Surgical resection of solitary metastases after chemotherapy in patients with nonseminomatous germ cell tumors and elevated serum tumor markers.

BACKGROUND. Chemorefractory metastatic germ cell tumors and elevated tumor markers generally indicate inoperable disease. METHODS. Solitary metastases were resected in 15 patients who had a nonseminomatous germ cell tumor and an elevated alpha-fetoprotein (AFP) and/or human chorionic gonadotropin (HCG) serum level after treatment with cisplatin-based chemotherapy. Patients underwent resection for a residual mass after chemotherapy or for a new solitary metastasis after achieving a complete response (CR) to salvage chemotherapy. RESULTS. Seven patients were disease-free after surgical resection alone. All five patients with an elevated HCG level had a relapse after surgery compared with 3 of 10 patients with only an elevated AFP level. Only 4 of 10 patients with a retroperitoneal metastasis had a relapse after surgery compared with 4 of 5 patients with visceral disease. Eleven of 15 patients overall were disease-free after surgery and subsequent chemotherapy after a relapse. CONCLUSIONS. Surgical resection of a solitary metastasis despite elevated serum tumor markers should be considered in patients who have not had a durable CR to cisplatin-based chemotherapy.     

Metastatic nonseminomatous germ cell tumors of the testis: results of elective and salvage surgery for patients with residual retroperitoneal masses

BACKGROUND: A mass may persist in the para-aortic region after patients undergo chemotherapy for metastatic, nonseminomatous germ cell tumor of the testis (NSGCT). Retroperitoneal lymphadenectomy removes the mass, which may contain residual active malignancy, and allows histologic assessment of the effectiveness of the chemotherapy. Whereas some have favored early, elective removal of such masses, others have chosen to observe them, reserving salvage surgery for patients who experience disease recurrence. A retrospective analysis was undertaken to define the outcome in these two groups of patients. METHODS: After receiving chemotherapy for metastatic NSGCT, 442 men underwent lymphadenectomy for residual masses (measuring > or = 1 cm in greatest dimension) between 1976 and 1999, inclusive. Three hundred thirty men underwent elective surgery within 3 months of the completion of chemotherapy, and 112 men underwent salvage surgery after receiving reinduction chemotherapy for tumor recurrence. RESULTS: The residual mass was removed completely in 87% and 72% of patients in the elective and salvage lymphadenectomy groups, respectively; was removed with difficulty and possibly incompletely in 9% and 21% of patients, respectively; and was definitely removed incompletely in 4% and 7% of patients, respectively. The operative mortality rate was 0.9% in the elective surgery group and 1.8% in the salvage surgery group. There was malignant teratoma, undifferentiated in 8.5% of patients in the elective surgery group and in 49% of patients in the salvage surgery group (P < 0.001). Differentiated teratoma and necrosis/fibrosis were present in 66.0% and 25.4% of patients in the elective surgery group, respectively, and in 38.4% and 12.5% of patients in the salvage surgery group, respectively. The authors were unable to produce a clinically useful model to predict the presence of necrosis/fibrosis only in either group. The 5-year recurrence free and overall survival rates were 83% and 89%, respectively, in the elective surgery group and 62% and 56%, respectively, in the salvage surgery group. For the salvage surgery group, the completeness of surgical excision and the presence of undifferentiated teratoma were of overriding importance for overall survival. A variety of other patient-related, tumor-related, and surgery-related factors also were significant in the final model for the elective surgery group. CONCLUSIONS: The current results demonstrate the low level of morbidity that can be obtained, even in the salvage surgery group, and the importance of complete surgical resection in this setting. Because it is not possible to predict with sufficient accuracy which patients will have favorable pathology (necrosis/fibrosis), the authors continue to recommend elective surgery for all suitable men with residual masses after they receive first-line chemotherapy.     

Multiple biological markers in germ cell tumor patients treated with platinum-based chemotherapy.

