Clinical Evidence Of Metastatic Disease Research Articles

Identification of a Novel MicroRNA Panel Associated with Metastasis Following Radical Prostatectomy for Prostate Cancer.

This is a case control study designed to identify one or more novel microRNA sequences associated with metastasis following radical prostatectomy for clinically localized prostate cancer. Samples were obtained from patients with clinical evidence of metastatic disease following surgery (cases) and patients who showed no evidence of metastasis or biochemical recurrence at least 5 years following surgery (controls) as identified from a single-center, institutional database. Cases and controls were matched for tumor grade and duration of follow-up. Whole miRNome analysis identified 2,792 expressed miRNAs in 19 patient pairs. The 497 miRNA sequences with reads per million over 10, were used for analysis, bootstrapping with backward selection identified a panel of 5-miRNA (miR-17-3p, miR-27a-3p, miR-200a-3p, miR-375, and miR-376b-3p) with a risk score strongly associated with metastasis (AUC=89.5%, 95%CI=79.5-99.5%). Methodologically, most studies use the magnitude of differential expression with or without clinical judgement for selection of predictors for inclusion in panels. In order to strengthen the predictive model, a selection strategy was employed, bootstrapping with automated backwards selection, which relied on the strength of association for inclusion. A genome-wide analysis of microRNA expression identified a panel of 5 miRNAs strongly associated with prostate cancer metastasis following radical prostatectomy.

Abstract ES9-3: ES9-3 (Neo)adjuvant systemic therapy of TNBC: How much is enough?

Abstract The use of neoadjuvant chemotherapy in ER-negative cancers has become quite popular in patients with stage II and III breast cancers, since it gives us important information on long-term prognosis, based on the amount of residual disease burden at the time of definitive surgical resection. Two relatively large phase II randomized neoadjuvant clinical trials have explored the addition of carboplatin to an anthracycline/taxane based chemotherapy regimen for patients with stage II or III triple-negative breast cancers (TNBC): GeparSixto, in Europe, and CALGB40603, in the US. Despite significant differences in chemotherapy backbone, and frequency and duration of carbo administration, both trials showed that the addition of carboplatin significantly increased the rate of pCR from ∼ 40% to 54%. Both trials also reported a significant amount of added toxicity for the carboplatin arms, with a significant amount of patient not being able to complete their planned treatment. However, whereas the GeparSixto trial reported an improvement in 3-year disease-free survival (DFS), the CALGB40603 did not. Since neither of these studies was powered to address disease-free or overall survival benefit from the addition of carboplatin to neoadjuvant systemic chemotherapy, lack of precision from small sample sizes are likely responsible for the difference seen in DFS between these two trials. Additionally, there's not yet a confirmed correlation between increases in frequency of pCR and event-free survival (EFS). A recently pooled analysis by Cortazar et al. could not validate pCR as a surrogate endpoint for improved EFS and overall survival (OS): as some patients who achieve a pCR go on to relapse and many with residual disease never experience a recurrence, small differences in pCR may never translate to improvements in EFS. Long term effects of the added toxicity of carboplatin are also not known. At present, upon completion of neoadjuvant therapy, the standard of care for patients with TNBC (who have no clinical evidence of metastatic disease after surgical excision of the cancer regardless of burden of residual disease) is observation. But recently, preliminary data from a Japanese phase III trial (CREATE-X) that randomized patients with HER2-negative breast cancer with lack of pCR post-neoadjuvant chemotherapy to observation or capecitabine x 8 cycles showed that the addition of capecitabine provided a statistically significantly higher 5-year DFS and OS in the TNBC group. EA1131, an ongoing adjuvant randomized phase III clinical trial seeks to address if patients with basal-like TNBC, with high risk of recurrence due to residual disease post completion of neoadjuvant chemotherapy, have a higher DFS benefit from a platinum agent than from capecitabine. The results of this trial will ultimately help avoid exposing upfront unselected patients, many of whom will never relapse, to toxic therapy in the absence of long-term known benefit. In summary, the addition of a platinum agent routinely in the neoadjuvant setting in TNBC is still an individualized decision and not yet standard of care for all patients. The decision to use capecitabine in patients with residual disease post-neoadjuvant chemo may still be slightly premature, confirmatory results of EA1131 are eagerly awaited. Citation Format: Mayer IA. ES9-3 (Neo)adjuvant systemic therapy of TNBC: How much is enough? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr ES9-3.

