in the neck dissection treatment group and those of the rest of the therapeutic strategies examined (neck radiotherapy, combined therapy and ‘wait and see’ policy).

Conclusions

The present systematic review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of cN0 of SGLC. Currently, based on the best available evidence, it seems that neck dissection is not superior to radiotherapy or combined therapy or a ‘wait and see’ policy in terms of survival and control of neck disease.     

Comparison of hepatic recurrences after resection or intraoperative radiofrequency ablation indicated by size and topographical characteristics of the metastases

Aims

Intraoperative use of radiofrequency ablation (IRFA) to treat liver metastases is controversial. The aim of this study was to compare local recurrence rate and survival after IRFA versus resection.

Methods

Three groups from 99 patients were consecutively operated on for 307 liver metastases with 2 years of follow up: group 1, IRFA alone (n = 34); group 2, IRFA plus resection (n = 28); group 3, resection alone (n = 37). The choice of IRFA or resection was made on the basis of the sizes and topographies of the metastases with the goal of achieving R0 treatment.

Results

Mortality was zero; morbidity was 9%, 11% and 11% in the three groups respectively. Median follow-up after surgery was 30 months. Total hepatic recurrences occurred in 59 (60%) patients. Median survival without hepatic recurrence was 17 months with no difference between the three groups (P = 0.474). Total local recurrence occurred in 4 (12%) patients in group 1, in 2 (8%) patients in group 2, and in 2 (6%) patients in group 3. Survival at 2 years was no different in the three groups.

Conclusion

Assessing IRFA indications by size and the topographical characteristics of the liver metastases yields identical local recurrence rates to resection after 2 years of follow up.     

Low rates of loco-regional recurrence following extended lymph node dissection for gastric cancer

Aim

The study by MacDonald et al. [Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725–30] has reported low loco-regional recurrence rates (19%) after gastric cancer resection and adjuvant radiotherapy. However, the lymph node dissection was often “inadequate”. The aim of this retrospective study is to analyse if an extended lymph node dissection (D2) without adjuvant radiotherapy may achieve comparable loco-regional recurrence rates.

Methods

A prospective database of 200 patients who underwent a curative resection for gastric carcinoma from January 2000 to December 2006 was analysed. D2 lymph node dissection was standard. Recurrences were categorized as loco-regional, peritoneal, or distant. No patients received neoadjuvant or adjuvant radiotherapy.

Results

The in-hospital mortality rate was 1% (2 patients). The mean number of dissected lymph nodes was 25.9. Overall and disease-free survival at 5 years were 60.7% and 61.2% respectively. During the follow-up, 60 patients (30%) have recurred at 76 sites: 38 (50%) distant metastases, 25 (32.9%) peritoneal metastases, and 13 (17.1%) loco-regional recurrences. The loco-regional recurrence was isolated in 6 patients and associated with peritoneal or distant metastases in 7 patients. The mean time to the first recurrence was 18.9 (95% confidence interval: 15.0–21.9) months.

Conclusions

Extended lymph node dissection is safe and warrants low loco-regional recurrence rates.     

Biological characteristics and behaviour of putatively curatively resected colorectal liver metastases

Aim

To identify whether positive resection margin tumours had a more aggressive phenotype, using tumour micro-vessel density and invasive margin.

Methods

Archival tissue was retrieved from 109 patients who had undergone resection for colorectal liver metastases. The nature of the invasive margin was determined by H&E histochemistry. MVD was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome were retrieved and collated with invasive margin and MVD data in a statistical database.

Results

41/68 patients with a positive resection margin (R1) had recurrences following liver resection, while only 16/41 patients with a clear margin (R0) developed recurrences. More of the margin clear patients also developed capsulated liver metastases (56%), compared to positive resection margin patients (22%) (Chi squared test p < 0.001). The stromal margin MVD in the R0 patients was 250 (11–609), compared to the R1 value of 122 (27–428) (Mann–Whitney U test p = 0.01).

Discussion

Positive resection margin, amongst other factors, is a predictor of poor prognosis. This appears to be in part explained by the expression of adverse tumour characteristics.     

The role of F-FDG PET/CT in detecting metastatic deposits of recurrent medullary thyroid carcinoma: A prospective study

Aim

To assess the diagnostic role of ¹⁸F-FDG PET/CT performed with a hybrid tomograph in the detection of tumoral deposits of recurrent medullary thyroid carcinoma (MTC).

