Locoregional Surgery Research Articles

Radio-guided surgery for persistent differentiated papillary thyroid cancer: case presentations and review of the literature

Persistent differentiated papillary thyroid cancer following radical locoregional surgery with metastases is an indication for limited reoperation or radioiodine therapy. Following injection of radioiodine, radio-guided surgery with application of an intraoperative gamma probe offers detection of metastases not seen by conventional imaging and control of completeness of resection. We demonstrate four patients with locoregional metastases, two of them with additional distant metastases of papillary thyroid cancer following radical neck surgery. Postoperative radioiodine scans demonstrated persistent ipsilateral or contralateral cervical and mediastinal lymph node and isolated rib metastases. Radio-guided surgery (RGS) leads to complete clearance of persistent lymph node metastases by limited recurrent neck surgery, resection of metastases not seen by conventional imaging and control of complete mediastinal lymph node dissection. Post-RGS scans allowed early diagnosis of occult diffuse or nodal pulmonary metastases in two patients. At last follow-up, 23 to 48 months following RGS and radioiodine therapy, there was no evidence of disease. Radio-guided surgery is an additive surgical technique with low morbidity in selected patients with persistent thyroid cancer individualizing tumor therapy options in multimode oncological therapy.

Preoperative sequential chemotherapy in locally advanced squamous cell carcinoma of the head and neck

Induction chemotherapy may contribute to decreased local and distant recurrences in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) resectable for cure. Patients with previously untreated locally advanced stage III-IV (N0-2, M0) SCCHN received a dose-dense sequential regimen combining cisplatin/5-fluorouracil followed by bleomycin/methotrexate/hydroxyurea. Induction chemotherapy was followed by locoregional surgery and/or radiation therapy. Among 37 patients, 23 (62%) had T4 primary tumors. Grade 3 to 4 asymptomatic hematologic toxicity occurred in less than 15% of patients. Nonhematologic toxicities were limited to grade 1 to 2 in less than 20% of patients. In the overall cohort (intent-to-treat; n = 35), 24 (68.5%) of 35 patients had objective clinical responses, including nine complete responses (25.7%). Fifty-seven percent of patients were free of disease at 2.5 years. Sequential induction chemotherapy is feasible and active in patients with locally advanced head and neck cancers and may further include recent compounds such as taxanes.

Prognostic Value of ERM Gene Expression in Human Primary Breast Cancers

We measured the expression of ERM gene, a nuclear transcription factor belonging to the ets family, in a series of 364 unselected primary breast cancers from patients who underwent locoregional surgery in the Centre Oscar Lambret between May 1989 and December 1991. The expression of ERM was quantified with a real-time one-step reverse transcription-PCR assay based on the 5'-nuclease activity of the TaqDNA polymerase and with an Abi Prism 7700 Sequence Detector System (Applied Biosystems, Courtaboeuf, France). ERM was positively correlated (Spearman test) to epidermal growth factor receptor (EGFR; P < 0.001, r = 0.296) and to histoprognostic grading (P = 0.044, r = 0.112), whereas it was negatively correlated to estradiol receptors (P = 0.019, r = -0.124), HER3 (c-erbB-3; P = 0.01, r = -0.135), and HER4 (c-erbB-4; P = 0.003, r = -0.154). Using the chi2 test, a positive relationship was found between the expression of ERM and EGFR (chi2 = 7.795, P = 0.007). In overall survival studies, Cox univariate analyses demonstrated a prognostic value of ERM (P = 0.006; risk ratio, 2.95) besides the classical prognostic factors histoprognostic grading, node involvement, tumor size, estradiol receptors, progesterone receptors, EGFR, HER3, and HER4. In multivariate analyses, ERM preserved its prognostic value (P = 0.004; risk ratio, 3.779) together with histoprognostic grading, tumor size, estradiol receptors, and progesterone receptors. In relapse-free survival studies, univariate analyses demonstrated that histoprognostic grading, node involvement, tumor size, and HER4 were prognostic factors. These parameters, except histoprognostic grading, retained their prognostic value in multivariate analyses. This study demonstrates for the first time that ERM gene expression is an independent adverse prognostic factor for overall survival in breast cancer patients.

