Evidence Of Metastasis Research Articles

Tumor vascularity as a prognostic indicator in intermediate-thickness (0.76-4 mm) cutaneous melanoma. A quantitative assay.

Tumor vascularity has been reported to be a prognostic factor in solid tumors. We studied the prognostic value of tumor vascularity in 19 primary stage I skin melanomas. Only intermediate-thickness melanomas (0.76-4.00-mm thick) were studied. They were treated surgically to provide two groups of patients. The first group of 11 patients had no evidence of metastases after a follow-up of a mean period of 72.36 months, whereas the second one developed metastases in a mean period of 46.87 months. The two groups were matched for important prognostic factors including tumor thickness, sex, and age. Vascularity was quantified by a morphometric stereological analysis on paraffin sections stained with anti CD31 monoclonal antibody. The percentage of vascular area was significantly higher in the metastasizing group than in the nonmetastasizing one. Our study suggests that increased vascularity may have a prognostic significance in intermediate-thickness melanoma.

Laparoscopic Retroperitoneal Lymph Node Dissection for Nonseminomatous Germ Cell Tumors: Indications and Limitations

Purpose We describe our experience with laparoscopic retroperitoneal lymph node dissection in 26 patients with nonseminomatous germ cell tumors: 17 had stage I disease with no clinical (computerized tomography, ultrasound or tumor markers) evidence of metastases and 9 (2 with stage IIb and 7 with stage IIc disease) had residual tumor after chemotherapy but with negative tumor markers. Laparoscopic dissection was performed to assess more fully pathological status of the relevant retroperitoneal lymph nodes in both groups. Materials and Methods The patient was positioned and trocars were introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position with 3, 10 mm. and 2, 5 mm. ports). After the white line of Toldt was incised and the colon was reflected anteromedially, the retroperitoneal space was exposed. The landmarks of lymph node dissection were then isolated, including the ureter, aorta, inferior vena cava and both renal veins. Lymph node dissection was performed identical to that for open surgery, with a modified template including the paracaval, interaortocaval, upper preaortic and right common iliac nodes for right tumors, and para-aortic and upper preaortic nodes for left tumors. Lymph node chains were retrieved with a small organ bag. Results The procedure was completed successfully in 16 of 17 patients with stage I disease (mean duration 268 minutes for the left and 312 minutes for the right sides). No intraoperative complications were encountered. One patient had delayed ureteral stenosis requiring operative repair, 1 had a pulmonary embolism with an uneventful outcome and 1 who underwent laparoscopic retroperitoneal lymph node dissection on the right side later had retrograde ejaculation. Embryonal carcinoma was found in 1 of the 17 patients. Average postoperative hospital stay was 4.5 days for patients without complications or conversion to an open procedure. After a median followup of 27 months no patient had regional relapse but 2 had pulmonary metastases that were treated successfully with 3 cycles of platinum based chemotherapy. Laparoscopic dissection was significantly more difficult in patients with stage II tumors after chemotherapy. Only in 2 patients with stage IIb disease was laparoscopic lymphadenectomy successful. In 5 of the 7 patients with stage IIc cancer portions of the dissection had to be done after conversion to an open (conventional) operation via a small incision (suprainguinal or pararectal). In 1 patient the laparoscopic approach was completely abandoned and converted to an open operation via a standard midline incision. In all 9 cases histopathological examination revealed complete necrosis. No patient has evidence of disease. Conclusions Our preliminary experience suggests that a modified laparoscopic retroperitoneal lymph node dissection is feasible for stage I tumors. However, it cannot be recommended after previous chemotherapy (stages IIb and IIc disease).

Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases

Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases

Stage I nonsmall cell lung cancer: A multivariate analysis of treatment methods and patterns of recurrence