Specificity of radiographic lymphadenopathy for lymph node metastasis in renal cell carcnioma.

442 Background: Approximately 30% of patients with renal cell carcinoma (RCC) will have metastatic disease at the time of diagnosis. Patients without preoperative lymphadenopathy (LAD) radiographically rarely have positive nodes at the time of nephrectomy. We sought to evaluate the specificity of radiographic LAD for lymph node metastases in patients with and without clinical metastatic RCC. Methods: We retrospectively reviewed all nephrectomies performed at our institution from 2003-2013. We identified patients with clinical stage classification T2-T3 (cT2-T3) RCC and stratified patients by clinical N and M classification. Lymphadenectomy was performed at surgeon discretion. Performance statistics for preoperative imaging for pathologic lymph node metastases and multivariable logistic regressions models to identify patient characteristics associated with lymph node metastases were generated. Results: A total of 223 patients were identified. Of these, 85 (38%) had clinical evidence of metastatic disease while 138 (62%) did not. In patients with clinical metastatic disease, LND was performed in 68%; of those without clinical metastatic disease, LND was performed in 48%. Radiographic LAD for those with clinical metastatic disease (26/85 patients, 31%) had sensitivity of 94%, specificity of 49%, positive predictive value (PPV) of 43%, and negative predictive value (NPV) of 95% for pathologically confirmed lymph node involvement. Radiographic LAD for patients without clinical metastatic disease (37/138 patients, 27%) had sensitivity of 90%, specificity of 52%, PPV of 25%, and NPV of 96% for pathologically confirmed lymph node involvement. On multivariate logistic regression analysis (adjusted for age, gender, smoking status, obesity, non-clear cell histology, and grade) having clinical metastatic disease was significantly associated with pathologic node positivity (RR = 3.37, 95% CI 1.19 – 20.6). Conclusions: Radiographic lymphadenopathy is a nonspecific finding in patients with RCC and LND is not routinely performed at our institution. However, in the setting of clinical metastatic disease, radiographic LAD is more likely to represent pathological lymph node metastases.

Preoperative FDG-PET/CT Is an Important Tool in the Management of Patients with Thick (T4) Melanoma

The yield of preoperative PET/CT (PET/CT) for regional and distant metastases for thin/intermediate thickness melanoma is low. Objective of this study is to determine if PET/CT performed for T4 melanomas helps guide management and alter treatment plans. Methods. Retrospective cohort of 216 patients with T4 melanomas treated at two tertiary institutions. Fifty-six patients met our inclusion criteria (T4 lesion, PET/CT and no clinical evidence of metastatic disease). Results. Fifty-six patients (M: 32, F: 24) with median tumor thickness of 6 mm were identified. PET/CT recognized twelve with regional and four patients with metastatic disease. Melanoma-related treatment plan was altered in 11% of the cases based on PET/CT findings. PET/CT was negative 60% of the time, in 35% of the cases; it identified incidental findings that required further evaluation. Conclusion. Patients with T4 lesions, PET/CT changed the treatment plan 18% of the time. Regional findings changed the surgical treatment plan in 11% and the adjuvant plan in 7% of our cases due to the finding of metastatic disease. Additionally 20 patients had incidental findings that required further workup. In this subset of patients, we feel there is a benefit to PET/CT, and further studies should be performed to validate our findings.

PSA doubling time (PSADT) and serum testosterone (T) during intermittent androgen deprivation (IAD) in patients with biochemically relapsed prostate cancer (BRCP; M0): Potential predictive implications.

