Pulmonary Recurrence Research Articles

Prolonged survival in selected patients following surgical resection for pulmonary metastasis from hepatocellular carcinoma.

Pulmonary metastasis is the commonest site of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the efficacy of surgical management in patients with solitary pulmonary metastases from HCC. This was a retrospective study of patients with HCC admitted for hepatectomy from July 1972 to June 1995. The records of patients who had a pulmonary resection for histologically proven pulmonary recurrence after curative hepatectomy were selected for analysis. In the study interval, 380 patients with HCC underwent hepatectomy. Some 48 patients (12.6 per cent) developed pulmonary metastases documented pathologically or radiologically. Nine (seven men and two women) were suitable for curative pulmonary resection. The median disease-free survival between hepatectomy and appearance of the lung metastasis was 21 months. The median survival after pulmonary resection was 42 months, and the 1-, 2- and 5-year survival rates were 100, 78 and 67 per cent respectively. Pulmonary resection for metastases from HCC resulted in long-term survival in these highly selected patients.

Pulmonary transplantation for advanced bronchioloalveolar carcinoma

Background: No effective therapy is currently available for the diffuse stage of bronchioloalveolar carcinoma. Objective: We tested the hypothesis that total lung replacement with standard lung transplantation techniques would provide curative therapy. Methods: Nine patients aged 31 to 58 years with bronchioloalveolar carcinoma were entered in the study. Five patients initially had bilateral diffuse tumor. Four patients had recurrence in the contralateral lung after pulmonary resection. Results: Between 1993 and 1998, all 9 patients underwent transplantation (2 single-lung and 7 bilateral transplants, 1 reoperative single-lung transplant, and 1 reoperative bilateral transplant). Two patients had mediastinal node metastasis (level 7) at the time of transplantation, and 1 of these had a frankly invasive adenocarcinoma. Of the 8 patients with pure bronchioloalveolar carcinoma, 6 had recurrent pulmonary tumor after transplantation. In 2 of these patients the tumor was localized and could be resected with left lower lobectomy in one case and left pneumonectomy in the other. One is alive 89 months after transplantation; the other died 82 months after transplantation. Four other patients had a diffuse pattern of pulmonary recurrence. Two died of progressive pulmonary failure; 1 of these had retransplantation with recurrence. A third patient died of cerebral edema shortly after bilateral retransplantation. The other patient is alive with recurrence 39 months after transplantation and has bronchiolitis obliterans. Two patients without recurrence are well with unrestricted performance levels 87 and 76 months after transplantation. Conclusions: Transplantation produces a powerful palliative outcome in patients with advanced bronchioloalveolar carcinoma, but the recurrence rate is high. Transplantation for this indication remains controversial.J Thorac Cardiovasc Surg 2003;125:45-8

Clinical stage I nonseminomatous testicular germ-cell tumors: surgery or watchful waiting, still an issue?

The optimal management for clinical stage I nonseminomatous testicular germ-cell tumors is still a subject open to controversy. The main options of standard-care surveillance and primary nerve-sparing retroperitoneal lymph node dissection result in the same high cure rate (close to 100%). It is the purpose, here, to present a critical review of recent developments concerning primary therapy for clinical stage I nonseminomatous testicular germ-cell tumors and to identify potential new prognostic risk factors predicting occult metastatic retroperitoneal lymph node disease. In accordance with the primary goal to improve quality of life, to protect fertility and to reduce long-term toxicity in survivors of testicular cancer, the major advantage of surveillance protocols is that adjuvant therapy will be administered only to those patients who require therapy. This advantage has to be balanced against a constant psychological threat and a relapse rate of 20-25% necessitating extensive polychemotherapy. Primary nerve-sparing retroperitoneal lymph-node dissection has diagnostic and therapeutic capabilities in low-volume disease; as local relapses are extremely rare, an effective and cost-saving follow-up concentrating on pulmonary recurrences can be initiated. Nerve-sparing retroperitoneal lymph node dissection represents the initial approach for mature teratomas; patients with purely embryonal carcinoma have a high risk for systemic relapses and might be better served by primary chemotherapy. The advantages of nerve-sparing retroperitoneal lymph-node dissection have to be balanced against surgery-related complications, which develop in about 17% of the patients. With regard to prognostic risk factors, the percentages of embryonal carcinoma and vascular invasion remain the most significant predictors for lymph node metastases. Surveillance and primary nerve-sparing retroperitoneal lymph-node dissection result in the same high cure rate (approaching 100%). The advantages and disadvantages of both treatment modalities must be discussed extensively with the patient, and it will be basically his decision as to which therapeutic approach is chosen.

