Conservative Surgery Group Research Articles

Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients

Until now, less than 5% of the patients with breast ductal carcinoma in situ (DCIS) have been enrolled in clinical trials. Consequently, we have analysed the results of ‘current practice’ among 716 women treated in eight French Cancer Centres from 1985 to 1992: 441 cases (61.6%) corresponded to impalpable lesions, 92 had a clinical size of less than or equal to 2 cm and 70 from 2 to 5 cm; in 113 cases, the size was unspecified. Median age was 53.2 years (range: 21–87 years). 145 patients underwent mastectomy (RS) and 571 conservative surgery (CS) without (136) or with (435) radiotherapy (CS+RT). The mean histological tumour sizes in these three groups were 25.6, 8.2, 14.8 mm, respectively ( P<0.0001). After a 91-month median follow-up, local recurrence (LR) rates were 2.1, 30.1 and 13.8% in the RS, CS and CS +RT groups, respectively ( P=0.001); LR were invasive in 59 and 60% in the CS and CS+RT groups, respectively. In these groups, the 8-year LR rates were 31.3 and 13.9%, respectively ( P=0.0001). Nodal recurrence occurred in 3.7 and 1.8% in the CS and CS+RT groups. Metastases rates were 1.4, 4.4 and 1.4% in the RS, CS and CS+RT groups. Among the 60 cases of invasive LR, in CS and CS+RT groups 19% developed metastases. After multivariate analysis, we did not identify any significant LR risk factor in the CS group, whereas young age (<40years) and incomplete excision were significant in the CS+RT group ( P=0.012 and P=0.02, respectively).

Surgical management of posterior pharyngeal wall carcinomas: Functional and oncologic results

The optimal primary treatment for posterior pharyngeal wall tumors remains controversial. To assess the relevance of surgical treatment from a functional and oncologic point of view, we reviewed the cases of 77 patients surgically treated between 1984 and 1995. Among them 23 had been previously irradiated. Fifty-five patients underwent a conservative surgery (CS) sparing the larynx; 19 direct closures, 6 reconstructions of the posterior wall with a thoracic myocutaneous flap, 15 with a platysma flap, and 15 with a free forearm flap were performed. Twenty-two patients underwent radical surgery (RS). All previously untreated patients had postoperative radiotherapy. The functional assessment concerned the CS group. Oncologic results, especially local control and survival were studied for the whole group. Of the 55 patients who underwent CS, 53 (96%) had their canula and 49 (89%) their feeding tube removed. At 1 year, in the platysma and free forearm groups, 21 of the 24 assessable patients were back to exclusive oral intake. For patients treated by primary surgery followed by radiotherapy, the rate of local failure was 11% (18% for tumors greater than 4 cm), and the 5-year survival rate was 35%. For patients who had previous radiotherapy, the rates were, respectively, 52% and 16%. The satisfactory functional results, caused by the improvement of reconstructive procedures, allow conservative surgery even in the case of large tumors. Oncologic results, especially local control, suggest that primary surgery followed by radiotherapy is effective for the treatment of posterior wall cancer. The oncologic results of surgery in a previously irradiated area are poor, and CS is not recommended in these cases.

Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of protocol B-17

Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of protocol B-17

Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight‐year update of protocol B‐17

Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight‐year update of protocol B‐17