Methods

Nineteen MTC patients with elevated serum calcitonin levels (58–1350 pg/ml) after first treatment were enrolled (11 F, 8 M, mean age 53.4 years, 14 sporadic MTC, 5 MEN-related MTC). All patients had previously undergone total thyroidectomy and lymphoadenectomy. When referred to us, they were studied with ultrasound (US), ¹⁸F-FDG PET/CT, ¹¹¹In-pentetreotide scan, and contrast-enhanced whole-body CT (c.e. CT). In 4 patients with equivocal abdominal findings at ¹⁸F-FDG PET/CT and/or at c.e. CT, laparoscopy was also performed.

Results

¹⁸F-FGD PET/CT depicted metastases in 15 patients, ¹¹¹In-pentetreotide in 8, c.e. CT in 11, US in 6. In 2 patients, liver micrometastases were detected at laparoscopy only. At a lesion-by-lesion analysis, ¹⁸F-FDG PET/CT visualized a total of 26 metastatic deposits, c.e. CT 18, ¹¹¹In-pentetreotide 12, US 8. Final diagnosis was obtained by cytological or surgical findings. Four patients with evidence of limited metastatic spread to neck/upper mediastinum were re-operated, and in 2 of them serum calcitonin levels normalized.

Conclusions

In our study, ¹⁸F-FDG PET/CT was the most sensitive imaging modality in detecting metastases in recurrent MTC patients with increased serum calcitonin levels. Moreover, ¹⁸F-FDG PET/CT was useful in some patients to plan a more accurate re-operation. From a diagnostic point of view, a multimodality imaging approach is recommended in recurrent MTC, especially based on the combination of c.e. CT and ¹⁸F-FDG PET/CT.     

Prophylactic thyroidectomy for MEN 2-related medullary thyroid carcinoma based on predictive testing for RET proto-oncogene mutation and basal serum calcitonin in China

Introduction

Early and normative surgery is the only curative method for multiple endocrine neoplasia type 2 (MEN 2)-related medullary thyroid carcinoma (MTC).

Aims

To study the timing of prophylactic total thyroidectomy (TT) for MEN 2-related MTC with different RET mutations in a Chinese population, and to compare the sensitivity and accuracy of fully-automated chemiluminescence immunoassay (FACLIA) and radioimmunoassay (RIA) for serum calcitonin (Ct).

Methods

We collected 24 asymptomatic individuals from 8 unrelated Chinese families with MEN 2, and analyzed RET mutation and Ct levels. Then we performed TT on 17 of the 24 individuals, including TT (2/17), TT with bilateral level VI lymph-node dissection (B-LND(VI); 12/17) and TT with B-LND(VI) + modified unilateral/bilateral/local neck dissection (3/17).

Results

Histopathology revealed bilateral/unilateral MTC in 15/17 (88.2%; median diameter, 1.0 cm) and bilateral C-cell hyperplasia in 2/17 (11.8%; p.V292M/R67H/R982C and p.C618Y). Lymph-node metastasis/fibro-adipose tissue invasion (p.C634R) or solely fibro-adipose tissue invasion (p.C634Y) were found in 2/17 (11.8%). Elevated pre-surgical Ct (pre-Ct) was identified by FACLIA in 17/17 (median age, 24.0), while pre-Ct by RIA was found in only 6/15 (P < 0.001). The median follow-up was 22.0 months, during which 16/17 had no abnormality (one p.C634R individual had elevated Ct), and another 7 carriers still had consistently undetectable Ct by FACLIA.

Conclusions

Our study highlights the importance and feasibility of individualized prophylactic TT for MEN 2-related MTC, based on predictive integrated screening of RET and pre-Ct levels. Besides, we recommend FACLIA to measure Ct for earlier diagnosis, treatment and follow-up monitoring of MTC.     

The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast

Aim

Ductal carcinoma in situ (DCIS) refers to the preinvasive stage of breast carcinoma and should not give axillary metastases. Its diagnosis, however, is subject to sampling errors. The role of sentinel lymph node biopsy (SLNB) in management of DCIS or DCISM (with microinvasion) remains unclear. The purpose of this study was to review our experience with SLNB in DCIS and DCISM.

Methods

A review of 51 patients with a diagnosis of DCIS (n = 45) or DCISM (n = 6), who underwent SLNB and a definitive breast operation between January 1999 and December 2006, was performed.