Isolated pulmonary recurrence after resection of colorectal hepatic metastases--is resection indicated?

Resection of colorectal hepatic metastases is an accepted treatment modality for stage IV colorectal cancer. Concurrent or sequential pulmonary metastasectomy continues to be a controversial strategy. We analyzed factors that predicted pulmonary recurrence in patients with resected hepatic metastases and examined the efficacy of these combined interventions in the treatment of metastatic colorectal cancer. A retrospective review of a database of patients who underwent resection of colorectal hepatic metastases was performed to identify patients who either had synchronous pulmonary metastases (defined as pulmonary recurrence at the time of or within 3 months of hepatic metastasectomy) or subsequently experienced pulmonary metastases. Patient demographics, operative interventions, and overall survival were analyzed. Statistical methods included unpaired Student's t-test, actuarial survival and log-rank analysis. Twenty-one patients (19%) had pulmonary metastases after hepatic resection, of which 12/21(57%) underwent pulmonary resection. No differences were observed between the resection group, the nine patients with pulmonary metastases who did not undergo resection, and the 87 patients without pulmonary metastases with regard to age, sex, race, or extent of hepatic metastases. When comparing the resected versus the unresected pulmonary recurrences, the disease-free interval from hepatic resection to detection of pulmonary metastases was 21 +/- 20 months (range, 3-72 months) versus 16 +/- 8 months (range, 4-25 months), respectively. All patients with pulmonary recurrence who underwent pulmonary metastasectomy had unilateral disease. Seven of 12 (58%) underwent wedge/segmental resections, and the remaining five (42%) required lobectomy in order to obtain a complete resection. Four patients who underwent pulmonary resection had multiple lung metastases (two to four lesions), and eight had isolated metastasis. There were no perioperative deaths in the pulmonary metastasectomy group. Contraindications to pulmonary resection included extensive pulmonary disease and concurrent extrapulmonary disease. A survival benefit was noted at 3 years for the resected versus the unresected group (60% vs 31%). Survival was no different between the resected pulmonary recurrence patients and the resected hepatic metastases only patients (60% vs 54%). Pulmonary metastasectomy can be performed safely and effectively in patients with recurrent disease after hepatic resection for colorectal metastases. Prolonged survival can be achieved with resection of isolated pulmonary recurrence after hepatic resection for colorectal cancer. Further studies that delineate selection criteria for pulmonary resection of colorectal metastases are warranted.

Pulmonary metastasis from endometrial carcinoma

The objective of this article is to investigate the clinical features of pulmonary metastasis (PM) from endometrial adenocarcinoma, in particular, the predictors of prolonged survival after PM detection. Fifteen patients who developed PM and underwent chest computed tomography (CT) scans for evaluation of PM were studied: 12 patients with pulmonary recurrence and 3 patients with PM on presentation. All patients with bilateral nodules or lymphangitic spread had metastases in other sites prior to or concomitant with PM, most of which were detected in para-aortic lymph nodes and/or the vaginal wall, while only one of five patients with a limited number (n≤ 5) of unilateral nodules had these metastases. The median survival time for the 10 patients with bilateral PMs was significantly shorter than that of the 5 patients with a limited number of unilateral nodules who were treated with surgery (7 versus 50 months,P= 0.005). Patients who developed pulmonary recurrence 2 years after the initial therapy had a significantly longer survival than those who developed it within 2 years (31 versus 10 months,P= 0.01). In conclusion, the distribution of PM determined by CT scans and the time interval between the initial therapy and the detection of pulmonary recurrence are the predictors of survival after PM detection.