Background. Nonsmall cell lung cancer (NSCLC) has become the leading cause of cancer-related deaths in women and men in the United States, with more than 157,000 estimated deaths in 1995. Surgical resection remains the mainstay of therapy in Stage I and II disease. However, local and distant recurrence account for the disappointing survival rates after resection. Appropriate selection of surgical procedures and effective use of adjuvant therapies will depend upon the elucidation of prognostic factors that predict for recurrence. Methods. A detailed analysis was undertaken to evaluate surgical therapy and to define risk factors associated with recurrence and cancer death in 289 consecutive patients with NSCLC who were diagnosed, resected and followed at the Duke University Medical Center from January 1, 1980, until December 31, 1988. These patients had no evidence of metastases on head and chest/abdominal computed tomograms and radionuclide bone scans before resection. Resected specimens from these patients pathologic verification of Stage I disease. Follow-up was complete in all cases through 8/1/94 (median, 61 months). Variables analyzed included age, sex, smoking history, presenting signs and symptoms, operative procedure, histopathology, hospital course including complications, and the time and location of any recurrence or cancer death. Results. The 30-day mortality rate was 5 of 289 (1.7%), with minor and major morbidity rates of 17% and 9%, respectively. Statistical comparison of lobectomy (193) wedge resection (75) and pneumonectomy (21) revealed significantly (P < 0.04) smaller tumors (T 1 ), more comorbidity, and fewer complications for wedge resection patients. A trend (P < 0.09) toward an increased rate of local/regional recurrence and no difference in survival was also observed for wedge resection. One hundred five patients died of cancer (13-month median time to recurrence) for an actual 5-year survival of 63%. Significant univariate predictors of early recurrence and decreased survival (P < 0.01) were : male sex, the presence of symptoms, hemoptysis, chest pain, type of cough, tumor size in cm and by T-classification, visceral pleural invasion, high mitotic index, and vascular invasion. Significant (P < 0.05) multivariate independent variables for early recurrence and cancer death were the presence of symptoms, vascular invasion, pleural invasion, high mitotic index, and tumor size greater than 3 cm. Conclusion. Current surgical therapy for stage I NSCLC has an acceptable morbidity and mortality rate. The current data also stratify patients with Stage I NSCLC into high and low risk populations that can be used in future randomized trials of adjuvant therapy

Rectal carcinoma metastatic to the thyroid gland

Clinically evident metastases to the thyroid gland are rarely found antemortem. A case of a 59-year-old woman with a history of rectal carcinoma, who presented with low back pain and a mass in the right lobe of her thyroid gland, is presented. The tumour of the thyroid was found to be metastatic adenocarcinoma from her previous rectal cancer. Other synchronous metastases were noted in her lumbar spine and kidneys. The clinical finding of metastases to the thyroid gland is rare, particularly from a colorectal primary. One must consider, however, the possibility of a tumour of the thyroid gland representing a secondary malignancy in any patient with a prior history of cancer.

Diagnosis and management of choroidal melanoma

We present a case report of a 40-year-old man with a malignant melanoma of the choroid. Systemic medical evaluation showed no evidence of metastases. Treatment with argon laser photocoagulation was ineffective in producing tumour reduction and resulted in the complications of uveitis, retinal vascular leakage and cystoid macular oedema. Treatment was altered to plaque irradiation with substantial regression of the tumour. We review the differential diagnosis and management of choroidal melanoma with reference to the current literature and to other cases. The role of fluorescein angiography, ultrasound, electro-oculography (EOG) and flicker perimetry in the diagnosis and monitoring of patients is described. The optometric considerations in detection and management of malignant choroidal melanoma are discussed.

Controversies old and new

The most significant contributions to the urological literature in 1995 were in areas of former or continued controversy. Several of these controversial topics have the potential to have an immediate impact on decisions about patient-care decisions. In the area of urinary stone management, Grasso showed that uncomplicated ureteral calculi were treated most cost effectively with endoscopic techniques as opposed to extracorporeal shock-wave lithotripsy (ESWL). While the authors acknowledged that ESWL remains the treatment of choice for most renal calculi, they questioned its cost-effectiveness in treating ureteral calculi. In female urology, Trockman reported the first long-term results (average 9.8 years, range 5-13) of the modified Pereyra bladder-neck suspension for the treatment of stress urinary incontinence. Using questionnaires and outcome analysis, they observed a significantly lower success rate--only a 49% cure of stress incontinence--than with previous studies. Nevertheless, 72% of women were satisfied with the results of surgery. Although questionnaires may eliminate some of the bias introduced by the physician-patient relationship, they also preclude objective physician assessment. In the area of urodynamics, several studies, including one by Yalla confirmed that lower-urinary-tract symptoms associated with benign prostatic hyperplasia (BPH) do not correlate with the presence of urodynamically proven bladderoutlet obstruction. A controversial topic in urology has been the early detection and diagnosis of prostate cancer. Opponents of screening claim that the disease will be overdiagnosed, as most patients will die with, and not of, the disease. Two important articles on the natural history of prostate cancer fuelled the debate concerning early detection of prostate cancer and seem to support early detection. Aus showed that there is a significant risk of dying from localised (non-metastatic) prostate cancer if the disease is not treated with curative intent. They specifically looked at the subgroup of patients without evidence of metastases at diagnosis (M0). The mortality rate due to prostate cancer in this group was 50%. However, M0 patients who lived at least 10 years from the time of diagnosis had an even higher prostate cancer mortality of 63%. Also, as the age at diagnosis decreased, the likelihood of dying from prostate cancer increased. All patients diagnosed at age 55 or less died from the disease. This report was a contradiction of earlier reports with shorter duration of follow-up in older subjects that suggested a significantly lower risk of dying from localised prostate cancer. One of the key factors in the study by Aus seems to be that longer

