Complete Resection Of Gross Disease Research Articles

External-beam radiotherapy for differentiated thyroid cancer locoregional control: A statement of the American Head and Neck Society.

The use of external-beam radiotherapy (EBRT) in differentiated thyroid cancer (DTC) is debated because of a lack of prospective clinical data, but recent retrospective studies have reported benefits in selected patients. The Endocrine Surgery Committee of the American Head and Neck Society provides 4 recommendations regarding EBRT for locoregional control in DTC, based on review of literature and expert opinion of the authors. (1) EBRT is recommended for patients with gross residual or unresectable locoregional disease, except for patients <45 years old with limited gross disease that is radioactive iodine (RAI)-avid. (2) EBRT should not be routinely used as adjuvant therapy after complete resection of gross disease. (3) After complete resection, EBRT may be considered in select patients >45 years old with high likelihood of microscopic residual disease and low likelihood of responding to RAI. (4) Cervical lymph node involvement alone should not be an indication for adjuvant EBRT.

Microscopic Margins of Resection Influence Primary Gastrointestinal Stromal Tumor Survival

Background: Primary gastrointestinal stromal tumors (GISTs) are stromal tumors that arise from the gastrointestinal tract. Both surgical resection and molecular therapy are crucial in the treatment of these tumors. This study analyzes the outcomes of 151 patients with GIST treated at 3 institutions. These institutions comprise the GISTologist Study Group and provided follow-up data. Patients and Methods: 151 patients with primary GIST were admitted and treated at the St. Orsola-Malpighi University Hospital in Bologna, Italy, the Catholic University Hospital in Rome, Italy, and the Modena University Hospital and National Cancer Institute in Naples, Italy, over the past 11 years. Patient data as well as tumor and therapy variables were studied to identify factors predicting survival with a focus on the microscopic margins of resection. Results: All 151 patients had primary disease without metastasis and underwent complete resection of gross disease. The 5-year disease-free survival rate was 77%. Disease-free survival was predicted by tumor size, mitotic count, and margins of resection. Recurrence of disease after resection was predominantly intra-abdominal. Conclusions: Tumor size, mitotic count, and microscopic margins of resection predict disease-free survival in patients with primary GIST.

Gastrointestinal stromal tumors (GISTs), 10-year experience: Patterns of failure and prognostic factors for survival of 127 patients

BackgroundGastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (GIT) and are believed to originate from the interstitial cell of Cajal. Management of GIST has evolved very rapidly in the last decade. AimTo report our surgical experience in the treatment of GIST patients, to evaluate the prognostic factors and to discuss some controversial issues about the role of target therapy. Patients and methodsOne hundred and twenty seven consecutive patients who underwent surgical resection for GISTs at Nasser Institute (98 patients) and NCI, Cairo University (29 patients) from January 2000 to December 2009 were reviewed retrospectively. The clinical and pathological features of patients were collected. Also data about treatment variables, patterns of failure and factors that predict survival were collected and analyzed. ResultsOf the 127 patients, 81 (64%) had primary disease without metastasis, 11 (9%) had metastatic lesions at presentation, and 35 (27%) presented with recurrence (isolated, metastasis or both). Patients with primary disease underwent complete resection of gross disease. The 5-year overall survival was 53.4% and disease free survival (DFS) was 46.5%. The median DFS was 43.0months (95% CI: 21.2–64.9). On multivariate analysis, survival was affected by mode of presentation, gastric origin and tumor size. Failures after resection were predominantly intra-abdominal (original site, peritoneal, and liver), and rarely lungs. ConclusionSurgical resection is the mainstay of treatment of GIST. Tumor size and gastric origin were the predicators for DFS in patients presenting with primary disease.