A Study of the Patient Factors Affecting Reconstruction after Mastectomy for Breast Carcinoma

Breast shape may be retained after surgery for breast cancer with either wide local excision (WLE) and radiotherapy or mastectomy (M) and immediate reconstruction (M+R). We determined the proportions of patients who would be suitable for these options, would accept them, and if they declined M+R their reasons for doing so. Over a 10-month period 177 women were assessed at a combined breast clinic by general and plastic surgeons and by radiation oncologists. A prospective record was made of the patient demographic data, the clinical decisions (and their reasons), and the patient choices (and their reasons). A transverse rectus abdominis myocutaneous flap was the commonest method of reconstruction. One hundred thirty-five (76%) were judged to be suitable for locoregional surgery. Of these M+R was offered to 83 patients, whereas 53 were not considered because of combinations of cosmetic considerations (31), risk factors (25), old age (13), and oncological factors (nine). Fifty-one of the 83 (61%) offered M+R declined it because they preferred a simpler procedure (34), regarded breast appearance as unimportant (15), preferred breast conservation (five), did not have a partner (three), felt that they were too old (two), or had religious reasons (two). Ultimately 69 (51%) underwent M, 34 (25%) WLE, and 32 (24%) M+R. There was no correlation between acceptance or not of M+R and age, race, employment, education level, or marital status. We conclude that many patients were suitable for M+R, but fewer than half accepted it; this decision was unrelated to age, race, employment, or marital status.

Combined Modality Treatment for Locally Advanced Breast Cancer

Purpose: To assess the value of aggressive loco-regional surgery in desperate situations with locally advanced breast cancer .Methods: In this study there were considered 31 patients with locally advanced breast cancer who underwent surgery in a 5-year period. 10 of them received 3 cycles of chemotherapy and radiotherapy before surgical intervention; the rest of the 21 patients had systemic or local contra-indications for neo-adjuvant therapy. We describe clinical aspects and technical difficulties. Surgical intervention focused on tumour removal and lymph node dissection. Skin defect was covered with flaps according to the Mortimer-Show technique. Postoperatively, the outcome was influenced in a favourable way by the use of Detralex, a micronised flavonoid; all but 2 patients received chemotherapy and locoregional radiotherapy.Results: 25 patients survived free of disease; from 6 patients who suffered recurrence, 2 are still living and 4 have died. Conclusions: In some forms of locally advanced breast cancer, aggressive surgery offers improvement in the quality of life and increases survival.

Squamous cell carcinoma of the superior gingivolabial sulcus.

The superior gingivolabial sulcus has not been recognised as a separate entity in the oral cavity for the localisation of carcinoma. These cancers are not uncommonly labelled as buccal carcinomas or as carcinomas originating from the superior alveolar process and sometimes as maxillary sinus carcinomas. Early symptoms of sensory disturbances are often missed. Although cervical nodal metastasis is not usual at first presentation, metastasis to parapharyngeal, retropharyngeal and nasolabial lymph nodes is known. This article presents the author's observations on carcinoma of the superior gingivolabial sulcus seen over a period of 4 years. Cancer at this site has poor prognosis. Despite aggressive treatment with radical locoregional surgery and postoperative radiotherapy, only one of nine patients survived 5 years.

Long-term prognostic and predictive factors in 107 stage II/III breast cancer patients treated with anthracycline-based neoadjuvant chemotherapy.

The heterogeneity of therapeutic modalities and eligibility criteria and the lack of long-term follow-up in most reports of neoadjuvant chemotherapy for breast cancer preclude us from drawing conclusions about its value in clinically relevant patient subgroups. The present study aims to identify predictive and prognostic factors in 107 non-inflammatory stage II/III breast cancer patients treated between November 1980 and October 1991 with an anthracycline-based induction regimen before locoregional surgery. Preoperative chemotherapy comprised 3-6 cycles of doxorubicin (pirarubicin after 1986), vindesine, cyclophosphamide and 5-fluorouracil. Type of subsequent surgery and adjuvant treatment were decided individually. In analysis of outcome, univariate comparisons of end points were made using the log-rank test, and significant (P < or = 0.05) pre- and post-therapeutic factors were incorporated in a Cox multivariate analysis. With a median follow-up of 81 months (range 32-164+ months), the median disease-free survival (DFS) is 90.5 months while median overall survival has not yet been reached. Cytoprognostic grade and histopathological response in both the primary and lymph nodes were independent covariates associated with locoregional relapse with or without DFS and overall survival. Eleven patients with pathological complete response remain free of disease with a 68-month median follow-up, while the 18 with residual microscopic disease on the specimen showed a 60% cumulative incidence of locoregional recurrence. Despite encouraging response rates based on clinical or radiological evaluation (87% or 70%), neither method showed any significant correlation with pathological response and failed to contribute prognostic information on patients' outcome. Pathological evaluation of antitumoral activity of primary chemotherapy remains a major source of prognostic information and might be used to select patients in need of additional adjuvant treatment.

