Screening Mammography Following Autologous Breast Reconstruction: An Unnecessary Effort

Background

Currently, no standard guidelines exist regarding routine screening imaging in breast cancer patients following autologous reconstruction. Concern over nonpalpable chest wall recurrence has prompted many to pursue screening imaging. We analyzed the pattern of locoregional recurrence (LRR) and yield of screening imaging and exam in these patients.

Methods

We performed a retrospective chart review of all patients who had mastectomy with autologous reconstruction between 2000 and 2009. Presentation of LRR and utility of imaging and breast exam were analyzed. Screening mammography was performed at the discretion of the treating physicians.

Results

A total of 615 patients were identified and follow-up data were available for 541. Median follow-up from time of reconstruction was 7 years. Twenty-seven patients developed a LRR (5.0 %). Among patients screened with mammography (n = 397), an abnormality led to 25 biopsies in 25 patients, and 2 were malignant (8 %). Among patients receiving routine clinical exam (n = 537), an abnormality led to 77 biopsies in 66 patients, and 30 were malignant (39 %). The median time from cancer surgery to LRR was 2.6 years. LRR was detected on clinical exam in 24 of 27 patients (88.9 %). Screening mammography detected two recurrences that were palpable on follow-up exam. One patient had an incidental chest wall recurrence found on PET/CT. In summary, 26 of 27 (96.3 %) patients had a clinically detectable LRR.

Conclusions

Diligent surveillance with clinical breast exam is a reliable method of detecting LRR after autologous reconstruction, identifying 96.3 % of recurrences in our study. Our results do not support routine mammographic screening in this population.     

Differences in Perioperative Care at Low- and High-Mortality Hospitals with Cancer Surgery

Objective

To evaluate adherence to perioperative processes of care associated with major cancer resections.

Background

Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes.

Methods

There were 1,279 hospitals participating in the National Cancer DataBase (2005–2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics.

Results

Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50–0.92 and aRR 0.80, 95 % CI 0.56–0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90–1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81–1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32–0.93).

Conclusions

HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.     

Efficacy of Adjuvant Radiation Therapy in the Treatment of Soft Tissue Sarcoma of the Extremity: 20-year Follow-Up of a Randomized Prospective Trial

Background

This update of a randomized, prospective study presents the effect of external beam radiation therapy (EBRT) on long-term overall survival, local control, and limb function following limb-sparing surgery (LSS) for the treatment extremity soft tissue sarcoma (STS).

Methods

Following LSS, patients with extremity STS were randomized to receive EBRT or surgery alone. All patients with high-grade STS received adjuvant chemotherapy. Long-term follow-up was obtained through telephone interviews using a questionnaire based on validated methods. Overall survival (OS) was determined by Kaplan–Meier method.

Results

A total of 141 patients with extremity STS were randomized to receive adjuvant EBRT (n = 70) or LSS alone (n = 71). Median follow-up was 17.9 years. The 10- and 20-year survival was 77 % (95 % CI 66–85 %) and 64 % (95 % CI 52–75 %) for patients receiving LSS alone and 82 % (95 % CI 72–90 %) and 71 % (95 % CI 59–81 %) for patients receiving EBRT (p = 0.22). Of the 54 patients who completed telephone interviews, the incidence of local recurrence during the follow-up period was 4 % (1 of 24) in the LSS alone cohort compared with 0 % (0 of 30) in those who received EBRT (p = 0.44). Patients treated with EBRT tended to have more wound complications (17 vs. 12.5 %, p = 0.72), clinically significant edema (25 vs. 12 %, p = 0.31), and functional limb deficits (15 vs. 12 %, p = 0.84).

Conclusions

Adjuvant EBRT following surgery for STS of the extremity provides excellent local control with acceptable treatment-related morbidity and no statistically significant improvement in overall survival.     

Adverse Tumor Biology Associated with Mesenterico-Portal Vein Resection Influences Survival in Patients with Pancreatic Ductal Adenocarcinoma

Background

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

Patients and Methods

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD?VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

Results

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD?VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD?VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD?VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

Conclusions

PD with VR has similar morbidity but worse OS compared with a PD?VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.     

Morbidity and Mortality Associated with Gastrectomy for Gastric Cancer

Background

Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning.

Material and Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated.

Results

Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028).

Conclusions

Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.     

The Effect of Elevated Body Mass Index on Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Background

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) can prolong survival in peritoneal-based malignancies. These malignancies harbor in visceral and omental adipose tissue, and as a result, obesity may contribute to greater tumor burden. Obesity also is an independent risk factor for perioperative complications following major surgery. No studies to date have investigated the effect of elevated body mass index (BMI) on disease burden and perioperative outcomes in CRS-HIPEC patients.