Aerodigestive Tract Invasion by Well‐Differentiated Thyroid Carcinoma: Diagnosis, Management, Prognosis, and Biology

1) To describe the clinical entity invasive well-differentiated thyroid carcinoma (IWDTC), 2) to determine prognostic factors for survival in patients with IWDTC, 3) to describe and compare types of surgical resection to determine treatment efficacy, 4) to offer a staging system and surgical algorithm for management of patients with IWDTC, 5) to examine alterations in expression of E-cadherin and beta-catenin adhesion molecules in three groups of thyroid tissue and propose a cellular mechanism for invasion of the aerodigestive tract. Basic science: quantification of expression of E-cadherin and beta-catenin in three groups of thyroid tissue. Clinical: retrospective review of patients with IWDTC surgically treated and followed over a 45-year time period. Basic science: immunohistochemical staining was used with antibodies against E-cadherin and beta-catenin in three groups of tissue: group 1, normal control thyroid tissue (n = 10); group 2, conventional papillary thyroid carcinoma (n = 20); group 3, IWDTC (n = 12). Intensity scores were given on the basis of protocol. One-way analysis of variance (ANOVA) was used to evaluate differences between groups. Post hoc ANOVA testing was completed. P < .05 was significant. Clinical: patients were divided into three surgical groups within the laryngotracheal subset: group 1, complete resection of gross disease (n = 34); group 2, shave excision (n = 75); group 3, incomplete excision (n = 15). Cox regression analysis was used to determine significance of prognostic factors. Kaplan-Meier plots were used to evaluate survival. P < .05 was significant. Basic science: a significant difference between the three thyroid tissue groups for E-cadherin expression was demonstrated on one-way ANOVA testing. When controls were compared with either experimental group in post hoc ANOVA testing, differences between all groups were demonstrated (P < .001). For beta-catenin, the intensities of the three groups were not different by one-way ANOVA testing. Similar nonsignificant results were found on post hoc ANOVA testing. Clinical: there was a statistically significant difference in survival for patients with and without involvement of any portion of the endolarynx or trachea (P < .01). There was a significant difference among all three surgical groups when compared (P < .001). When complete and shave groups were compared with gross residual group there was a significant decrease in survival in incomplete resection group (P < .01). Cox regression analysis demonstrated invasion of larynx and trachea were significant prognostic factors for poor outcome. The type of initial resection was significant on multivariate analysis. Removal of all gross disease is a major factor for survival. Basic science: there is a decrease in membrane expression of E-cadherin in IWDTC, and loss of this tumor suppressor adhesion molecule may contribute to the invasive nature of well-differentiated thyroid carcinomas. Clinical: laryngotracheal invasion is a significant independent prognostic factor for survival. Patients undergoing shave excision had similar survival when compared with those undergoing radical tumor resection if gross tumor did not remain. Gross intraluminal tumor should be resected completely. Shave excision is adequate for minimal invasion not involving the intraluminal surfaces of the aerodigestive tract.

Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy with mitomycin C for peritoneal carcinomatosis from nonappendiceal colorectal carcinoma.

Cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC) are efficacious in patients with disseminated mucinous tumors of the appendix. We reviewed our experience using this approach for nonappendiceal colorectal cancer (NACC). We performed a retrospective chart review of a prospective database for patients undergoing CS and IPHC with mitomycin C for peritoneal carcinomatosis from colorectal primary lesions between December 1991 and April 2002. There were 77 patients, with a median age of 54 years. Peritoneal carcinomatosis was synchronous and metachronous in 27% and 73% patients, respectively. Seventy-five percent of patients (n = 58) had received chemotherapy prior to IPHC. Complete resection of all gross disease was accomplished in 37 patients (48%). The mean carcinoembryonic antigen level decreased from a preoperative value of 31.2 to a postoperative value of 6.9 (P <.0001). Overall survival (OS) at 1, 3, and 5 years was 56%, 25%, and 17%, respectively. With a median follow-up of 15 months, the median OS was 16 months. Perioperative morbidity and mortality were 30% and 12%, respectively. Hematologic toxicity occurred in 15 patients (19%). Cox regression analysis identified poor performance status (P =.018), bowel obstruction (P =.001), malignant ascites (P =.001), and incomplete resection of gross disease (P =.011) as independent predictors of decreased survival. Patients with complete resection of all gross disease had a 5-year OS of 34%, with a median OS of 28 months. CS and IPHC with mitomycin C can improve outcomes for select patients with peritoneal spread from NACC. One third of patients who undergo complete resection of gross disease have long-term survival.

Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival.