Blood samples from 36 germ cell tumor patients receiving chemotherapy with either cisplatin or carboplatin in combination with other drugs [etoposide or vinblastine, cyclophosphamide, dactinomycin, and bleomycin (VAB-6)] were analyzed for the presence of 7 different biological markers. The biomarkers included platinum-protein adducts, platinum-DNA adducts, sister chromatid exchange (SCE), micronuclei (MN), and somatic gene mutation at the hypoxanthine phosphoribosyl transferase (HPRT) locus and the glycophorin A (GPA) loci (NO and NN). Patients were asked to donate 9 serial blood samples: a pretreatment sample followed by another drawn 12-24 h after each of four cycles of treatment and a final sample provided 3-6 months after the last cycle. Most individuals gave 7-8 samples; 7 individuals donated all 9. Because of limited amounts of cells in some cases, it was not possible to carry out all 7 assays on every sample. Pt-protein adducts, Pt-DNA adducts, and SCE showed a direct and consistent effect of treatment and were very highly correlated. A significant correlation was also seen between both Pt-protein and Pt-DNA adducts and HPRT mutation. All of the posttreatment samples were significantly elevated compared to the baseline sample. These markers also remained elevated 3-6 months after the end of treatment. By contrast, MN, HPRT mutation, and GPA mutation (both NO and NN variants) showed varying patterns of dose response, probably reflective of the differing biology of these markers scored in lymphocytes (MN and HPRT) and erythrocytes (GPA). MN were significantly elevated in the posttreatment samples drawn at cycles 2 and 3. Although induction of HPRT mutation was only of marginal significance, results here are for the mutant frequency determination assay only. In progress is the potentially more informative analysis of the type of mutations by Southern blot and the sequencing of mutations to look for characteristic mutational spectra. The GPA assay showed a significant increase over baseline in samples drawn after cycles 3 and 4 (NO variants) and after cycles 2, 3, and 4 (NN variants). The level of GPA mutation (both NO and NN variants) was clearly elevated even 3-6 months after the last cycle of chemotherapy. Correlations were seen between HPRT and MN as well as between GPA NO and GPA NN variants. Analysis of biomarkers by treatment group does not reveal a consistent pattern or trend across all cycles.(ABSTRACT TRUNCATED AT 400 WORDS)     

Correlation of serum tumor markers in advanced germ cell tumors with responses to chemotherapy and surgery

Remission rates induced by chemotherapy alone or by combined chemotherapy and surgery were analyzed in relation to specific serum tumor marker abnormalities immediately before treatment in 103 patients with Stage III or bulky Stage II nonseminomatous germ cell tumors. Complete remission occurred in 92% (12 of 13) of patients with normal levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), in 26% (6/23) with elevated AFP only, in 46% (13/28) with elevated HCG only, and in 39% (13/36) with abnormalities of both AFP and HCG. Patients with elevated AFP less frequently had a complete remission (CR) to chemotherapy (CR, 34% versus 61% with normal AFP), but benefitted from adjunct surgery (CR, up to 59%). Patients with very high (greater than 1000 ng/ml) serum AFP or HCG responded poorly to chemotherapy (CR, 17%) but especially large tumor burdens may have contributed to these unfavorable responses. Patients with both minimal and advanced metastatic disease had higher CR rates if they had serum tumor marker levels below rather than above 1000 ng/ml. Adjunct surgery eliminated the correlation between the "poor prognostic factors" associated with specific marker abnormality and an incomplete response to chemotherapy by rendering a significant number of such patients free of disease through resection of residual metastatic deposits.     

The role of tumor markers in the treatment of germ cell tumor

Alfa fetoprotein (AFP), human chorionic gonadotropin (HCG), beta HCG and lactate dehydrogenase (LDH) are powerful markers of germ cell tumors. The role of tumor markers is very important in the diagnosis, treatment and follow-up of germ cell tumors, respectively. We can often deduce the histological typing of germ cell tumors by tumor marker elevation before surgery. Tumor markers also frequently provide clues as to outcome in individual cases before treatment. The half-life of tumor markers during chemotherapy indicate the effect of the treatment. The optimal regimen of chemotherapy should therefore be selected based on the half-life of tumor markers. Normalized tumor markers designate the phase of discussion on surgical indications. Determination of tumor markers is important in following patients after treatment of germ cell tumors. The elevation of serum tumor markers denotes recurrence and is often the first sign of treatment failure.     