Pulmonary metastasis from endometrial carcinoma.

The objective of this article is to investigate the clinical features of pulmonary metastasis (PM) from endometrial adenocarcinoma, in particular, the predictors of prolonged survival after PM detection. Fifteen patients who developed PM and underwent chest computed tomography (CT) scans for evaluation of PM were studied: 12 patients with pulmonary recurrence and 3 patients with PM on presentation. All patients with bilateral nodules or lymphangitic spread had metastases in other sites prior to or concomitant with PM, most of which were detected in para-aortic lymph nodes and/or the vaginal wall, while only one of five patients with a limited number (n < or = 5) of unilateral nodules had these metastases. The median survival time for the 10 patients with bilateral PMs was significantly shorter than that of the 5 patients with a limited number of unilateral nodules who were treated with surgery (7 versus 50 months, P = 0.005). Patients who developed pulmonary recurrence 2 years after the initial therapy had a significantly longer survival than those who developed it within 2 years (31 versus 10 months, P = 0.01). In conclusion, the distribution of PM determined by CT scans and the time interval between the initial therapy and the detection of pulmonary recurrence are the predictors of survival after PM detection.

Multiple repeat resections of intra- and extrahepatic recurrences in patients undergoing initial hepatectomy for colorectal carcinoma metastases.

Recent evidence suggests that single repeat metastasectomy may provide survival benefits for selected patients experiencing hepatic or pulmonary recurrences following initial hepatectomy for colorectal carcinoma metastases. The aim of this retrospective study was to clarify the efficacy of multiple repeat resections of intra- and extrahepatic recurrences following initial hepatectomy. A total of 100 patients underwent curative partial hepatectomy as the initial procedure for colorectal carcinoma metastases. Tumor relapse after initial hepatectomy was seen in 72 patients, of whom 28 underwent 45 repeat metastasectomies of various sites: 18 patients underwent a single repeat metastasectomy, and 10 underwent multiple repeat metastasectomies. The overall survival rate at 5 years after initial hepatectomy was 36.6%, while the 5-year survival rate after repeat metastasectomy in the 28 patients was 43.6%. The outcome of initial hepatectomy was comparable with that of repeat metastasectomy (p = 0.6924). Among the 28 patients undergoing repeat metastasectomy, the outcome of resection of intrahepatic recurrences in 11 patients was comparable with the outcome of resection of extrahepatic recurrences in 17 patients(p = 0.3926). The outcome of multiple repeat metastasectomies compared favorably with single repeat metastasectomy(p = 0.1803). Multivariate analysis(p < 0.0001) showed that repeat metastasectomy was the strongest prognostic factor. In conclusion, both single and multiple repeat resections of intra- and extrahepatic recurrences after initial hepatectomy are efficacious in colorectal carcinoma patients. Repeat resection should be considered for any resectable recurrences after hepatectomy.

Laryngeal osteosarcoma: A clinicopathologic analysis of four cases and comparison with a carcinosarcoma

We report the clinicopathologic findings of four cases of laryngeal osteosarcoma and one of carcinosarcoma with osteosarcoma components. The tumors occurred in men ranging in age from 50 to 69 years within a median age of 63.3 years. The most common symptoms were hoarseness, dyspnea, and obstruction, or a combination of these. Biopsy material and intraoperative frozen sections usually showed a high-grade sarcoma, but the diagnosis of osteosarcoma was quite apparent on microscopic examination of the surgical specimen. The primary differential diagnosis is spindle cell carcinoma with osteoid formation. Pulmonary metastases and local recurrences were common. Surgery is the treatment of choice, followed by adjuvant chemotherapy. Whether to use radiotherapy or not should be decided on an individual basis.