150 Background: The systemic management of patients with BRPC remains controversial. IAD is commonly employed. Aims: To evaluate the PSA dynamics and serum T in pts with BRPC treated with IAD until the development of PSA refractoriness or clinical evidence of metastatic disease. Methods: Data were retrospectively analyzed in all pts with BRCP treated with GnRH at PSA thresholds according to pre-treatment PSADT (10-15ng/mL, 15-20, and 20-30 for PSADT ≤3 mos, 3-9 mos, and ≥ 9 ms, respectively) and continued until PSA nadir. Antiandrogen (AA) was added for PSA > 1.0 ng/mL after 3 mos). Follow-up (FU) consisted of PSA and T q3 mos. Cycles were repeated at the above preselected PSA thresholds and continued until lack of PSA response. Scans were obtained prior to cycles and at the time of CRPC state. Mixed effects model was used to study PSADT change over cycles. Multivariate cox regression model was used to identify prognostic variables. Results: From 1995-2010, with a mean FU of 71 mos (range 22-183 months), 96 pts received a mean of 2.8 cycles (range 1-9) of IAD; 58 (60%) remain on treatment and 38 (40%) were switched to continuous ADT due to PSA refractoriness (n=11) or positive scans (n=27). PSADT at the first off treatment (tx) interval (mean 3.1, 0.59-30.5 range, median 2.3) was significantly shorter than the baseline (p<0.0001; mean 9.7, range 0.27-53.9, median 7.34) but remained relatively stable (p=0.29) in subsequent cycles. PSADT adjusted for T recovery (≥3 ms after T recovery to ≥ 150 ng/dL) was significantly longer (p=0.006) than that based only on all PSA determinations (mean 5.4, range 1.31-30.5, median 3.7 versus mean 3.1, range 0.59-30.5, median 2.3). Significant factors associated with probability of PSA refractoriness were pre-IAD PSADT (≥ 6 vs <6 ms), first off tx interval PSADT (≥3 ms vs <3m), the use of AA during first tx cycle, and PSA nadir during the first tx interval (<0.1 vs ≥0.1 ng/mL). Conclusions: Our data suggest that PSADT becomes shorter after the initial cycle of IAD and correlate with T recovery. PSA dynamics and need for AA to enhance PSA nadir are associated with PSA refractoriness in pts BRPC treated with IAD. No significant financial relationships to disclose.

Giant Melanoma: Novel Problem, Same Approach

Thick melanomas are relatively common; however, melanomas greater than 10 cm in size are rarely encountered. Though the size may seem daunting, the work up and principles of wide surgical excision remain the same. Sentinel lymph node biopsy should also be considered in patients with no clinical evidence of metastatic disease.

Clinical and histopathological risk factors to predict sentinel lymph node positivity, disease-free and overall survival in clinical stages I–II AJCC skin melanoma: Outcome analysis from a single-institution prospectively collected database

Background To investigate if the tumour infiltrating lymphocytes (TILs) are able to predict the sentinel lymph node (SLN) positivity, the disease-free survival (DFS) and overall survival (OS) in clinical stages I-II AJCC primary cutaneous melanoma (PCM). Methods The study included consecutive patients with PCM, all diagnosed, treated and followed up prospectively. Logistic regression was used to investigate the association between DFS, OS, SLN positivity and Breslow thickness, Clark level, TIL, ulceration, lesion site, gender, regression and age. Results From November 1998 to October 2008, 1251 consecutive patients with PCM were evaluated. Median age was 51 (range 15–96) with 32.2% ( N = 393) of them older than 60; 44.8% of them were males. Of the whole series, a total of 404 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease underwent SLN biopsy. Of these, 74 (18.8%) had a positive SLN. In a multivariate analysis, primary melanoma on the extremities versus that on the axial locations (truncal and head/neck) (OR 0.49, 95% CI 0.25–0.98, p 0.04) and TILs (TILs versus no TILs) (OR 0.47, 95%CI 0.25–0.90, p 0.02) were predictive for lower probability of SLN involvement, while thickness (>4 mm versus 0–1 mm) (OR 24, 19, 95% CI 4.91–119.13, p < .001) was predictive for higher risk of SLN positivity. A multivariate stepwise analysis confirmed these results. The histological status of the SLN was the most significant predictor of DFS and OS. Patients with a negative SLN had a 5-year DFS of 75.9%, compared with 35.2% in patients with a positive SLN ( p < .0001) and a 5-year OS of 88.7% versus 42.9%, respectively ( p < .0001). Conclusions Our study demonstrates that the absence of TILs predicts SLN metastasis, in multivariate analysis the SLN positivity predicts DFS and OS.