Successful 2-year-long remission following repeated salvage surgery in a patient with chemotherapy-resistant metastatic nonseminomatous germ cell tumor

A 34 year-old man with a diagnosis of nonseminomatous testicular cancer with retroperitoneal lymph node metastasis (T1N3M0S2, stage IIIb; intermediate prognosis, made after right inguinal orchiectomy was performed) was referred to our hospital after having had a total of eight courses of systemic chemotherapy and external-beam radiotherapy to the retroperitoneal region in the previous 1 year. His serum α-fetoprotein (AFP) level remained elevated. Two courses of paclitaxel, etoposide, and cisplatin combined chemotherapy (TEP; paclitaxel 120 mg/m² day 1, etoposide 80 mg/m² days 2–5, cisplatin 20 mg/m² days 2–5) failed to normalize the AFP level. During the following 2 years he underwent salvage surgery four times; infrarenal retroperitoneal lymph node dissection (RPLND), left neck lymph node dissection, thoracic duct excision, and suprarenal RPLND. Viable cancer cells were found in all surgically resected specimens, except for the neck lymph node specimen. The serum AFP level was normalized and he has been well without relapse for 2 years after the last surgery. The present case suggests that repeated salvage surgery may be beneficial in selected patients with a chemotherapy-resistant metastatic germ cell tumor.     

Trophoblastic proteins as tumor markers in nonseminomatous germ cell tumors

In order to examine the relative usefulness of measurements of oncoplacental proteins as tumor markers in patients with nonseminomatous germ cell tumors, the authors measured alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), pregnancy-specific beta 1-glycoprotein (SP1), human placental lactogen (hPL), and placental cystine aminopeptidase (oxytocinase, CAP) in serial blood samples obtained from 26 men with these neoplasms. HCG and AFP were each elevated in 62% of the patients and both were elevated in 38%. SP1 and hPL were increased in 31% and 12%, respectively. None of the patients had elevated CAP activity. Serum hCG and SP1 concentrations were strongly correlated (r = 0.78, P less than 0.001). No patient had an elevated SP1 without a concomitant elevation in serum hCG. Serial measurements of hCG and SP1 indicated that they were concordant in five of the eight patients in whom both were elevated, and AFP and hCG were concordant in only one half of the ten patients in whom both markers were elevated. The number of patients with hPL elevations were too few for meaningful comparison of this marker with the others. These results indicate that measurements of SP1, hPL, and CAP do not provide additional useful information over that obtained from measurements of hCG and AFP in patients with nonseminomatous germ cell tumors.     

Incidence of late-relapse germ cell tumor and outcome to salvage chemotherapy.

PURPOSE: To define the incidence, clinical features, and outcome to salvage chemotherapy in patients with late-relapse germ cell tumor (GCT) after a complete response to first-line chemotherapy. PATIENTS AND METHODS: Two patient populations were examined. First, retrospective analysis of 246 patients treated on a clinical trial with salvage chemotherapy was performed; 29 patients with late-relapse GCT were identified and evaluated for treatment outcome and survival. Salvage regimens included paclitaxel, ifosfamide, and cisplatin, single agents, or a high-dose chemotherapy program. Second, the incidence of late relapse was assessed by retrospective analysis of 551 patients after a complete response (CR) to first-line chemotherapy. RESULTS: Twenty-nine patients received salvage chemotherapy on a clinical trial for late relapse GCT. The median survival was 23.9 months. At a median follow-up of 50.6 months, there were nine survivors. The chemotherapy regimens varied, but the only CRs were observed in patients treated with paclitaxel, ifosfamide, and cisplatin. Seven (50%) of 14 patients treated with paclitaxel, ifosfamide, and cisplatin achieved a continuous CR. Among the second population of 551 patients who had previously achieved a CR to a first-line chemotherapy trial, 17 were identified as having a late relapse (3%). The median time to relapse for these 17 patients was 7.8 years. CONCLUSION: Late-relapse GCT is uncommon and is associated with a poor prognosis resulting from a high degree of resistance to chemotherapy. Chemotherapy with paclitaxel, ifosfamide, and cisplatin followed by surgery may be effective in patients with late-relapse GCT who are not considered candidates for primary surgery.     