Survival after recurrence of Ewing tumors: the St Jude Children's Research Hospital experience, 1979-1999.

Despite improved therapies, 30-40% of patients with Ewing tumors (ET) experience recurrence and have a poor prognosis. The authors analyzed factors prognostic of survival in patients with recurrent ET. The authors assessed the relation between postrecurrence survival (PRS) and demographic, disease, and treatment factors in 71 patients who experienced recurrent ET after treatment on one of three consecutive institutional protocols. Thirty-four patients (47.9%) had distant recurrence, 25 patients (35.2%) had local recurrence, and 12 patients (16.9%) had both distant and local recurrence at a median of 1.7 years after diagnosis. The probability of 5-year PRS (+/- 1 standard error) was 17.7%+/-4.5%. Recurrence > or = 2 years after diagnosis predicted a significantly better outcome (5-year PRS, 34.9%+/-8.5%) compared with earlier recurrence (5.0%+/-2.8%; P < 0.001). Patients who had both local and distant recurrence fared worse (5-year PRS, 12.5%+/-8.3%) compared with patients who had local recurrence alone (21.7%+/-7.8%) or distant recurrence alone (17.6+/-6.1%). Among patients with local recurrence alone, those who underwent salvage with radical surgery had significantly higher 5-year PRS estimates (31.4%+/-11.6%) compared with the other patients (9.1%+/-6.1%; P = 0.023). Pulmonary irradiation significantly improved the outcomes of patients with isolated pulmonary recurrence (5-year PRS estimate, 30.3%+/-12.5% vs. 16.7%+/-10.8%, respectively; P = 0.018). Although outcomes are generally poor after patients experience recurrence of ET, certain patient groups differ appreciably in their likelihood of survival. Patients who experience recurrence > or = 2 years after diagnosis and patients who have local recurrence that can be treated with radical surgery and intensive chemotherapy have the most favorable outcomes.

Is a 1- cm margin necessary during nephron-sparing surgery for renal cell carcinoma?

Objectives. To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC). Methods. A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests. Results. Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up. Conclusions. This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.

Intraoperative high-dose-rate brachytherapy for the treatment of pediatric tumors: the Ohio State University experience

Purpose: To determine whether intraoperative high-dose-rate brachytherapy (IO-HDRBT) can be used to decrease the dose of external beam radiotherapy (EBRT) in the treatment of children with soft-tissue sarcomas and, thereby, reduce morbidity without compromising local control.Methods and Materials: From March 1992 through April 1999, 13 pediatric patients were treated with IO-HDRBT, low-dose EBRT, chemotherapy, and radical surgery at 21 sites that were not amenable to intraoperative electron beam therapy. The IO-HDRBT dose at 5 mm depth was 10 to 12.5 Gy for close margins/microscopic disease at 14 sites and 12.5 to 15 Gy for gross disease at 7 sites. The treatment volumes ranged from 4 to 96 cm3 (mean 27). The EBRT dose was limited to 27–30 Gy in most cases to minimize growth retardation and preserve normal organ function.Results: After a median follow-up of 47 months (range 12–97), 11 patients were alive and without evidence of disease (overall survival rate 85%, 4-year actuarial survival rate 77%). Of the 2 who died, 1 had Stage III pulmonary blastoma with a sacral recurrence; the other had Stage IV undifferentiated synovial sarcoma with a pulmonary recurrence. One local failure occurred in a patient with gross residual disease after incomplete resection for Stage IV pulmonary blastoma. The local control rate was 95%, and morbidity was observed in 3 patients (23%). One patient developed impaired orbital growth with mild ptosis. Another patient required orthopedic pinning of her femoral subcapital epiphysis and construction of a neobladder secondary to urethral obstruction. The third patient required reimplantation of her autotransplanted kidney secondary to chronic urinary tract infection and ureteral reflux.Conclusions: IO-HDRBT allowed for reduction in EBRT without compromising local control or disease-free survival in children with soft-tissue sarcomas. Tumor beds inaccessible to electron beam methods could be satisfactorily encompassed with IO-HDRBT techniques.