Single Center Preliminary Experience with Hand-Assisted Laparoscopic Resection of Isolated Renal Cell Carcinoma Fossa Recurrences

Solitary metastasis to the renal fossa after radical nephrectomy for renal cell carcinoma is uncommon. We report the first series on hand-assisted laparoscopic excision for renal cell carcinoma fossa recurrences. We performed a retrospective review of patients who underwent hand-assisted laparoscopic excision of renal cell carcinoma fossa recurrence. Patients with distant metastasis or local lymph node or adrenal metastasis were excluded from analysis. We collected data on patient and tumor characteristics, nephrectomy and fossa mass excision procedures, and postoperative outcomes. Between 2001 and 2007, 5 patients underwent laparoscopic resection of a renal fossa recurrence. Mean time to recurrence after radical nephrectomy was 23 months (range, 5 to 46 months) and mean size of the renal fossa mass was 6 cm (range, 4.2 to 9.5 cm). The average operative time was 232 minutes (range, 150 to 300 minutes) and average estimated blood loss was 175 mL (range, 25 to 400 mL). One patient required conversion to open surgery. There were no postoperative complications and mean hospital stay was 4 days. With mean follow-up of 43 months, the cancer-specific and disease-free survival rates were 60% and 20%, respectively. Of the 4 patients who underwent complete resection, 2 died from metastatic disease at 13 and 56 months, 1 continues to have progressive metastatic disease at 69 months, and 1 remains free of any clinical evidence of metastatic disease or recurrence at 37 months. One patient who underwent incomplete resection as a result of inferior vena cava invasion continues to have progressive local and distant metastatic disease at 40-month follow-up. Hand-assisted laparoscopic excision of renal fossa recurrence after radical nephrectomy appears to be safe and effective for carefully selected patients.

Predicting sentinel node status in AJCC stage I/II primary cutaneous melanoma

Sentinel lymph node (SLN) status is an important prognostic factor for survival for patients with primary cutaneous melanoma. To address the issue of selecting patients at high and low risk for a positive SLN, prognostic factors were sought that predict SLN involvement by examining characteristics of both the primary tumor and the patient within the context of a biological model of melanoma progression. The study included 682 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease who underwent SLN biopsy (1995-2003). Logistic regression and classification tree analyses were used to investigate the association between SLN positivity and Breslow thickness, Clark level, tumor infiltrating lymphocytes (TIL), ulceration, mitotic rate (MR), lesion site, gender, and age. RESULTS.: In all, 88 of the 682 patients had > or =1 positive SLN (12.9%). In the multivariate analysis, MR, TIL, and thickness were found to be independent prognostic factors for SLN positivity. In the classification tree, four different risk groups were defined, ranging from minimal risk (2.1%) to high risk (40.4%). In lesions < r =2.0 mm, MR was important in risk-stratifying patients, and in lesions >2.0 mm TIL was important. By incorporating biologically based variables such as VGP, TIL, and MR along with thickness into a prognostic model, both patients at high risk and minimal risk for SLN positivity can be identified. If validated, this model can be used in patient management and trial design to select patients to undergo or be spared SLN biopsy.

No immediate treatment after biochemical failure in patients with prostate cancer treated by external beam radiotherapy

Objectives The treatment of patients with asymptomatic prostate cancer with biochemical failure (BF) remains controversial. The early introduction of hormonal therapy causes important secondary effects and increases costs. Our general policy has been to follow-up patients with low prostate-specific antigen (PSA) levels and a long PSA doubling time without therapy. We report our experience using such an approach. Methods Between 1992 and 2000, 676 patients with localized prostate cancer were treated with radical radiotherapy, with or without adjuvant hormonal therapy at our institution. Asymptomatic patients with BF, no clinical evidence of metastatic disease, a low PSA level, and long PSA doubling time were considered for follow-up without immediate hormonal therapy. The prognostic factors such as stage and Gleason score were not considered when electing follow-up without additional therapy. The follow-up included at least two annual visits with physical examination and PSA determination. Results With a median follow-up of 85 months, 285 patients (42%) had BF. In 178 of these men, the rising PSA level was the only abnormality. Of these, 113 were followed up without additional therapy and 65 received hormonal therapy. Of the 113 patients in the untreated group, 101 (89%) were alive and asymptomatic at the last follow-up visit and 12 (11%) had died of causes other than prostate cancer. The long-term outcomes were similar in both groups. Conclusions Expectant management, without initial hormonal therapy, may be a reasonable option for selected patients with prostate cancer who present with BF without metastatic disease after radical external beam radiotherapy. This decision is important because the early introduction of hormonal therapy is associated with side effects and is expensive.