Results

In 10 patients (19.6%) definitive histology revealed an invasive carcinoma. SLN (micro)metastases were detected in 5 out of 51 patients, of whom 2 had a preoperative diagnosis of grade III DCIS and 3 of DCISM. Three patients (75%) had micrometastases (<2 mm) only. In 2 patients, histopathology demonstrated a macrometastasis (>2 mm). All 5 patients underwent axillary dissection. No additional positive axillary lymph nodes were found.

Conclusions

In case of a preoperative diagnosis of grade III DCIS or a grade II DCIS with comedo necrosis and DCIS with microinvasion, an SLNB procedure has to be considered because in almost 20% of the patients an invasive carcinoma is found after surgery. In this case the SLNB procedure becomes less reliable after a lumpectomy or ablation has been performed. SLN (micro)metastases were detected in nearly 10% of the patients. The prognostic significance of individual tumour cells remains unclear.     

Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: A prospective trial with 13 years median follow-up in 216 patients

Aim

Validation of the oncological safety of nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants (NSM) and of the outcome in patients with locoregional recurrences (LRRs) after this procedure.

Methods

Two-hundred and sixteen patients, mean age of 52.8 (29–81) years with primary unilateral breast cancer, not suitable for partial mastectomy because of large (>3 cm) or multifocal carcinoma, underwent NSM, a single procedure lasting about 1 h 30 min, between December 1988 and September 1994. Lymph node metastases were found in 40.3% of the patients, and 47 patients received radiotherapy (RT) postoperatively. All patients were monitored for at least 11.6 years or as long as they lived. Median follow-up was 13 years. The end-points were locoregional recurrence (LRR) or distant metastases (DM) as first events, disease-free survival (DFS) and overall survival (OS).

Results

Specificity at frozen section from sub-areolar tissues was 98.5%. LRR occurred in 52 patients and DM in 44 patients. DFS was 51.3% and OS was 76.4%. The frequency of LRR was 8.5% among irradiated and 28.4% among non-irradiated patients (p = 0.025). These results compare well with results after conventional mastectomy in other trials. All patients were monitored for at least 6 years after the occurrence of LRR, finding 5 years freedom from further LRR or DM of 60% and OS of 82%.

Conclusions

NSM is an oncologically safe procedure and could be offered to most patients with breast cancer unsuitable for sector resection only. RT effectively lowers the frequency of LRR. The occurrence of LRR after this operation does not significantly affect OS.     

Recurrences after intensity modulated radiotherapy for head and neck squamous cell carcinoma more likely to originate from regions with high baseline [18F]-FDG uptake

Background and purpose

To analyze the recurrence pattern in relation to target volumes and ¹⁸F-fluorodeoxyglucose (FDG) uptake on positron emission tomography in head and neck squamous cell carcinoma (HNSCC) patients treated with definitive chemoradiation.

Material and methods

520 patients received radiotherapy for HNSCC from 2005 to 2009. Among 100 patients achieving complete clinical response and a later recurrence, 39 patients with 48 loco-regional failures had a recurrence CT scan before any salvage therapy. The estimated point of origin of each recurrence was transferred to the planning CT by deformable image co-registration. The recurrence position was then related to the delineated target volumes and iso-SUV-contours relative to the maximum standard uptake value (SUV). We defined the recurrence density as the total number of recurrences in a sub-volume divided by the sum of that volume for all patients.

Results

54% (95% CI 37–69%) of recurrences originated inside the FDG-positive volume and 96% (95% CI 86–99%) in the high dose region. Recurrence density was significantly higher in the central target volumes (P < 0.0001) and increased with increasing FDG avidity (P = 0.036).

Conclusions

The detailed pattern-of-failure data analysis suggests that most recurrences occur in the FDG PET positive areas or the solid tumor.     

Impact of target volumes and radiation technique on loco-regional control and survival for patients with unilateral cervical lymph node metastases from an unknown primary

Purpose

To compare the impact of an unilateral post-operative irradiation or a bilateral irradiation in terms of loco-regional control and survival in patients with cervical lymph node of squamous cell carcinoma from an unknown primary (CUP).

Methods and materials

Ninety five patients with epidermoid carcinoma involving unilateral cervical lymph nodes from an unknown primary were treated in two institutions from 1990 to 2007. Post-operative radiation therapy was delivered to one side of the neck in 59 cases, to both sides of the neck in 36 cases. There were 11 women and 84 men ranging in age from 38 to 80 years (median 59 years). Neck dissection was performed in 79 patients while 16 patients underwent single lymph node sampling only.