To analyze the outcome of 200 patients with gastrointestinal stromal tumor (GIST) who were treated at a single institution and followed up prospectively. A GIST is a visceral sarcoma that arises from the gastrointestinal tract. Surgical resection is the mainstay of treatment because adjuvant therapy is unproven. Two hundred patients with malignant GIST were admitted and treated at Memorial Hospital during the past 16 years. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor recurrence and factors that predict survival. Of the 200 patients, 46% had primary disease without metastasis, 47% had metastasis, and 7% had isolated local recurrence. In patients with primary disease who underwent complete resection of gross disease (n = 80), the 5-year actuarial survival rate was 54%, and survival was predicted by tumor size but not microscopic margins of resection. Recurrence of disease after resection was predominantly intraabdominal and involved the original tumor site, peritoneum, and liver. GISTs are uncommon sarcomas. Tumor size predicts disease-specific survival in patients with primary disease who undergo complete gross resection. Tumor recurrence tends to be intraabdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

2131 Results of postoperative irradiation for squamous cell carcinoma of the head and neck: Is there a difference between primary and recurrent disease?

Purpose/Objective: Postoperative irradiation (XRT) following surgical resection is the often recommended treatment for resected advanced primary and resected recurrent squamous cell carcinoma (SCC) of the head and neck. Despite common use, there is little literature comparatively evaluating the results of such a management approach between those patients irradiated postoperatively for primary versus recurrent disease. This study evaluates the efficacy of postoperative XRT in patients with recurreni SCC of the head and neck and compares their outcome to patients with primary SCC of the head and neck treated with postoperative XRT over the same time period. Materials & Methods: Between 1981 and 1993, 174 patients with SCC of the head and neck, 143 with primary and 31 with recurrent disease, were treated with standard postoperative XRT. All had complete resection of gross disease, no distant metastasis, or prior XRT. All patients were treated with non-split course XRT at 1.8-2.0 Gy per fraction. Median total postoperative XRT dose was 66 Gy (range = 50. 72Gy). Median follow-up is 68 months (range = 22-159 months). Several potential prognostic factors for disease-specific survival (DSS) and local-regional control (LRC) were analyzed and included tumor type (primary vs. recurren& site and stage of original tumor, status of surgical margins, disease-free interval, site and extent of recurrence, and dose. Results: For all 174 patients, the .5-year DSS and LRC rates were 50% and 65%, respectively. On univariate analysis, both tumor type and original tumor site significantly influenced DSS and LRC. Patients treated forprimary disease had 5.year DSS and LRC rates of 54% and 69%, respectively, as compared to 32% and 46%, respectively for patients treated for recurrem disease (P=O.O4 and 0.03, respectively). Patients with a non-oral cavity original tumor had 5-year DSS and LRC rates of 55% and 73%, respectively, as compared to 39% and 44%, respectively, for patients with an oral cavity original tumor ( P=O.O5 and 0.002, respectively). On multivariate analysis, only primary tumor site significantly influenced DSS (P=O.O4) and only tumor type significantly influenced LRC (P=O.O03). Among the 143 patients treated for primary disease, no factors analyzed significantly influenced DSS, while on multivariate analysis, only surgical margin status significantly influenced LRC. Patients treated for primary disease with negative margins had a 5-year LRC rate of 78% as compared to 61% for those with positive /close margins (P&03). Among the 3 1 patients treated for recurrent disease. the factor which significantly influenced both DSS and LRC on multivariate analysis was site of recurrence. Patients whose recurrence was limited to previously undissected tissue had 5-year DSS and LRC rates of 60% and 74%, respectively, as compared to 19% and 29%, respectively, for patients whose recurrence was within previously dissected tissue (P=O.OOl and 0.008, respectively). Conclusion: Patients with recurrent SCC of the head and neck do poorly when treated with standard postoperative XRT following surgical resection, especially if the recurrence is within previously dissected tissue, as compared to patients treated forprimaiy disease. This may be related to the negative effects of hypoxia on the efficacy of XRT or an intrinsically resistant tumor clone. This patient group should be targeted for alternative local treatment strategies, including dose escalation and/or altered fractionation.