Haemangiopericytoma of the sigmoid mesentery

Haemangiopericytoma is a rare, vascular soft tissue tumour originating from the pericytes surrounding capillaries. We report a case of haemangiopericytoma in the sigmoid mesocolon and are aware of only one previously case. A 61-year-old man was referred with a left iliac fossa mass. At operation, a 10-cm diameter mass was found to be arising from the sigmoid mesentery (Fig. 1). The mass did not involve the bowel wall and there was no clinical evidence of metastatic disease. A sigmoid colectomy with primary anastomosis was performed. The patient made an uneventful recovery. Pathological assessment of the specimen revealed a 95 x 70 x 50 mm(3), purple, lobulated mass within the sigmoid mesocolon adjacent to the bowel. Immunohistological analysis (positive CD34, focal factor VIII) was consistent with a diagnosis of a haemangiopericytoma. Complete excision with adequate margins remains the treatment of choice. We therefore suggest that patients be carefully followed for long periods and advised of the risk of long-term relapse.

Desmoplastic and neurotropic melanoma.

Desmoplastic and neurotropic melanoma (DNMM) occasionally metastasizes to regional lymph nodes and extranodal sites. The value of sentinel lymph node biopsy (SLNB) has not been demonstrated clearly for patients with DNMM. The authors report on the utility of SLNB in the management of patients with DNMM. The authors identified 33 patients with DNMM who were seen during a 5-year period in their institution who underwent lymphatic mapping and SLNB. Clinical and histopathologic data were reviewed. Thirty-three patients with DNMM underwent SLNB (mean Breslow depth, 4.0 mm; median, 2.8 mm). There were 25 male patients and 8 female patients with a median age of 61 years (range, 31-86 years). Fifty-two percent of tumors presented in the head and neck region, and 24% were associated with lentigo maligna. Four of 33 patients (12%) without clinical evidence of metastatic disease who underwent SLNB had at least 1 positive sentinel lymph node. No additional positive lymph nodes were found in subsequent therapeutic regional lymphadenectomy in any of these four patients. SLNB detected subclinical metastases of DNMM to regional lymph nodes. SLNB at the time of resection can provide useful information to guide early treatment and, coupled with lymphadenectomy in positive patients, may limit tumor spread and prevent recurrence at the draining lymph node basin.

Salvage radiotherapy in the treatment of prostate cancer

For patients undergoing radical prostatectomy for prostate adenocarcinoma, the most common cause of failure is an asymptomatic increase in levels of prostate-specific antigen (PSA). Salvage radiotherapy (RT) to the prostate bed has been used when there is no clinical evidence of metastatic disease. However, this is still not widely accepted because there is currently no consensus on the optimal management of an isolated PSA failure. Salvage RT given in a select group of patients is effective, with a 70% to 80% biochemical response rate and a long-term biochemical control rate as high as 35% to 40%. These data indicate that RT offers a substantial risk of curative salvage of patients who fail radical prostatectomy. Although there is interest in studying investigational modalities (eg, vaccine therapy) among patients with asymptomatic, PSA-detected recurrences after surgery, caution must be applied, and treatment modalities with known curative potential (ie, RT) should be used before noncurative techniques are attempted. This article outlines the rationale, results, and toxicity of salvage RT for an asymptomatic increase in PSA levels, with emphasis on identifying patients with favorable prognostic factors with higher rates of long-term biochemical control with local treatment.

Lymphatic mapping and sentinel lymph node biopsy in the detection of early metastasis from sweat gland carcinoma.