Clinical utility of elevated tumor markers in patients with disseminated appendiceal malignancies treated by cytoreductive surgery and HIPEC

Background

Appendiceal malignancies with peritoneal spread have been successfully treated with Cytoreductive Surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to clarify the utility of common tumor markers in selecting patients for the combined treatment.

Methods

Data on 56 patients with appendiceal neoplasms treated with CRS and HIPEC were prospectively collected. Chi square test was used to analyze a link between common tumor markers and completeness of cytoreduction score (CC score) and preoperative peritoneal cancer index score (PCI score). Cox proportional hazard model was used to perform survival analysis.

Results

Forty-two patients were alive after 3 years of follow-up. Hazard ratio of disease related death was 5.6 (95% CI, 1.8–17.2) among patients with high CC score as compared to those with low CC score. Number of abnormal tumor markers (0 vs 1/2/3) correlated with PCI score 16.2 vs 32.5 (p < 0.001) but not with completeness of cytoreduction or survival. The 3-year survival rates in patients with normal vs abnormal CA 125 levels were 83% vs 52%(p = 0.003).

Conclusions

Multiple abnormal tumor markers were not useful as an exclusion criterion for patients undergoing CRS. Elevation in CA 125 was an important indicator of survival in these patients. Complete cytoreduction was crucial for long-term survival.     

Tumor markers at the time of recurrence in patients with germ cell tumors

BACKGROUND: alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH) closely follow the course of germ cell tumors (GCTs) and are widely used for diagnosis, prognosis, and follow-up purposes. The objective of this study was to assess the concordance of tumor markers at the time of diagnosis and recurrence. METHODS: The authors reviewed the records of 794 patients with GCTs treated in three Spanish hospitals from 1977-1996 and analyzed the concordance between AFP, HCG, and LDH levels at diagnosis and first and second recurrence. A positive marker was defined as a level of AFP > 10 ng/mL, HCG > 5 IU/L, or LDH > the upper limit of normal. One hundred twenty-five patients were identified who developed a first recurrence (123 had marker levels recorded). The median age was 27 years (range, 14-78 years). Histology was seminoma in 36 patients (29%) and nonseminomatous GCT (NSGCT) in 87 patients (71%). RESULTS: Seventy-nine patients (64%) had elevated tumor markers at diagnosis and 76 (62%) at first recurrence. An elevated marker was present at first recurrence in 58 of 79 patients (73%) with initially positive markers and in 18 of 44 patients (41%) with initially negative markers. In 84 of 123 patients (68%), the same marker pattern (positive or negative) was present at the time of diagnosis and at first recurrence, 78% in seminomas and 64% in NSGCTs. The earliest indicator of recurrence was an elevated marker in patients with NSGCTs and a radiologic finding in patients with seminomas. Thirty patients developed a second recurrence, 27 of whom (90%) had the same marker pattern as at first recurrence. CONCLUSIONS: Tumor marker pattern at diagnosis is not a good predictor of the pattern at recurrence, particularly in patients with NSGCTs. Marker assessment should be included in the follow-up schedule regardless of levels at the time of diagnosis. Early detection of recurrence should not rely only on marker levels, even in patients with elevated levels at presentation.     

Prognosis after salvage treatment for unselected male patients with germ cell tumours.