PCV20: ASSESSING THE TOTAL COST OF MANAGEMENT OF A PATIENT WITH DEEP VEIN THROMBOSIS (DVT) IN FRANCE AND IN ITALY

OBJECTIVES: Economic studies on the cost of DVT usually take into account the acute care costs only although the patients are treated and followed-up after hospital discharge for at least six months. We calculated the true economic burden of the disease. METHODS: We assessed from the Health Care System perspective the total cost of managing a patient with DVT over a one-year period in France and in Italy. For assessing the inpatients costs, we used the National inpatient Diagnosis Group data base in France and in Italy. We studied the patient profile, the mean length of stay and the subsequent complications. Data on outpatient care for DVT were based on literature, questionnaire filled in by practitionners, ambulatory care data base (in France) and compared to practice guidelines. Inpatient and outpatient costs were combined to provide total costs of care for DVT over an one-year period. In addition, we modelled, from published data, the risk of pulmonary embolism (PE) and DVT recurrences, and we costed these complications. RESULTS: The average French inpatient cost for DVT is 3,220 Euros (average length of hospital stay: 9.6 days) while this cost is 2,865 Euros in Italy (average length of hospital stay: 7 days). In both countries, the total cost of management of a DVT patient over an one-year period was calculated to be at least 30% higher than the only costs of acute care. CONCLUSION: The assessment of the global economic burden of DVT has to take into account the costs occurring after hospital discharge. Our approach was conservative as we did not take into account the risk of occurrence of Post Phlebitic Syndrome and its economic consequences.

Posttherapy Surveillance of Women with Cervical Cancer: An Outcomes Analysis

Objective. The aim of this study was to develop a surveillance program that optimizes clinical outcome following primary treatment of women with cervical cancer.Methods. The records of 1096 patients with FIGO stage IB cervical cancer treated from 1983 to 1993 were retrospectively reviewed. Recurrence was analyzed by site, presence or absence of symptoms, method of detection, and survival. Univariate and multivariate analyses using a Cox proportional hazards model were performed.Results. One hundred thirty-three patients (13%) developed recurrent disease. Of these, 114 were symptomatic and 19 were asymptomatic at the time of recurrence. Thirty-seven patients recurred in the central pelvis, 21 each in the lung or pelvic wall, 22 in nodes, and 35 in other sites. The median disease-free interval was 17 months for symptomatic patients and 16 months for asymptomatic patients. The median survival from initial diagnosis was 31 months for symptomatic and 83 months for asymptomatic patients (P = 0.001). The median survival from recurrence was 11 months for symptomatic and 42 months for asymptomatic patients (P < 0.001). Multivariate analysis revealed that symptom status at time of recurrence was a significant predictor of survival, even when known prognostic factors were considered (P < 0.001). All asymptomatic pelvic recurrences were diagnosed by pelvic exam; all asymptomatic pulmonary recurrences were detected by chest radiographs. Pap smears did not detect a single asymptomatic recurrence.Conclusions. Posttherapy surveillance programs are directed toward asymptomatic patients in whom early detection of recurrence may impact survival. These data indicate that a subset of women may benefit from surveillance. A model for surveillance is proposed.

Isolated pulmonary recurrence after resectionof colorectal hepatic metastases—Is resectionindicated?

Isolated pulmonary recurrence after resectionof colorectal hepatic metastases—Is resectionindicated?