Short-term outcomes after cryosurgical ablation of the prostate in men with recurrent prostate carcinoma following radiation therapy

Cryosurgical ablation of the prostate represents a possibly efficacious method of treating prostate carcinoma in men failing radiation therapy. In addition to eradicating the disease, cryosurgery has the potential to avoid some of the morbidity associated with other treatment modalities. Therefore, a prospective Phase II trial was conducted to determine the safety and efficacy of cryosurgery following radiation therapy in men with local recurrence. Cryosurgical ablation of the prostate was performed in men with prostate cancer previously treated by radiation therapy. All patients had biopsy-proven recurrent disease and no evidence of metastases. Initial follow-up occurred at approximately 3 months and included repeat biopsy and serum prostate-specific antigen (PSA) determinations. Biochemical disease-free survival defined as a PSA value less than 0.3 ng/mL was assessed using the Kaplan-Meier method. Thus far, 23 patients have been treated with cryosurgery with follow-up ranging between 12 and 23 months. Approximately 3 months after treatment, sextant biopsies revealed no cancer in 19 of 22 (86%) of the specimens; however, 10 of 22 (45%) showed small amounts of benign glandular tissue. The PSA at 3 months postoperatively declined in 18 of 22 (82%) patients but reached female levels in only 8 men (36%). Nineteen of 22 (86%) patients followed up a minimum of 1 year after cryotherapy have a PSA level equal to or greater than 0.3 ng/mL. Complications occurred in 100% of the patients with 12 of 22 (55%) requiring at least one transurethral resection of sloughed, necrotic tissue. Our preliminary results suggest that the current cryosurgical technique used in men failing radiation therapy has a low probability of biochemical cure and a high complication rate. Until more data are available, cryosurgery for men with locally recurrent disease after radiation therapy should be considered strictly experimental.

Stage I nonsmall cell lung cancer. A multivariate analysis of treatment methods and patterns of recurrence

Nonsmall cell lung cancer (NSCLC) has become the leading cause of cancer-related deaths in women and men in the United States, with more than 157,000 estimated deaths in 1995. Surgical resection remains the mainstay of therapy in Stage I and II disease. However, local and distant recurrence account for the disappointing survival rates after resection. Appropriate selection of surgical procedures and effective use of adjuvant therapies will depend upon the elucidation of prognostic factors that predict for recurrence. A detailed analysis was undertaken to evaluate surgical therapy and to define risk factors associated with recurrence and cancer death in 289 consecutive patients with NSCLC who were diagnosed, resected and followed at the Duke University Medical Center from January 1, 1980, until December 31, 1988. These patients had no evidence of metastases on head and chest/abdominal computed tomograms and radionuclide bone scans before resection. Resected specimens from these patients pathologic verification of Stage I disease. Follow-up was complete in all cases through 8/1/94 (median, 61 months). Variables analyzed included age, sex, smoking history, presenting signs and symptoms, operative procedure, histopathology, hospital course including complications, and the time and location of any recurrence or cancer death. The 30-day mortality rate was 5 of 289 (1.7%), with minor and major morbidity rates of 17% and 9%, respectively. Statistical comparison of lobectomy (193) wedge resection (75) and pneumonectomy (21) revealed significantly (P < 0.04) smaller tumors (T1), more comorbidity, and fewer complications for wedge resection patients. A trend (P < 0.09) toward an increased rate of local/regional recurrence and no difference in survival was also observed for wedge resection. One hundred five patients died of cancer (13-month median time to recurrence) for an actual 5-year survival of 63%. Significant univariate predictors of early recurrence and decreased survival (P < 0.01) were: male sex, the presence of symptoms, hemoptysis, chest pain, type of cough, tumor size in cm and by T-classification, visceral pleural invasion, high mitotic index, and vascular invasion. Significant (P < 0.05) multivariate independent variables for early recurrence and cancer death were the presence of symptoms, vascular invasion, pleural invasion, high mitotic index, and tumor size greater than 3 cm. Current surgical therapy for stage I NSCLC has an acceptable morbidity and mortality rate. The current data also stratify patients with Stage I NSCLC into high and low risk populations that can be used in future randomized trials of adjuvant therapy.