Long-term outcome of salvage treatment was reviewed in 67 unselected male patients relapsing during or after their primary cisplatin-based chemotherapy for metastatic germ cell tumours. Seven patients underwent only surgery and/or radiotherapy as curatively intended salvage treatment. Thirty-five patients (52%) had a complete or partial response to salvage treatment, 20 (57%) of whom relapsed again. With a median follow-up of 90 months (range 3-143 months) 20 patients (30%) are alive with no evidence of disease, 15 continuously disease-free and five currently disease-free. The 5 year survival from start of salvage treatment is 37% for the group as a whole. Multivariate analysis identified age < or = 35 years, complete response to primary treatment and a relapse-free interval > 3 months as independent predictors of favourable outcome of salvage treatment. A group of patients with these good-risk factors (42%) had a 5 year survival of 72% compared with the remaining patients (58%) with a 5 year survival of only 11%. Whereas patients with good-risk features may be adequately managed by conventional salvage treatment, the remaining patients carry a very poor prognosis and require innovative and more aggressive approaches.     

睾丸生殖细胞肿瘤综合治疗的长期疗效

目的 分析睾丸生殖细胞肿瘤(TGCTs)患者的临床特征、综合治疗疗效、生存率以及与预后有关的因素。方法 对107例行高位睾丸切除 精索静脉结扎术、术后均行化疗的TGCTs患者进行回顾性分析。近期疗效比较采用χ^2检验;生存率的计算采用Kaplan-Meiel生存曲线;生存率的比较采用Log rank检验。结果 107例患者中位年龄32岁。精原细胞瘤33例(30．8％),其中Ⅰ期14例,占42．4％;非精原细胞瘤74例(69．2％),其中I期21例,占28．4％。临床分期和病理类型是影响患者预后的主要因素。患者总的3,5,10年生存率分别为75．8％、73．5％和73．5％。精原细胞瘤患者3,5,10年生存率分别为100％、96．8％和96．8％;非精原细胞瘤患者3,5,10年生存率分别为63、5％、61．7％和61．7％。64例患者可评价疗效,单用化疗的患者中,17例(26,6％)达CR,另有8例(12．5％)化疗加放疗或解救手术后达CR。获CR与未获CR者5年生存率分别为91．7％和26．2％。结论 Ⅰ期TGCTs预后好。采用以化疗为主的综合治疗可明显提高转移性TGCTs患者的疗效和生存率。     

保乳术联合辅助化疗治疗乳腺癌术后患者乳房美容效果及对相关肿瘤标志物的影响

目的探讨保乳术联合辅助化疗治疗乳腺癌术后患者乳房美容效果及对相关肿瘤标志物表达水平的影响。方法选取2016年1月至2018年12月间福建省肿瘤医院收治的100例乳腺癌手术患者进行回顾性分析。采用保乳术联合辅助化疗治疗的50例患者纳入观察组,采用改良根治术联合术后辅助化疗治疗的50例患者纳入对照组。比较两组患者术中出血量、手术时间、住院时间及术后并发症发生率,调查患者术后乳房美容效果并检测患者血清中YKL-40和TGF-β水平。结果观察组患者治疗术中出血量、手术时间、住院时间及并发症发生率均低于对照组,差异均有统计学意义(均P <0. 05)。观察组患者术后美容效果优良率为82. 0%,优于对照组患者的4. 0%,差异有统计学意义(P <0. 05)。治疗后,两组患者血清中YKL-40和TGF-β水平均降低,且观察组患者YKL-40和TGF-β水平均低于对照组患者,差异均有统计学意义(均P <0. 05)。结论采用保乳术联合辅助化疗方案治疗乳腺癌患者,在保证治疗效果的同时,可提高乳房美观程度,并有效降低患者血清中YKL-40和TGF-β水平。     

Serum tumor markers and patient allocation to good-risk and poor-risk clinical trials in patients with germ cell tumors.