All-trans retinoic acid and interferon-α in the treatment of a patient with resistant metastatic osteosarcoma

A boy age 14 years who was in complete remission from Stage IIB small cell osteosarcoma, which was misdiagnosed as Ewing sarcoma and consequently was treated, developed inoperable lung metastases when he was off therapy. He received second-line treatment for recurrent Ewing sarcoma, including chemotherapy and radiotherapy, and obtained only a temporary response. A compassionate treatment with all-trans retinoic acid (ATRA) and interferon-alpha (IFNalpha) was then undertaken.The patient initially was treated according to the national SE91 protocol for nonmetastatic Ewing sarcoma. After a bilateral pulmonary recurrence, he received second-line chemotherapy and irradiation of the largest metastasis, with a temporary partial response. The patient was then treated with a combination of oral ATRA (90 mg/m(2) for 3 days per week) and subcutaneous IFNalpha (3 x 10(6) U/m(2) 5 days per week) for 4 months. The same therapy also was administered for the control of residual disease after surgery for a total duration of 1 year of ATRA/IFN treatment. During the first 3 weeks of therapy, ATRA pharmacokinetics were studied.After progression of the patient's disease, despite the administration of first-line and second-line chemotherapy, combined treatment with ATRA/IFNalpha yielded a partial remission, which allowed surgical resection of the largest metastasis. The same therapy was effective in preventing tumor recurrence after incomplete removal of the remaining metastases. Treatment was well tolerated, and the patient is in stable complete remission 14 months after the end of therapy. The pharmacokinetics results confirmed the indication of an intermittent schedule for oral ATRA therapy.ATRA/IFNalpha treatment may be considered as an alternative approach in the treatment of patients with metastatic osteosarcoma who have disease that is resistant to conventional chemotherapy and in the treatment of patients with minimal tumor residue.

Pneumonectomy for lung metastases: indications, risks, and outcome

Background. Resection of pulmonary metastases (PM) by pneumonectomy is infrequently performed and benefits are uncertain.Methods. From 1985 to 1995, 42 patients underwent pneumonectomy for PM. Twenty-nine patients had PM from sarcomas, 12 patients from carcinomas, and 1 patient from melanoma. The indications for pneumonectomy were pulmonary recurrences in 12 patients, PM centrally located in 26 patients, and high number of PM in 4 patients. There were 11 intrapericardial and 6 extended pneumonectomies. The average number of PM resected was 3. Twenty-two patients (52%) had lymph nodes involvement.Results. There were 2 postoperative deaths (4.8%) related to pneumonectomy and one death within 30 days for rapidly evolving disease; 4 patients (9.5%) had major postoperative complications that were medically treated. Five patients (12%) were operated on for recurrences on the residual lung. At the completion of the study, 12 patients were still alive, 8 without recurrences. The median survival was 6.5 months (range, 1 to 144 months); the 5-year survival was 16.8%.Conclusions. Pneumonectomy should not be considered an absolute contraindication in patients with PM, but the poor outcome of our series suggests strict criteria of selection.

Bronchioloalveolar Lung Carcinoma: Results of Surgical Treatment and Prognostic Factors

To determine the long-term results after surgical treatment of bronchioloalveolar lung carcinoma (BALC) and to identify prognostic factors.A retrospective study of 70 patients (49 men, 21 women), mean age 61+/-10 years, was carried out. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. All the diagnosed BALC cases were reviewed and were classified into histologic types: mucinous, nonmucinous (including fibrotic center), and mixed tumors. Univariate and multivariate analyses were carried out.The nodular or tumoral type was identified in 42 patients, pneumonic in 21, and diffuse in seven. Histologically, there were 36 mucinous, 25 nonmucinous, and nine mixed tumors. Resection was complete in 61 instances (87%) and incomplete in five. The 5-year survival rate was 34% in patients with curative resections. Five prognostic factors were identified by univariate analysis, but in multivariate analysis, only three factors remained significant: the absence of symptoms, the TNM stage, and completeness of resection. Thirty-six patients with curative resection (59%) developed recurrences (in the lung in 26 patients; mediastinal lymph nodes, four; distant metastases, nine). The frequency of recurrence was significantly greater in patients with pneumonic-type BALC than in nodular or tumoral types (p<0.01), and pulmonary recurrences were significantly more frequent in pneumonic than in tumoral types (p<0.02).This study confirmed that the overall prognosis of BALC is not significantly different from that of the other non-small cell lung cancers. We found that the lungs are the predominant site of recurrence in BALC, especially in the pneumonic types. The complete surgical resection of localized BALC offers the best chances of long-term survival.