Results

After a median follow-up of 3.3 years, the nodal relapse rate was 34% after unilateral neck irradiation and 25% after bilateral radiotherapy (p = 0.21). Six contralateral lymph node relapses occurred after unilateral irradiation (10%). The 5-year overall survival rate of the entire group was 24%. The 5-year OS rates were 22% after unilateral irradiation and 23%, after bilateral radiotherapy (p = 0.944). The occult primary occurred in 12% after unilateral irradiation and 6% after bilateral radiotherapy. The radiation technique (3D-CRT or IMRT vs. 2D: p = 0.026) was prognostic on loco-regional control. Independent prognostic determinants on overall survival were the WHO status (p = 0.013) and the radiation technique (2D vs. 3D-CRT or IMRT; p = 0.029). There was no difference in loco-regional control (p = 0.639) and no difference in survival (p = 0.493) when chemotherapy was associated.

Conclusions

Retrospective comparisons between bilateral and unilateral neck radiotherapies did not show differences in terms of loco-regional control and survival. However, patient’s local regional control and survival are significantly improved after 3D-CRT or IMRT.     

Challenging a dogma – Surgery yields superior long-term results for T1a squamous cell carcinoma of the glottic larynx compared to radiotherapy

Aims

The aim of this study was to compare laser surgery, conventional endoscopic surgery and radiotherapy in the treatment of early T1a glottic cancer.

Methods

We conducted a retrospective analysis of patients with early vocal cord cancer (who underwent either conventional surgery via endoscopy or laryngofissur, or primary radiotherapy) at the Medical University of Vienna. By univariate and multivariate Cox regression models the influence of treatment and other parameters on survival and locoregional control were analysed.

Results

337 Patients were analyzed with a mean follow-up period of 133.8 months. Overall survival rates where similar in all three treatment groups. Five-year, 10-year and 15-year estimates of disease specific survival for laser-treated patients were 100%, for conventional surgery were 100%, 98% and 98%, and for radiotherapy were 96%, 92% and 91%, respectively. Locoregional recurrences were observed after laser surgery in 10%, after conventional surgery in 13% and after radiotherapy in 30% of the patients treated. According to the log-rank test, time to relapse was significantly shorter for irradiated patients compared to patients who underwent surgery (p < 0.0001). Mortality caused by the laryngeal tumour was significantly higher in the radiotherapy group (p = 0.003).

Conclusion

Patients undergoing laser or conventional surgery have a significantly lower incidence of locoregional recurrences and longer disease-free intervals when compared to patients treated by radiotherapy.     

Metachronous hepatic metastases from gastric carcinoma: A multicentric survey

Background

The treatment of hepatic metastases from gastric cancer is controversial, due to biologic aggressiveness of the disease.

Objective

To survey the clinical approach to the subset of patients presenting with metachronous hepatic metastases as sole site of recurrence after curative resection of gastric cancer, focusing on the results achieved by different therapies and to investigate the prognostic factors of major clinical relevance.

Methods

Retrospective multi-center chart review evaluating 73 patients, previously submitted to D ≥ 2 gastrectomy for gastric cancer, who developed exclusive hepatic recurrence. Prognostic factors related to the patient, to the gastric malignancy and its treatment, and to the metastatic disease and its therapy were evaluated.

Results

Forty-five patients received supportive care, 17 were submitted to chemotherapy, and 11 to hepatic resection. Survival was independently influenced by the variables T (p = 0.019), N (p = 0.05) and G (p = 0.018) of the gastric primary and by the therapeutic approach to the metastases (p < 0.005). In particular, T4 gastric cancer, presence of lymph-node metastases and G3 tumor displayed a negative prognostic value. Therapeutic approach to the metastases was the principal prognostic variable: 1, 2, and 3 years survival rates were 22.2%, 4.4% and 2.2%, respectively, for patients without specific treatment; 44.9%, 12.8% and 6.4% after chemotherapy (p = 0.08) and 80.8%, 30.3% and 20.2% after surgical resection (p < 0.001).

Conclusions

Our data suggest some clinical criteria that may facilitate selection of therapy for patients with hepatic recurrence after primary gastric cancer resection. The best survival rates are associated with surgical treatment, which should be chosen whenever possible.     