The allocation of patients with advanced germ cell tumors (GCT) to different treatment programs based on clinical characteristics is standard in the design of clinical trials today. Studies have shown that substantial differences exist between entry criteria and that these differences could influence the outcome of clinical trials. The factors contributing to these differences are not clear due to patient selection biases. Two hundred five unselected and consecutive patients allocated to and treated in good-risk and poor-risk treatment programs at Memorial Sloan-Kettering Cancer Center (MSKCC) were reassigned risk status by the Indiana University (IU) Classification. The results were compared with those of the Southeastern Cancer Study Group (SECSG). The results using both criteria indicated substantial agreement in total end results and the identification of good-risk patients. The results in poor-risk patients differed substantially, with 39 patients (19%) classified as poor-risk by MSKCC criteria and 66 (32%) by Indiana criteria. The major discrepancy occurred in IU Stage 7, in which 26 of 32 patients (81%) achieved a complete response. The major factor contributing to this difference in risk assignment was the use of serum tumor markers. Serum tumor markers must be incorporated into risk assignment criteria for GCT clinical trials to minimize the number of good-risk GCT patients in poor-risk trials.     

Sequential dose-intensive paclitaxel, ifosfamide, carboplatin, and etoposide salvage therapy for germ cell tumor patients.

PURPOSE: To evaluate the efficacy and toxicity of sequential, dose-intensified chemotherapy with paclitaxel/ifosfamide and carboplatin/etoposide administered plus peripheral blood-derived stem-cell (PBSC) support for patients with germ cell tumors (GCT) who have unfavorable prognostic features in response to conventional-dose salvage programs. Carboplatin was dose escalated by target area under the curve (AUC; in [milligrams per milliliter] x minutes) among patient cohorts, and pharmacokinetic studies were performed for comparison. PATIENTS AND METHODS: Thirty-seven previously treated patients who had cisplatin-resistant GCT and unfavorable prognostic features for response to conventional-dose salvage therapy were treated. Two cycles of paclitaxel 200 mg/m(2) plus ifosfamide 6 g/m(2) were given 2 weeks apart with leukapheresis, followed by three cycles of carboplatin plus etoposide given 14 to 21 days apart with reinfusion of PBSCs. The dose of etoposide was 1, 200 mg/m(2), and the carboplatin target AUC ranged among cohorts from 12 to 32 (mg/mL) x min. Pharmacokinetic studies of carboplatin were performed for comparison of target to measured AUC. RESULTS: Twenty-one patients (57%) achieved a complete response and an additional two patients (5%) achieved a partial response with normal tumor markers; therefore, 23 (62%) achieved a favorable response. Eight patients relapsed, and 15 (41%) of the favorable responses remained durable at a median follow-up of 30 months. Myelosuppression was the major toxicity; 58% of carboplatin/etoposide cycles were associated with hospitalization for nadir fever. The AUC of carboplatin measured in serum was lower than the target AUC; this may be related to underestimation of the glomerular filtration rate used in the dosing formula. CONCLUSION: Dose-intense therapy with sequential, accelerated chemotherapy of paclitaxel/ifosfamide and carboplatin/etoposide administered with PBSC support was relatively well tolerated. The durable complete response proportion was substantial in patients with unfavorable prognostic features for achieving durable complete response to conventional-dose salvage programs. Optimal dosing of carboplatin in the high-dose setting warrants further investigation.     

Cisplatin and etoposide salvage therapy and resection of the residual tumor in pretreated germ cell testicular cancer

Thirty-two consecutive patients with pretreated germinal testis cancer received three to four inductions of cisplatin and etoposide therapy (PE). Patients not pretreated, or only partially pretreated with bleomycin (B), also received this drug for a maximum of 12 doses. Sixteen patients underwent secondary surgery for the removal of residual masses. Twelve (37.5%) entered complete remission (CR) with chemotherapy alone, and an additional 9 cases (28%) were rendered tumor-free by surgery. The 21 disease-free patients (65.5%) received two further inductions and no maintenance. Toxicity was moderate, and 1 of the 16 patients who underwent surgery died postoperatively of pulmonary embolism. After a median follow-up period of 26 months (range, 9-60), 2 patients have died in CR and 15 (47%) are currently alive and have been continuously disease-free. The major determinant of tumor response was prior therapy. Eleven of 14 (78%) patients who were not pretreated with cisplatin achieved a continuous disease-free status versus only 4 of the 18 pretreated patients (22%, P less than 0.01). In this set of cases, complete responders to prior PVB therapy did better than incomplete responders treated for tumor progression. It can be concluded that normal-dose PE +/- B therapy, followed by surgical resection of the residual tumor, is a satisfactory salvage therapy in patients not pretreated with cisplatin and is also active in complete responders to prior PVB therapy.     