Conservative surgery for malignant ovarian tumor in women of childbearing age

Background. The traditional operative procedures for the treatment of ovarian cancer have been simple total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. However, young patients who want to preserve fertility are occasionally encountered. This study was designed to assess the results of conservative surgical management for young women with stage I epithelial ovarian carcinoma or malignant germ cell tumor and to explore the indications for such surgical treatment. Methods. Fifty-eight patients aged under 35 years were treated for malignant ovarian tumors (germ cell tumor, n = 20; epithelial tumors, n = 38) between 1971 and 1996. We studied all 20 patients with germ cell tumors and 22 pa-tients with stage I epithelial tumors; we excluded the 12 patients with stage II and more advanced disease and the 4 patients with stage I clear cell carcinoma, because these patients had poor prognoses. Eleven of the 22 patients with stage I epithelial tumors and 8 of the 20 patients with germ cell tumors received conservative surgery (conservative surgery group); the remaining 23 patients underwent radical surgery, including hysterectomy and bilateral salpingo-oophorectomy (radical surgery group). The overall survival rates of the two groups were compared, and ovarian function and pregnancy outcome were evaluated in the conservative surgery group. Results. Of the patients with malignant epithelial tumor who were treated with conservative surgery, 3 patients with stage Ic mucinous adenocarcinoma died 1 year and 8 months, 7 years and 6 months, and 8 years, respectively, after the initial surgery. The 10-year survival rate was 65% for the conservative surgery group and 91% for the radical surgery group. All patients with stage Ia epithelial tumors in both groups survived, and there were no differences in survival curves between the two groups among the patients with stage Ic epithelial tumors. All patients with germ cell tumors in the conservative surgery group survived. Their survival rate, however, was not significantly better than that in the radical surgery group. All patients with germ cell tumors who received platinum-based chemotherapy survived and had a significantly better survival rate than those who received non-platinum-based regimens (P < 0.05). All the patients in the conservative surgery group received postoperative chemotherapy; 10 of these patients had transient ovulation failure after the completion of chemotherapy, although a normal menstrual cycle was restored within 1 year. Of the 10 patients who wished to have babies, 6 became pregnant, and they have had a total of 11 children. Conclusion. Conservative surgery is feasible in patients with stage Ia epithelial carcinoma and germ cell tumor. Postoperative chemotherapy suppressed ovarian function in these patients, but only for a brief period.

Conservative management of T1-T2N0 supraglottic cancer: A retrospective study

Purpose: Evaluate the results of conservative management of early-stage supraglottic cancer. Patients and Methods: A retrospective analysis of 166 consecutive T1-T2N0 cases of squamous cell carcinoma of the supraglottic larynx, treated conservatively between 1983 and 1992, was performed. Sixty-six patients received conservative surgery (CS), whereas 100 patients received definitive radiation therapy (RT). Surgical procedures included horizontal supraglottic laryngectomy in 38 patients, extended supraglottic laryngectomy in 16 patients, and reconstructive laryngectomy with cricohyoidopexy in 12 patients. Elective bilateral neck dissection was always performed. Radiotherapy was delivered with 60Co or 6 MV photons to the primary laryngeal tumor and the upper and mid neck nodes (level II and III), whereas supraclavicular nodes (level IV) were electively irradiated only in 54 patients with T2N0 tumors. Fifty-two patients received conventional fractionation, whereas 31 patients were irradiated according to a twice-a-day fractionation regimen. The median total tumor dose was 67 Gy (range, 64 to 72 Gy). Results: The 5-year overall survival of the whole series was 72.7% ± 4.5. In patients treated with CS, the 5-year disease-free survival was 88.4% ± 4.5 versus 76.4% ± 6.1 for patients who received RT Salvage surgery was effective in rescuing 2 of 3 CS failures and 12 of 25 RT failures. The overall incidence of secondary tumors (11 %) and distant metastases (5%) was relatively low, although together they account for 15% of all deaths. Complications of CS were significantly correlated to the extent of surgical procedure. A multivariate analysis performed in the RT group showed that performance status, tumor grade, and fractionation regimen significantly influenced disease-free survival. Conclusion: Conservative management of T1-T2N0 supraglottic cancer, either by CS or RT, can achieve good cure rates with larynx preservation for the majority of the patients (82% overall; 95% in the CS group and 72% in the RT group). The decision between different conservative treatment modalities may be influenced by the patient's conditions, tumor characteristics, treatment modalities, and also economic costs.

Ductal carcinoma in situ of the breast: the clinical significance of histological classification.