Methods

Observational study of consecutive patients taken to the operating suite from 2007 to 2012 for CRS-HIPEC. Data were reviewed retrospectively, and patients for whom complete cytoreduction was not achieved and those with BMI <18.5 were excluded. Various operative data points, including peritoneal cancer index, surgery length, and estimated blood loss, were measured prospectively. Perioperative complications were identified and recorded.

Results

Complete data for review was available for 114 patients. Patients were subdivided based on BMI (group A 18.5–24.9, n = 43; group B 25–29.9, n = 49; group C ≥ 30, n = 22). There was no statistically significant difference in tumor burden, operative length, probability of unresectable disease, operative blood loss, or length of stay between groups. Rates of respiratory, gastrointestinal, infectious, renal, and hematologic complications were not statistically different, with the exception of deep vein thrombosis (A = 0, B = 13.5 %, C = 0; p = 0.026).

Conclusions

CRS-HIPEC can be safely performed in overweight and obese patients without significant increase in perioperative morbidity. Despite the limitations in physical examination and increase in visceral fat, they do not appear to present later than patients with normal BMI, nor do they have higher tumor burden.     

Ovarian Cancer in BRCA Mutation Carriers: Improved Outcome After Intraperitoneal (IP) Cisplatin

Background

Ovarian cancer arising in women with BRCA mutations is known to have a more favorable outcome and to be more responsive to platinum-based regimens than in those without a hereditary background. We analyze our previously published intraperitoneal (IP) studies in relation to BRCA mutation status and update their outcomes.

Methods

Among 62 patients with ovarian cancer enrolled in IP platinum doublet studies in clinical trials (with etoposide (n = 18), with floxuridine (n = 30), and with topotecan (n = 14)), a deleterious BRCA mutation was eventually identified in 10 patients. The outcomes in these BRCA mutation carriers are described and compared with survival of others in respective trials.

Results

Ten patients that were confirmed to have BRCA mutations—all with high-grade and stages IIC to IV disease—survived a median of 10 years (range: 4–18+) after receiving IP cisplatin-based regimens. Two continue with no evidence of disease since their IP treatment, while four others remain alive with recurrences after 8, 9, 10, and 11 years, respectively.

Conclusions

This experience suggests that IP cisplatin leads to favorable long term outcomes in advanced ovarian cancer in women with defective homologous recombination (i.e., with deleterious BRCA mutations). Whether such cisplatin dose-intensification from IP relative to (intravenous) IV drug administration leads to superior results in these mutation carriers requires further study.     

Intensity of Follow-Up After Melanoma Surgery

This contemporary review of melanoma surveillance strategies seeks to help practitioners examine and improve their surveillance protocols based on the currently available data. In general, there is no definitive benefit from increased screening or more aggressive use of interval imaging. Low-intensity surveillance strategies do not appear to adversely affect patient outcomes and should be the preferred approach compared with high-intensity strategies for most melanoma patients. All surveillance programs should emphasize education in order to maximize the effectiveness of patient-based detection of recurrent disease.     

Evaluation of Malignant Breast Lesions in the Diagnostic Setting with Cone Beam Breast Computed Tomography (Breast CT): Feasibility Study

To investigate the feasibility of noncontrast and contrast‐enhanced cone beam breast Computed Tomography (CT) in demonstrating malignant breast lesions in the diagnostic setting. This Institutional Review Board approved, Health Information Portability and Accountability Act compliant, prospective study enrolled BI‐RADS four and five patients from 2008 to 2010. Eighty‐seven subjects had noncontrast breast CT, 42 had contrast‐enhanced breast CT (CE‐breast CT) with 70 pathologically confirmed cancer diagnoses. All 70 comprise the study cohort for noncontrast breast CT, and 23 who had CE‐breast CT comprise the cohort for CE‐breast CT. All had diagnostic work‐up. Patient age, breast density, lesion size and characteristics, biopsy method, and core pathology were recorded. A Fisher's exact test was used to detect a difference in detectability. For agreement in size measurement between the imaging modalities, a paired t‐test was employed. Reported p‐values were based on 2‐sided tests. Two one‐sided tests were calculated to determine equivalence within ±0.3 cm at a 90% significance level. Noncontrast breast CT identified 67 of 70 malignant lesions, detected by diagnostic work‐up. CE‐breast CT identified 23 of 23 index malignant lesions and in addition, found three malignant lesions in three cases not previously detected. Noncontrast breast CT demonstrated the index lesion in 67 of 70 cases and CE‐breast CT demonstrated the index lesion in all 23 cases. An additional three new malignant lesions not seen with conventional diagnostic work‐up were detected. In this preliminary study, breast CT with or without contrast was shown to be accurate at identifying malignant breast lesions in the diagnostic setting.