Impact on survival by method of recurrence detection in stage I and II cutaneous melanoma.

The impact on survival by components of a surveillance program (physical examination, blood tests, and chest radiograph) used to detect recurrences in patients with cutaneous melanoma was assessed. Data were collected from medical records and tumor registry information on a historical cohort of 1004 patients who presented with AJCC Stage I or II cutaneous melanoma at Roswell Park Cancer Institute from 1971 through 1995. Information on method of detection was available on 154 out of 174 identified first recurrences (89%). Physical examination detected 72% of recurrences, constitutional symptoms indicated 17% of recurrences, and chest radiograph revealed 11% of recurrences. Blood tests did not predict any recurrence. Only 9 of 17 patients with recurrences detected by chest radiograph alone underwent curative surgical resection. These patients had a statistically significant prolonged survival after diagnosis of recurrence compared to those surgical candidates who did not undergo resection. There was no statistically significant difference in overall survival between patients with asymptomatic pulmonary recurrences and those whose pulmonary recurrences were detected after symptoms of metastatic disease had developed. Most recurrences are detected on physical examination. Blood tests have no role in surveillance programs. Chest radiographs can detect pulmonary recurrences in a small number of asymptomatic patients at a stage when surgery may prolong survival.

Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis.

Samlal RAK, van der Velden J, van Eerden T, Schilthuis MS, Gonzalez Gonzalez D, Lammes FB. Recurrent cervical carcinoma after radical hysterectomy: an analysis of clinical aspects and prognosis. Int J Gynecol Cancer 1998; 8: 78-84. The purpose of the present study was to evaluate the clinical aspects and prognosis of patients with tumor recurrence in surgically treated stage IB and IIA cervical carcinoma patients. Two hundred and seventy-one stage IB and IIA cervical carcinoma patients underwent a Wertheim Okabayashi radical hysterectomy with pelvic lymphadenectomy. The median follow-up time was 60 months. Recurrence occurred in 27 patients (10%): 14 had a pelvic recurrence and 13, and extrapelvic recurrence. The site of recurrence was influenced by various pathological factors as well as by the primary treatment mode. 77% of recurrences were detected within three years after primary treatment. The median recurrence-free interval in patients with a pelvic recurrence was significantly shorter than in patients with an extrapelvic recurrence (14 months vs. 17 months, P = 0.03). The mortality rate of the group of patients with recurrent disease was 85% (23/27). Patients with a pelvic central recurrence had a significantly better outcome than did patients whose recurrences were located at the pelvic sidewall. Two patients with a pulmonary recurrence were treated with surgery and show no evidence of disease after 4 and 8 years respectively, of follow-up. The overall detection rate of recurrent disease by routine follow-up was only 36%. However, asymptomatic patients had a significantly better prognosis when compared with symptomatic patients. Therefore, we recommend frequent follow-up visits during the first 3 years after primary treatment to detect recurrence in an early stage.

Completion right lower lobectomy for recurrence after left pneumonectomy for metastases

Resection of pulmonary recurrences on the residual lung after pneumonectomy for metastases is exceptional. A 37-year-old woman was submitted to left extended pleuro-pneumonectomy after left leg amputation for fibrosarcoma. At 43 months later, a wedge resection on the right lower lobe was performed followed 32 months later by a further wedge resection in the same lobe. A completion right lower lobectomy for a new recurrence was performed 17 months after the last pulmonary resection. The patient did not develop postoperative complications. She is still alive and free of disease 10 years and 9 months after pneumonectomy and 36 months after completion lobectomy on the residual lung. In highly selected patients, aggressive surgery for metastases on the residual lung can be successfully performed and it can improve survival.