A New Protocol for the Followup of Renal Cell Carcinoma Based on Pathological Stage

There is no consensus concerning which laboratory and imaging studies should be obtained to assess patients after radical nephrectomy for renal cell carcinoma. We restrospectively reviewed 158 patients who underwent radical nephrectomy with a final pathological diagnosis of renal cell carcinoma. Of the patients 21 had node-positive or metastatic disease and 137 had no evidence of metastases at diagnosis. Of the latter group 19 had pathological stage T1NOMO, 82 stage T2N0M0 and 36 stage T3N0M0 (18 stage T3a, 10 stage T3b and 8 stages T3a and b) tumor. Disease recurred in 0 percent, 14.6 percent and 52.8 percent (50 percent, 44.4 percent and 75 percent) of the patients, respectively. The average interval to recurrence was 29.5 months (range 3.5 to 88.8) for patients with stage T2 carcinoma and 22 months (range 3 to 138) for those with stage T3 disease. Based upon our data, followup studies should include a symptom history, serum liver function studies and chest x-rays at defined intervals. Routine use of bone scans and computerized tomography does not appear to be necessary.

Iodine-131 therapy for thyroid cancer patients with elevated thyroglobulin and negative diagnostic scan.

Seventeen patients with papillary thyroid cancer whose serum thyroglobulin (Tg) levels were elevated when hypothyroid, but whose diagnostic whole body scans were negative, were treated with 150-300 mCi 131I. All patients had total thyroidectomy and 131I ablation for thyroid remnants. Before the study, 9 patients had 131I therapy for tumor recurrence and/or metastases, and 5 patients had excisions of nonfunctioning metastasis. Radiological studies did not reveal evidence of metastases. In the initial evaluation, Tg levels ranged from 8-480 ng/mL (24 pmol/L to 1.5 nmol/L), and posttherapy whole body scans (RxWBS) revealed undiagnosed local recurrence and/or metastases in 16 of 17 patients. Follow-up from 6 months to 5 yr is available in 16 patients. RxWBS after a second treatment was positive in 8 of 13 patients, and after a third treatment in 5 of 5 patients, although in 3 cases, uptake in distant metastasis had disappeared. In 8 patients, Tg fell to 5 ng/mL or less. In 1 patient, RxWBS became negative, but Tg remained elevated; subsequent treatment revealed local and mediastinal uptake, but previous lung uptake had disappeared. In 8 patients, RxWBS remains positive, and elevated Tg persists. A total of 35 RxWBS were performed; 29 were positive. Follow-up Tg concentrations decreased in 81% of patients after the first treatment, in 90% after the second treatment, and in 100% of the patients after the third treatment. Tg (mean +/- SE) decreased from 74 +/- 33 ng/mL in the first evaluation to 62 +/- 32 ng/mL in the second study and 32 +/- 20 ng/mL in the third study. The therapeutic effectiveness of 131I treatment in patients with elevated Tg and negative diagnostic whole body scans is indicated by the conversion to negative RxWBS, the statistically significant decrease in the mean Tg level, and the reduction of serum Tg to 5 ng/mL or less in 50% of patients. Further experience with this therapeutic approach is required to evaluate its effectiveness in improving prognosis and survival.

Surgical Treatment of Verrucous Carcinoma of the Bladder Unassociated With Bilharzial Cystitis: Case Report and Literature Review

Verrucous carcinoma of the bladder unassociated with bilharzial cystitis is rare with only 6 cases reported to date. Verrucous carcinoma of the bladder, like that involving the cervix, vagina, oral cavity, perineum and lower extremities, may invade surrounding structures but remain surgically curable. Although it is similar to condyloma acuminatum, verrucous carcinoma is considered malignant because of its invasive growth pattern and it should be treated accordingly. However, no evidence of metastases has been noted to date. To our knowledge we report the first case of extravesical extension of verrucous carcinoma of the bladder that was treated successfully by surgical removal.