Thyroid cancer: Different outcomes to chemotherapy according to tumour histology

IN THE MANAGEMENT of thyroid carcinoma, doxorubicin alone, or in combination with cisplatin , is considered the most active regimen, although it gives unsatisfactory response rates with significant side-effects [1-3]. Epirubicin is endowed with a spectrum of activity similar to doxorubicin and an equivalent response rate with less cardiotoxicity and acute myelosuppres­ sion [4, 5]. Carboplatin produces less nephrolOxicity, neurotox­ icity and vomiting than cisplatin [6 , 7]. In an attempt lO identify a well tolerated regimen which does not affect patients' quality of life, the association of epirubicin 75 mg/m2 given by i.v. (intravenous) bolus on day l, and carboplatin 100 mg/m2 by 30 min infusion on days 1-3, repeated every 28 days, was proposed as fust-line chemotherapy to pati­ ents aged ,,; 70 years, ECOG perfonnance status ,,; 2, affected by histologically proven thyroid carcinoma (except medullary) not suitable for surgery or radioactive iodine . Eight cycles were planned except for the cases showing progressive disease. Response and toxicity were evaluated according to WHO-UICC criteria [8] . 20 patients entered the study: all were suitable for the evalu­ ation of response and toxicity. lO patients were male and lO female, the median age was 64 years (range 35-70), ECOG perfonnance status was O in 8 patients and l in 12. Sites of disease were thyroid (8 patients), local relapse (7), regional nodes (12), distant nodes (3), lung (12) and bone (1 ). 12 patients were pretreated with locoregional surgery, 5 with radioactive iodine and 2 with radiotherapy. A total of 83 cycles of chemotherapy have been delivered, with a median of four cycles per patient (range 1-8). Treatment was well lOlerated. No cases of grade 4 toxicity occurred; grade 3 anaemia occurred in 15% of patients, leucopenia was observed 'in 5% and nausea/vomiting in 5%. Alopecia was complete in 7 patients . 2 male patients achieved complete responses both lasting 12+ months: they were 70 years old with disease limited to the regional nodes, and in one case, local relapse . In these cases, the time to the best response was 5 and 3 months, respectively. One patient achieved a partial response lasting 4 months; 7 patients had stable disease for a median duration of 9 months (range

Primary systemic therapy for operable breast cancer

Eighty-eight patients presenting with operable breast cancer of 4 cm or greater in diameter (T2, T3, N0, N1, M0) have received primary systemic therapy. Response was assessed following 12 weeks of systemic therapy by linear regression analysis of changes in tumour volume. Definitive locoregional surgery (mastectomy n = 82, wide local excision n = 6) was performed on completion of systemic therapy (3-6 months). Response was observed in 24 (39%) of the 61 patients who received endocrine therapy; all 24 had tumours with an oestrogen receptor (ER) concentration of greater than or equal to 20 fmol mb-1 cytosol protein. Cytotoxic therapy was reserved for patients with tumours of ER concentration less than 20 fmol mg-1 cytosol protein (n = 27) or when endocrine therapy had failed (n = 20). Response was observed in 34 patients (72%). The overall survival rate at 3 years was 86%, with 81% remaining free from local relapse. We propose that the treatment policy outlined in this paper should now be tested against orthodox management by controlled randomised trial.

Prognostic factors in advanced metastatic and recurrent melanoma treated with DTIC.

Thirty-five patients with recurrent and 25 patients with metastatic malignant melanoma after previous radical locoregional surgery were treated with DTIC at the Institute of Oncology in Kraków between 1976 and 1981. Complete and partial remissions were observed in 19/60, i.e., in 31% of the patients. Our results show an advantage for patients with locoregional recurrence, soft-tissue and lung metastases, provided that the largest deposit is no larger than 5 cm in diameter. There is little chance of remission in patients with liver and bone metastases.