One hundred and twenty-one cases of ductal carcinoma in situ, including 26 cases with T1a invasive carcinoma, were reviewed. Seventy-nine patients (65%) were treated by mastectomy and 42 (35%) had conservative surgery. Ductal carcinoma in situ was classified as well differentiated (11%), intermediately differentiated (22%) or poorly differentiated (67%) according to nuclear morphology and the presence or absence of cell polarization. Poorly differentiated lesions were significantly larger than intermediately and well differentiated lesions (P = 0.03 and P = 0.01, respectively) and were significantly associated with the presence of extensive necrosis, marked periductal inflammation and periductal fibrosis (P < 0.0001). Invasive carcinoma was more common in the poorly differentiated group (25% compared with 18% in the intermediate group and 8% in the well differentiated group) but this was not statistically significant. The spectrum of differentiation was similar in symptomatic and mammographically detected ductal carcinoma in situ. Clinical follow-up was available in 90 patients (median period 45 months in patients who had undergone mastectomy and 23 months in those who had conservative surgery). Two incidences of recurrent local disease were recorded in the mastectomy group: one patient had well differentiated and the other poorly differentiated ductal carcinoma in situ. No local recurrences were observed in the conservative surgery group, possibly reflecting the shorter follow up period. All histological grades of ductal carcinoma in situ have the potential to progress to invasive carcinoma and mastectomy does not guarantee a cure.

High grade soft tissue sarcoma

The management of our patient was similar to that of many patients with soft tissue sarcomas. His primary care was in a General Hospital where the surgeon had no specialist experience of these tumours and did not anticipate such a diagnosis. As a result the diagnostic procedure was inappropriate and compromised the chances of success of further more radical conservative surgery. Radiotherapy was unable to prevent local recurrence and amputation became necessary. Pulmonary metastases developed and were resected but within a short space of time extensive inoperable metastases recurred. Although these responded to chemotherapy, the response duration was short and the patient died soon afterwards. The major lessons to be learned are the need to have a high index of suspicion about a possible neoplastic cause of increasing soft tissue swellings and to refer patients for biopsy to a specialist centre where there is experience of all aspects of the management of these rare but potentially curable malignancies.

Body Image in Women Treated For Breast Cancer

Body image, as a component of self-concept, was compared in four groups of women (N = 257) who received the most common types of treatment for breast cancer: mastectomy, mastectomy with delayed reconstruction, mastectomy with immediate reconstruction, and conservative surgery. Data were collected by mailed questionnaires using self-report instruments. Comparison of groups using analysis of covariance with age as a covariate indicated that mean body image in the conservative surgery group was significantly more positive than in either the mastectomy group or in the mastectomy with immediate reconstruction group. No differences in self-concept were evident among the four groups.

Paediatric craniopharyngiomas: a regional review.

Forty paediatric craniopharyngioma cases treated between 1956 and 1987 by conservative surgery (15), radical surgery (10), conservative surgery and radiotherapy (9) and shunting (6) are reviewed. The conservative surgery and radiotherapy group's local control and survival (100%) is significantly better than that of any other group. This group also achieved the most consistent level of employment or tertiary education. Overall morbidity was high. Overall survival has improved since 1976. Whether given as an adjuvant or salvage a radiotherapy dose of TDF 83 or greater gave a significantly better survival (100%) than lower doses.

A comparison of repair and replacement for mitral stenosis with partially calcified valve

From January 1978 to December 1987 we operated on 135 patients with calcified mitral stenosis. In 60 patients a conservative operation was performed (group I). Nine patients required mitral annuloplasty associated with the commissurotomy. The other 75 patients underwent mitral valve replacement (group II). In 37 patients a mechanical prosthesis was used and in 38 a biologic one. The patients given mitral valve replacement had a more heavily calcified valve than those undergoing a conservative procedure. Twenty-one patients (12 from group I and 13 from group II) required associated tricuspid annuloplasty. The mean follow-up time was 69.1 months (1 months to 10 years). There were no significant differences between the two groups in terms of operative death (0% and 4%, respectively), postoperative functional class, actuarial survival rate at 10 years (84% and 96%, respectively), and probability of freedom from thromboemboli at 10 years (98% and 96%, respectively). However, the probability of freedom from reoperation at 10 years significantly favored the conservative surgery group (84% and 69%, respectively, p less than 0.01). Finally, the probability of freedom from complications at 10 years was also significantly higher in the conservative surgery group (82% and 64%, respectively, p less than 0.005). Because of these results we believe that conservative surgery is, at present, a better alternative than mitral valve replacement for patients with partially calcified mitral stenosis.

Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors

In a study designed to determine the merit of preserving ovarian function and childbearing capability in women with unilateral malignant ovarian tumors, the results of radical surgery ( n = 86) and conservative surgery ( n = 106) were compared. The mean length of survival was slightly but not significantly shorter following conservative surgery. There were 15 recurrences (14%) and 11 deaths among the conservative surgery group. The incidence of metastasis to the preserved ovary was high. In the most cases restoration of normal menses was fairly rapid after initial treatment, but this appeared to depend on whether or not chemotherapy was given postoperatively, the specific agents used, and the duration of their administration. Hypergonadotropic hypogonadism was the most common finding among the anovulatory patients. Sixteen women experienced a total of 27 pregnancies and 18 normal infants were born. Abortion was induced when conception occurred during a course of chemotherapy. These findings are encouraging in terms of the feasibility of preserving childbearing capability in ovarian cancer patients. However, they also underscore the necessity for close, long-term follow-up, which will be improved as new technologies become available.

Conservation laryngeal surgery. A critical analysis.

Three hundred forty-two cases of laryngeal cancer were treated at the University of Michigan, Ann Arbor. One hundred ten supraglottic cancers and 150 glottic cancers were studied in depth. Conservation surgery was performed on 63 patients. Determinate two-year disease-free survival for glottic cancer was 90% in those irradiated primarily, 83% for those treated with vertical hemilaryngectomy, and 58% in the group that had total laryngectomy. Supraglottic cancers had a determinate survival rate at two years of 62% for those irradiated primarily, 80% for those treated with a supraglottic laryngectomy, and 62% when total laryngectomy was required. The cost of preserving the respiratory and sphincteric functions of the larynx in some cases amounted to the morbidity associated with a protracted hospital stay, altered deglutition, instances of a weak but functional voice, and the possibility of a permanent tracheostomy. Despite high recurrence rates of 30% to 40%, the overall determinate survival with salvage was an acceptable 80% for the conservation surgery group.

Conservative treatment of breast cancer: A trial in progress at the cancer institute of Milan

The report describes a clinical trial on conservative surgery in progress at the National Cancer Institute of Milan, Italy. The randomized clinical trial compares radical mastectomy with a more conservative procedure consisting of mammary resection plus axillary dissection plus radiotherapy. The resection comprises an entire quadrant of the breast together with the overlying skin and the corresponding portion of the fascial sheet of the pectoralis major. The axillary dissection is performed in continuity with the resected breast quadrant except in cases with tumors of lower inner quadrants, who need two separate incisions. After surgery the patients receive 6000 rads to the residual breast tissue over five to six weeks, starting 15 days after operation. The cosmetic results are satisfactory in approximately 70% of cases. The trial is limited to cases with tumors less than 2 cm and no palpable axillary nodes (T1N0M0). Patients with histologically positive lymph nodes (N+) are submitted to adjuvant chemotherapy with CMF for one year. From September 1973, to October 1976, 331 cases entered the trial. One hundred sixty were treated with radical mastectomy and 164 with the conservative procedure. Axillary metastases were found in 23% of the radical and in 29% of the conservative surgery group. Four local-regional recurrences have occurred till now, two in each group. Five cases in the radical mastectomy group and one in the conservative group had distant metastases. The clinical trial will collect some 500 cases by the end of 1977 and significant preliminary results are expected to be available from 1978.

A comparison of conservative and radical surgery combined with radiotherapy in the treatment of stage I carcinoma of the breast.

Abstract A retrospective study was made of 1,008 cases of stage I mammary carcinomas. The treatment of 415 was conservative surgery plus post-operative radiotherapy—of 593 radical mastectomy and radiotherapy. The five-year survival rate for the conservative surgery group was 79 per cent and the ten-year rate 71 per cent; the corresponding figures for the radical surgery group were 82 and 71·5 per cent. These differences were not statistically significant. A local recurrence developed in the spared mammary gland in 25·8 per cent of the patients managed by conservative surgery and was treated by new operation and radiotherapy. The radiotherapy given was with orthovoltage apparatus, with supervoltage apparatus it is possible to give a higher tumour dose and the results may be improved.