CA 15-3 value and neoplastic disease predictivity in the follow-up for breast cancer.

The role of CA 15-3 in breast cancer has been widely studied by several authors. This study was designed to describe the predictivity of CA 15-3 determinations for the metastasis or second primary tumor in patients subjected to follow-up for breast cancer. All the 1,123 determinations of CA 15-3 carried out during 1991 in a hospital laboratory were analyzed. By cross-matching anagraphic items of patients with clinical data from different hospital databases, it was possible to reconstruct the clinical history. At the cutoff point of 40 U/ml, the positive predictive value of the CA 15-3 was 99.4%. This study shows the very close association between CA 15-3 > or = 40.0 U/ml and disease, suggesting a careful restaging when the marker increases without clinical evidence of metastases. Hormonal treatment should also be considered.

Nonconvulsive status epilepticus in patients with cancer

Patients with systemic cancer may have altered mental status without evidence of metastases, strokes, or metabolic encephalopathies. Six such patients are described whose EEGs showed continuous generalized epileptiform discharges in the absence of clinical signs of seizures. Two patients had never had any clinical evidence of seizures and four had seizures that were thought to have stopped before the EEG. Three patients were confused and three were stuporous or comatose. In some patients the nonconvulsive epileptic activity may have been directly related to the cancer; three had findings suggestive of possible paraneoplastic encephalopathies. Anticonvulsants led to an improved mental status in four patients, but all except one died. Nonconvulsive generalized status epilepticus may explain altered mental status in some patients with cancer and anticonvulsant medication treatment can be beneficial.

Successful treatment of lentigo maligna and lentigo maligna melanoma with Mohs' micrographic surgery aided by rush permanent sections.

Lentigo maligna (LM) is a pigmented neoplasm on sun-exposed skin of elderly patients. LM slowly increases in size and may become lentigo maligna melanoma (LMM), a potentially fatal malignancy. Complete excision is the treatment of choice. Mohs' micrographic surgery (MMS) with frozen and permanent sections may be used for complete eradication of the lesion, while sparing as much normal tissue as possible. The authors studied the efficacy of MMS for the treatment of LM and LMM. Between 1985 and 1992, 45 patients with LM (26) and LMM (19) were treated with MMS. The authors' technique was to use examination of frozen sections and rush permanent sections (prepared and read within 24 hours). Positive frozen sections warranted further excision. For negative or equivocal frozen sections, surgery was interrupted until the examination of permanent sections was performed. All 45 patients were free of local disease and evidence of metastases at an average of 29.2 months (range, 4-81 months) after therapy. MMS aided by rush permanent sections yielded a prolonged disease free survival for all 45 patients with LM or LMM. Because the MMS technique minimizes the removal of normal tissue, and the local cure rate in this study was superior to that reported for conventional surgery, the authors recommend this technique for the treatment of LM and LMM.

Intensive Diagnostic Follow-up After Treatment of Primary Breast Cancer

Objective. —To evaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients. Design. —Randomized clinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years. Setting. —Twelve breast clinics (referral centers) in different areas in Italy. Patients. —A total of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics. Intervention. —Patients in both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months. Main Outcome Measures. —Vital status at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed. Results. —Overall, 393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups. Conclusions. —Periodic chest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy. (JAMA. 1994;271:1593-1597)

Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up

To evaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients. Randomized clinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years. Twelve breast clinics (referral centers) in different areas in Italy. A total of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics. Patients in both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months. Vital status at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed. Overall, 393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups. Periodic chest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy.