The impact of caudate lobe involvement after hepatic resection for colorectal metastases

Background

Hepatic resections involving the caudate lobe are technically challenging with results from some centers indicating inferior outcomes. We assessed outcomes following hepatic resection for colorectal metastases involving the caudate lobe in a tertiary care center.

Methods

Operative and oncological data from a prospectively maintained database were analyzed on 687 patients undergoing hepatic resection for colorectal metastases between 1993 and 2006. Patients were analyzed as those with caudate lobe metastases (CLM) and compared with those without caudate lobe involvement (NCLM).

Results

Fifty-two of 687 patients had metastases involving the caudate lobe (8%). Patients with caudate lobe involvement were more likely to require an extended hepatic resection (75% vs 27%, P = 0.001), perioperative blood transfusion (29% vs 14%, P = 0.002), have a positive resection margin (57% vs 32%, P = 0.001) and stay longer in hospital (12 vs 8 days, P = 0.001). There was no difference in the complication rates (37% vs 29%) or 30-day mortality between the two groups (2% vs 1%). The median disease free (20 months vs 21 months), and cancer specific survival (42 months vs 59 months) were also similar in the CLM and NCLM groups.

Conclusions

Although caudate lobe involvement adds to the technical complexity of hepatic resection, these patients can be offered long term survival, similar to other patients with hepatic metastases from colorectal cancer.     

Micrometastases and isolated tumour cells in sentinel lymph nodes in oral and oropharyngeal squamous cell carcinoma

Background

The occurrence of micrometastases (MMs) and isolated tumour cells (ITCs) in oral sentinel lymph node (SLN) biopsy is poorly known, and the definitions and clinical significance of MMs and ITCs in SLN biopsy are controversial. We compared the UICC/TNM definitions of MMs and ITCs with our previously published sentinel node protocol to assess how the adoption of the UICC/TNM criteria would affect the staging of nodal micrometastatic disease.

Methods

Of 107 patients who had a SLN biopsy and pathology at 150 μm intervals, 35 with metastatic tumour were included. Eighty-six SLNs were reassessed using the UICC/TNM definitions for MMs and ITCs. Findings were linked to the final pathology in the subsequent neck dissection.

Results

Initial H&E sections showed metastases in 24 patients (in 34 out of 61 SLN), 8 of whom (9 SLNs) had MMs. Additional step serial sections revealed metastatic deposits in a further 11 patients (15 out of 25 SLNs were positive) which were reassessed as MMs (6 patients) or ITCs (5 patients). Subsequent neck dissection revealed additional metastases in 46% of patients with MM, whilst one of the ITC patients had subsequent neck metastases (20%).

Conclusion

Despite some limitations, the UICC/TNM classification provides an objective, uniform method of detecting MMs and ITC's. Unlike in cases with ITC, metastases in other non-SLNs were common when a micrometastasis was detected in a SLN, indicating need for further treatment of the neck.     

Surgeon's awareness of the synchronous liver metastases during colorectal cancer resection may affect outcome

Aim

There is conflicting evidence about the importance of synchronous metastases upon tumor outcome. The aim of this study is to identify the effect of finding synchronous colorectal liver metastases on the performance of the surgeon whilst operating on primary colorectal cancer.

Methods

Patients with completed colorectal cancer data who underwent liver resection for colorectal metastases between 1993 and 2001 were included. Two hundred seventy patients were categorised according to the site of the primary tumour (colon or rectum) and knowledge of the presence of liver metastases by the colorectal surgeon (SA = surgeon aware, n = 112, SNA = surgeon not aware, n = 158). The number of retrieved lymph nodes and colorectal resection margin involvement were used as surgical performance indicators. Survival and local recurrence rate were monitored.

Results

The SA group had a higher rate of colorectal circumferential resection margin involvement, the local and intra-abdominal recurrence rate was also significantly higher in this group (p < 0.001).

Conclusions

Awareness of the presence of liver metastases by the operating surgeon is an independent predictor of intra abdominal extra hepatic recurrence of colorectal cancer following potentially curative hepatic resection. This is related to an increased rate of primary colorectal resection margin involvement.     

Clinical features of surgical resection for pulmonary metastasis from breast cancer

Background and objectives

Metastatic breast cancer has been defined as a systemic disease. The discussion concerning the resection of lung metastases in patients with breast cancer is controversial. To confirm the role of resection of pulmonary metastases from breast cancer and to identify possible prognostic factors, we reviewed our institutional experience.