Several subtypes of sweat gland carcinoma have been found to demonstrate a propensity to metastasize systemically and to regional lymph nodes. The predictive value and benefit of sentinel lymph node (SLN) biopsy have been established in numerous other malignancies, but to the authors' knowledge there is little literature published to date regarding the use of SLN biopsy in patients with sweat gland carcinoma. In the current study, the authors demonstrated the utility of SLN biopsy in detecting subclinical metastases of sweat gland carcinoma, which may result in early treatment. The authors identified five patients with malignant eccrine tumors in whom SLN biopsy was performed at the study institution. Clinical and histopathologic data were reviewed. The five study cases included two cases of aggressive digital papillary adenocarcinoma (both occurring on upper extremity digits), two cases of hidradenocarcinoma (occurring on the knee and foot, respectively), and an eccrine carcinoma (occurring on the scalp). In each biopsy-established case, there was no clinical evidence of metastatic disease, and a wide local excision or amputation was performed with concurrent SLN biopsy. Four of 18 SLNs in 3 of the 5 patients (60%) were found to be positive for metastatic carcinoma, as identified in hematoxylin and eosin stains and/or cytokeratin immunohistochemical stains. All three lymph node-positive patients subsequently underwent regional lymphadenectomy and were found to have no evidence of additional metastases. The results of the current study demonstrate that SLN biopsy detects subclinical metastases from sweat gland carcinomas to regional lymph nodes. SLN mapping and biopsy at the time of resection can provide useful information with which to guide early treatment. Further studies are necessary to determine whether this procedure results in a survival benefit in patients with sweat gland carcinomas.

Sentinel node biopsy in the management of malignant melanoma

The technique of sentinel lymph node (SLN) biopsy has been in use for almost a decade, but its effect on survival has not yet been established. It is however the most accurate method for staging patients with primary cutaneous melanoma who lack clinical evidence of metastatic disease. This article discusses the rationale and logistics of SLN biopsy, and the management strategies that can be employed in those patients who are SLN positive. Future therapeutic trial in patients with primary cutaneous melanoma will only be meaningful if the SLN status of the subjects is established.

Bilateral breast metastases from choroidal melanoma

PURPOSE: To report an unusual case of solitary sequential bilateral breast metastases from choroidal melanoma. METHOD: Case report. RESULTS: A 48-year-old woman with a large choroidal melanoma in the left eye was treated with Iodine-125 brachytherapy and responded satisfactorily with decrease in tumor thickness. Thirty-seven months after treatment, she developed a solitary, circumscribed melanoma metastasis to the right breast, and 54 months after treatment, a similar metastasis was detected in her left breast. Both breast tumors were managed with lumpectomy. Systemic examination including magnetic resonance imaging of abdomen, chest, and head have been performed regularly and have been normal. At 61 months after treatment, the patient has no clinical evidence of metastatic disease elsewhere. CONCLUSIONS: Uveal melanoma rarely metastasizes to breast tissue. A breast nodule in a patient with a history of uveal melanoma is most likely a primary breast tumor but may rarely represent a metastasis from uveal melanoma.

Treatment of malignant melanoma.

To review the current treatments for cutaneous melanoma and discuss treatment approaches for each patient population. MEDLINE and IOWA database search from January 1990 to December 1998. Clinical trials and review articles were selected and classified to answer questions considered of clinical relevance. Patients with stage I, II, and III melanoma should undergo excision after biopsy. In patients with stage IV melanoma, surgical excision of metastatic melanoma is not considered curative but can provide palliation and improve quality of life. Therapeutic lymph node dissection should be performed in patients with melanoma in stages III and IV once pathologic confirmation is obtained. Patients at high risk for recurrence or metastasis may also be considered for elective node dissection. Adjuvant therapy after surgery excision is not a standard of care in patients with stage I and IIa melanoma. In patients with stage IIb and III melanoma, the best results have been obtained with high doses of interferon alfa-2b, although toxicity is of concern. Isolated limb perfusion with melphalan adjuvant to surgery has demonstrated clinically significant benefit in patients with locally recurrent melanoma and in-transit metastases. Studies comparing efficacy and quality of life with this technique or with high doses of interferon alfa-2b are needed. The technique cannot be recommended for high-risk primary melanoma of an extremity with no clinical evidence of metastatic disease. To date, dacarbazine still appears to be the treatment of first choice in metastatic melanoma, outside of a clinical trial. The combination of chemotherapy with interferon alfa-2b or interferon alfa-2a enhances toxicity without a significant survival advantage. Aldesleukin may be an alternative in selected patients when other treatments have failed, but the higher toxicity and cost must be considered.