Significance of elevated preoperative alpha-fetoprotein in postchemotherapy residual tumor resection for the disseminated germ cell tumors

BACKGROUND AND OBJECTIVES: The purpose of the study is to determine the significance of elevated serum alpha-fetoprotein (AFP) in the setting prior to residual tumor resection (RTR) following chemotherapy for metastatic germ cell tumor in terms of the prediction of histology of the specimen and postoperative survival. METHODS: We conducted a retrospective review of 68 patients undergoing RTR for metastatic nonseminomatous germ cell tumor or extragonadal germ cell tumor after at least a first-line chemotherapy. Pretreatment and postchemotherapy serum markers were evaluated in association with other clinical findings including results of pathological examination of RTR specimen and surgical outcome. RESULTS: Of the 68 study patients, 54 (79%) and 45 (66%) had positive AFP and beta-human chorionic gonadotropin (beta-HCG) in pretreatment settings. Rates of presence of residual malignant cell in RTR specimen were similar between patients with normal AFP (7/28 or 25%) and with mildly elevated (10-30 ng/ml) AFP (3/11 or 27%). In 26 patients who had residual viable malignancy in RTR specimen, patients with preoperative positive AFP had significantly better survival (P = 0.02) compared to those with preoperative positive beta-HCG. CONCLUSIONS: Sole and mild elevation of AFP is not always associated with postoperative poor prognosis. It should be carefully considered individually whether a mild elevation of AFP after chemotherapy represents residual malignancy or benign pathogenesis.     

The role of salvage surgery in patients with recurrent squamous cell carcinoma of the oropharynx

BACKGROUND:

The objective of this study was to comprehensively review overall survival, functional outcomes, and prognostic factors in patients who underwent salvage surgery for locally recurrent squamous cell carcinoma of the oropharynx (SCCOP) after initial radiotherapy.

METHODS:

The authors retrospectively reviewed 1681 consecutive patients who completed definitive therapy for primary SCCOP and identified 168 patients with locally recurrent SCCOP who underwent salvage surgery (41 patients), reirradiation or brachytherapy (18 patients), palliative chemotherapy (70 patients), or supportive care (39 patients).

RESULTS:

Twenty‐six of 39 patients (67%) developed a second recurrence after salvage surgery. The 3‐year overall survival rate for patients who underwent salvage surgery or received reirradiation, palliative chemotherapy, or supportive care were 48.7%, 31.6%, 3.7%, and 5.1%, respectively. For patients who underwent salvage surgery, older age (P = .03), the absence of a disease‐free interval (P < .01), and advanced recurrent tumor stage (P = .07) were associated with lower overall survival. Patients with recurrent neck disease (P = .01) and positive surgical margins (P = .04) had higher rates of recurrence after salvage surgery. Postoperative complications occurred in 19 patients (46%), and there were no perioperative deaths. Functionally, 71% of patients demonstrated ≥80% speech intelligibility, 68% were able to tolerate some oral intake, and 87% who required a tracheotomy subsequently were decannulated.

CONCLUSIONS:

Age, disease‐free interval, recurrent tumor stage, recurrent neck disease, and surgical margin status influenced overall survival or recurrence rate after salvage surgery for recurrent SCCOP. Although most patients had good functional outcomes, only a select group of patients with recurrent SCCOP achieved long‐term survival after salvage surgery. Cancer 2009. © 2009 American Cancer Society.