Methods

Between 1991 and 2007, 41 patients with pulmonary metastases from breast cancers underwent complete pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm the role of metastasectomy and to analyze prognostic factors for overall survival after metastasectomy.

Results

All patients were female with a median age of 55 years (range, 35–81 years). The overall survival rate after metastasectomy was 51% at 5 and 10 years. On multivariate analysis, fewer than four pulmonary metastases and a disease-free interval of more than 3 years were significantly favorable prognostic factors for overall survival (p = 0.023 and 0.024, respectively).

Conclusions

The current practice of pulmonary metastasectomy for breast cancers in our institution was well justified. Pulmonary metastasectomy in patients with previous breast cancer might be justified when fewer than four pulmonary metastases or a disease-free interval of more than 3 years.     

Radical treatment of synchronous oligometastatic non-small cell lung carcinoma (NSCLC): Patient outcomes and prognostic factors

Objectives

Metastatic non-small cell lung carcinoma (NSCLC) generally carries a poor prognosis, and systemic therapy is the mainstay of treatment. However, extended survival has been reported in patients presenting with a limited number of metastases, termed oligometastatic disease. We retrospectively reviewed the outcomes of such patients treated at two centers.

Materials and methods

From September 1999–July 2012, a total of 61 patients with 1–3 synchronous metastases, who were treated with radical intent to all sites of disease, were identified from records of two cancer centers. Treatment was considered radical if it involved surgical resection and/or delivery of radiation doses ≥13 × 3 Gy.

Results

Besides the primary tumor, 50 patients had a solitary metastasis, 9 had two metastases, and 2 had three metastases. Locations of metastases included the brain (n = 36), bone (n = 11), adrenal (n = 4), contralateral lung (n = 4), extra-thoracic lymph nodes (n = 4), skin (n = 2) and colon (n = 1). Only one patient had metastases in two different organs. Median follow-up was 26.1 months (m), median overall survival (OS) was 13.5 m, median progression free survival (PFS) was 6.6 m and median survival after first progression (SAFP) was 8.3 m. The 1- and 2-year OS were, 54% and 38%, respectively. Significant predictors of improved OS were: smaller radiotherapy planning target volume (PTV) (p = 0.004) and surgery for the primary lung tumor (p < 0.001). Factors associated with improved SAFP included surgery for the primary lung tumor, presence of brain metastases, and absence of bone metastases. No significant differences in outcomes were observed between the two centers.

Conclusion

Radical treatment of selected NSCLC patients presenting with 1–3 synchronous metastases can result in favorable 2-year survivals. Favorable outcomes were associated with intra-thoracic disease status: patients with small radiotherapy treatment volumes or resected disease had the best OS. Future prospective clinical trials, ideally randomized, should evaluate radical treatment strategies in such patients.     

Metastasis of oral cancer to the parotid node

Background

The parotid node is an uncommon site of metastasis in head and neck cancer. This study was intended to clarify the incidence and indicators of oral cancer metastases to the parotid node.

Patients and methods

We reviewed the records of 253 patients with oral carcinomas who had undergone a total of 289 neck dissections between April 2001 and December 2006. The histologic diagnoses of the primary tumors were squamous cell carcinoma in 239 patients, mucoepidermoid carcinoma in 5, adenoid cystic carcinoma in 4, and miscellaneous others in 5. In all neck dissections, the tail of the parotid gland below the marginal mandibular branch of the facial nerve was resected. The cervical and parotid lymph nodes were isolated from the surgical specimens. One section through the maximum cross-sectional area of each node was examined histologically.

Results

From 183 of the 289 neck specimens, we collected 539 parotid nodes: 222 extraglandular and 317 intraglandular. Of the 253 patients, 10 (4.0%) had 19 parotid node metastases, of which 4 were extraglandular and 15 intraglandular. Parotid node involvement occurred in 2.5% of oral squamous cell carcinoma cases. For the other cancers, there were too few cases to determine a meaningful frequency. In terms of indicators, the likelihood of metastasis to the parotid nodes increased with the number of cancer-positive cervical nodes.

Conclusions

Metastasis to the parotid nodes should be considered in patients with oral cancer. Resection of the tail of the parotid gland is warranted during the neck dissection.