Expression of EGFR, HER-2/neu, P53, and PCNA in Endometrioid, Serous Papillary, and Clear Cell Endometrial Adenocarcinomas

Expression of four biologic markers was studied in 69 cases of endometrial cancer to identify their association with cell type, decreased survival, and increased tumor metastasis. Cell types included endometrioid (n = 45), serous papillary (n = 16), and clear cell (n = 8). Immunohistochemical stains were employed to detect the presence of epidermal growth factor receptor (EGFR), HER-2/neu, p53, and proliferating cell nuclear antigen (PCNA). Analysis revealed that EGFR was expressed in 49%, HER-2/neu in 59%, p53 in 9%, and PCNA in 16% of tumor specimens. HER-2/neu overexpression was significantly associated with depth of myometrial invasion. p53 and PCNA immunoreactivity significantly correlated with nonendometrioid histology, although PCNA was less specific in labeling these less favorable cell types. EGFR immunoreactivity also significantly correlated with nonendometrioid cell types and tumor metastases at time of diagnosis. Seventy-seven percent of patients with metastatic disease were EGFR-positive versus 36% positivity in patients with no evidence of metastases (P < 0.002). For patients with endometrioid adenocarcinoma, evidence of EGFR overexpression decreased survival from 89 to 69% (P < 0.04). In the serous papillary and clear cell category, EGFR positivity decreased survival from 86 to 27% (P < 0.03). EGFR strongly correlates with tumor metastasis and patient survival in endometrial cancer. Altered expression of this oncoprotein may serve as a guide to prognosis and treatment in these patients.

A novel method for monitoring high-risk breast cancer with tumor markers: CA 15.3 compared to CEA and TPA

An early and reliable diagnosis of metastatic spread has increased interest in serum tumor markers. This study investigated the ability of CA 15.3, CEA, and TPA to identify, predict, and exclude metastases in bone/viscera during adjuvant treatment and follow-up of high-risk breast cancer. Ninety females with high-risk breast cancer were included in the study. Response evaluation was based upon clinical examination, x-rays or histology and elaborated marker criteria. During the marker monitoring period, metastases in four patients were confined to skin or lymph nodes, 21 developed metastases to bone/viscera, and 65 females had no evidence of metastases. CA 15.3, CEA, and TPA correctly classified 48%, 10%, and 19% of the patients with metastases in bone/viscera, and 100%, 94%, and 98% without. Following CA 15.3, CEA, and TPA recurrence, 100%, 33%, and 60% of the patients developed metastases in bone/viscera. Metastases in bone/viscera were excluded in 86%, 76%, and 79% of patients without CA 15.3, CEA, and TPA recurrence. Only CA 15.3 gave reliable information about recurrence. Metastases in bone/viscera were identified in 10 of the 21 patients with CA 15.3. There was no false-positive CA 15.3 information on the 65 patients without clinical recurrence. The PVneg (86%) indicated that when CA 15.3 did not signal recurrence, metastases to bone/viscera were not likely.

Intensive diagnostic follow-up after treatment of primary breast cancer: A randomised trial

Objective.\p=m-\Toevaluate the effectiveness of early detection of intrathoracic and bone metastases in reducing mortality in breast cancer patients. Design.\p=m-\Randomizedclinical trial allocating breast cancer patients to two alternative follow-up protocols (intensive vs clinical) for at least 5 years. Setting.\p=m-\Twelvebreast clinics (referral centers) in different areas in Italy. Patients.\p=m-\Atotal of 1243 consecutive patients (either premenopausal or postmenopausal) surgically treated for unilateral invasive breast carcinoma with no evidence of metastases. The two study groups were well balanced in terms of clinical and prognostic characteristics. Intervention.\p=m-\Patientsin both treatment groups had physical examination and mammography, while patients of the intensive follow-up group had, in addition, chest roentgenography and bone scan every 6 months. Main Outcome Measures.\p=m-\Vitalstatus at 5 years was the main outcome; information was available for all except five patients (0.4%). Relapse-free survival was also analyzed. Results.\p=m-\Overall,393 recurrences (104 local and 289 distant) were observed during the study. Increased detection of isolated intrathoracic and bone metastases was evident in the intensive follow-up group compared with the clinical follow-up group (112 vs 71 cases), while no difference was observed for other sites and for local and/or regional recurrences. The 5-year relapse-free survival rate was significantly higher for the clinical follow-up group, with patients in the intensive follow-up group showing earlier detection of recurrences. No difference in 5-year overall mortality (18.6% vs 19.5%) was observed between the two follow-up groups. Conclusions.\p=m-\Periodicchest roentgenography and bone scan allow earlier detection of distant metastases, but anticipated diagnosis appears to be the only effect of intensive follow-up, and no impact on prognosis is evident after 5 years. Periodic intensive follow-up with chest roentgenography and bone scan should not be recommended as a routine policy.