Distant metastasis of squamous epithelial carcinomas of the upper aerodigestive tract. The effect of clinical tumor parameters and course of illness

Screening for distant metastases from head and neck tumors is still controversial. In the present study, the records of 1087 patients with newly diagnosed squamous cell carcinomas of the upper aerodigestive tract were reviewed retrospectively to determine clinical factors influencing the incidence and location of distant metastases. Overall, 130 patients (12.0%) developed clinical evidence of metastatic disease, 17 of whom (1.6%) had metastases at the time of initial presentation. The rate of distant metastases significantly increased with the initial stage of tumors (P < 0.00001) and the occurrence of local and/or regional recurrences (P < 0.00001) or of second primaries below the clavicles (P < 0.0005). The locations of primary cancers as well as histopathologic grading were not independent risk factors for the development of distant metastases. They mainly reflected different frequency distributions of stages. The lungs, liver and bones were the most common sites of metastatic disease, being involved in 68.5%, 23.8% and 20.0% of cases, respectively. Our findings show that at the time of initial presentation chest X-ray alone appears to be sufficient to exclude distant metastases from tumors classified as T1-3 NO. Further screening comprising abdominal ultrasound, bone scanning and/or CT scans of the thorax is particularly indicated for patients with advanced-stage disease, local and/or regional recurrences and second primaries below the clavicles. However, the individual decisions should consider whether the detection of distant metastases will significantly affect clinical management.

Current trends in the detection and management of carotid body tumors

Purpose: Because the natural history of carotid body tumors is believed to be unpredictable, immediate surgical removal has been recommended. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions. Methods: The medical records of patients who appeared for treatment with carotid body tumors between 1981 and 1997 were reviewed. Patients demographics, mode of presentation, imaging and treatment modalities, Shamblin classification, and neurologic complications (stroke, cranial nerve injuries) were analyzed. Results: Over the past 16 years, 31 patients with 32 carotid body tumors have been evaluated, with an average follow-up of 3.2 years. The patients were arbitrarily classified into two groups on the basis of the mode of detection. Seventy percent (23 of 32) of the tumors discovered on clinical or self-examination were classified as Group 1; 28% (9 of 32) of the tumors detected during duplex scanning for carotid artery disease (8) or MRI (1) were classified as Group 2. The mean size of chemodectomas found on palpation (4.3 ± 1.7 cm) was larger than that of those detected by duplex ultrasound (2.7 ± 1.0 cm; p < 0.05, by paired t test). Preoperative embolization was successfully performed in 5 of 6 instances of large tumors; the remaining patient suffered a procedure-related stroke. Thirty-one carotid body tumors were resected. In one case, the tumor was felt by the primary surgeon to be too small (0.9 × 0.7 cm on duplex scan) to warrant immediate excision; this patient is being followed by periodic duplex scanning. Five neurologic complications were noted in Group 1, one after preoperative embolization and four after surgery. One cranial nerve injury occurred in Group 2. One patient had a large recurrent chemodectoma with clinical evidence of metastatic disease. Conclusion: The increasing use of sophisticated imaging modalities may allow earlier discovery of carotid body tumors before they can be clinically detected. Resection of carotid body tumors of all sizes in appropriate surgical candidates remains the standard of care. Unfortunately, resection of even small tumors is associated with a low but constant incidence of neurologic complications. (J Vasc Surg 1998;28:84-93)

Detection of Unsuspected Metastasis in a Melanoma Patient With Positron Emission Tomography

A 41-year-old obese woman had a nodular melanoma removed from the right calf 14 years ago. At the time of the diagnosis, she also underwent right inguinal lymph node dissection with no evidence of metastatic tumor. She presented with a new 2 cm mass just above the excision site on the calf wound. Fine needle aspiration was consistent with recurrent melanoma. Chest x-ray results were negative, and the patient had no clinical evidence of metastatic disease. Whole body PET images were obtained approximately 1 hour after injection of 10 mCi of F-18 FDG.