Surgical Removal Of Residual Disease Research Articles

Comparative Evaluation of USG-Guided Single Tissue Marker Versus Multiple Tissue Marker Placements in Breast Malignancy Patients Undergoing Neoadjuvant Chemotherapy for Tumor Localization.

Background Breast cancer remains one of the most common malignancies affecting women globally, contributing significantly to the disease burden. The advent of neoadjuvant chemotherapy (NAC) has revolutionized the treatment for locally advanced breast cancer, allowing tumors to be downstaged and making breast-conserving surgery (BCS) feasible. Accurate localization of the tumor bed post-NAC is crucial for successful surgical removal of residual disease. While traditional single tissue marker placement has been effective, recent advances suggest multiple markers might provide superior localization by comprehensively delineating the entire tumor area. This study aims to compare the effectiveness of single versus multiple tissue marker placements in breast malignancy patients undergoing NAC. Materials and methods A prospective study was conducted in the Department of Radio-diagnosis at Saveetha Medical College over 18 months, including 10 patients diagnosed with breast carcinoma, selected through convenience sampling. Inclusion criteria involved patients diagnosed with breast cancer via mammography, sonography, and histological confirmation, referred for clip placement before NAC. Exclusion criteria were patients unwilling to participate. The procedure involved placing one to two surgical clips within the tumor using a 14/16-gauge coaxial guiding needle under USGguidance, with additional clips for larger or multiple tumors. Data collection included pre-procedural USG, post-procedural mammography (MG1), pre-operative mammography (MG2)/USG, and gross specimen histopathological examination/specimen mammography. Statistical analysis Demographic data, clipping distribution, receptor status, localization methods, surgical outcomes, operation diagnoses, and correlation analysis were statistically analyzed. Mean age, standard deviation, and p-values were calculated to determine the significance of differences between single and multiple clip groups. Results The study included 10 patients with a mean age of 52.5 years. Of these, five (50%)had a single clip, and two (20%)had four clips. The average time from clipping to the second mammogram (MG2) was 106.3 days, and from clipping to operation was 111.0 days, with longer follow-up times for multiple clip patients. Six (60%) of the patients were estrogen receptor (ER) positive, and six (60%) were human epidermal growth factor receptor 2 (HER2) negative. Localization methods were similar between single and multiple clip groups. However, multiple clip patients tended to undergo more extensive surgeries like modified radical mastectomy (MRM). Imaging responses showed no preoperative ultrasound lesions in single clip patients, while multiple clip patients had higher inconsistent diagnoses (10 (100%)) suggesting that multiple clips provide better tumor localization but are linked to increased complexity and longer follow-up times. Conclusion Patients with multiple clips experienced significantly longer follow-up times, reflecting more complex clinical scenarios. Despite no significant differences in receptor status distributions, multiple clip patients required more extensive surgeries, emphasizing the need for tailored surgical planning. The study underscores the importance of considering the number of clips in clinical decision-making. Future research should focus on larger, prospective studies to validate these findings and explore underlying mechanisms.

What are the current outcomes of advanced gastrointestinal stromal tumors: who are the long-term survivors treated initially with imatinib?

The introduction of imatinib to clinical practice revolutionized therapy of advanced gastrointestinal stromal tumors (GIST), but its long-term results have been only just collected. We have attempted to identify factors related to the long-term survival. We have analyzed the data of 430 inoperable/metastatic/recurrent GIST patients treated with imatinib in reference centers, assessed the factors influencing the long-term overall survival (OS), and compared the outcomes in three periods of initiation of imatinib therapy during one decade (2001–2003, 2004–2006, 2007–2010). During analyzed time periods, we have found decrease in median largest tumor size at the start of imatinib therapy: 90.5 mm (2001–2003) versus 74 mm (2004–2006) versus 58 mm (2007–2010) (p = 0.002). Median progression-free survival (PFS) on 1st line imatinib was 37.5 months, without differences in PFS between three groups. Median OS was 5.8 years, 8-year OS rate was 43 %, and no difference in OS was demonstrated for patients treated in analyzed time periods. Independent good prognostic factors for longer OS were as follows: surgery of residual disease, initial WHO performance status 0/1, normal baseline albumin level, and the presence of exon 11 KIT mutations. Current median OS in advanced GIST reaches 6 years. The long-term survivors were characterized by smaller maximal tumors at imatinib start, better blood tests results, better performance status, and the surgical removal of residual disease. The latter might reduce the impact of tumor size and equalize the long-term results of therapy during last decade from introduction of imatinib. After introduction of subsequent lines of therapy (as sunitinib), the effect of primary mutational status on the long-term OS is also less visible.

Triplet schedule of weekly 5-Fluorouracil and alternating irinotecan or oxaliplatin in advanced colorectal cancer: A dose-finding and phase II study

A weekly administration of alternating irinotecan or oxaliplatin associated to 5-Fluorouracil in advanced colorectal cancer was planned in order to evaluate a new schedule maintaining dose intensities of each drug as in double combinations and tolerability of the triplet association. The following weekly schedule was administered: irinotecan, days 1 and 15; oxaliplatin, days 8 and 22; 5-fluorouracil (5-FU) over 12-h (from 10:00 p.m. to 10:00 a.m.) timed flat infusion, days 1-2, 8-9, 15-16 and 22-23, every 4 weeks. Dose- finding and phase II study were planned. Thirteen patients were enrolled in the dose-finding study and 23 in the phase II study. The recommended doses of our study are: irinotecan 160 mg/m(2); oxaliplatin 80 mg/m(2); 5-FU 900 mg/m(2). The dose-limiting toxicity was diarrhea (35% of patients) but no cases of febrile neutropenia were observed. In 30 patients assessable for response two complete (6.7%) and 18 partial (60%) responses were observed, for an overall response rate of 66.7% (alpha 0.05, CI+/-17). The triplet association using this weekly alternating schedule is an active and well-tolerated outpatient regimen. Surgical removal of residual disease was considered in 5 patients and a radical resection was performed in 5 patients (147 %).

Surgical resection of residual disease in initially inoperable imatinib-resistant/intolerant gastrointestinal stromal tumor treated with sunitinib

Aim Sunitinib malate therapy in inoperable and/or metastatic gastrointestinal stromal tumor (GIST) resistant to imatinib mesylate may facilitate surgical removal of residual disease. We explored this possibility in the course of treating patients as part of a treatment-use trial, the objective of which was to provide access to sunitinib treatment. Methods Four patients with inoperable and/or metastatic GIST resistant to imatinib who had responded to sunitinib therapy administered at a starting dose of 50 mg daily in 6-week cycles of 4 weeks on treatment followed by 2 weeks off underwent surgical removal of residual disease. Disease progression on or clinical response to treatment was defined based on Response Evaluation Criteria in Solid Tumors. Results In three of four cases it was possible to perform macroscopically complete resection of residual disease, resulting in surgical complete clinical responses, two with durations of 13 months. The fourth patient achieved a dramatic partial response to sunitinib that required emergency surgical resection of the necrotic tumor mass, with the partial response having been maintained for 15 months. In all cases, viable GIST cells were detected histologically in the resection specimens, and sunitinib treatment was resumed post-surgery. None of the patients experienced any postoperative complications during 13–16 months of follow-up. Conclusions Combining sunitinib treatment with surgical removal of residual disease may allow selected imatinib-resistant GIST patients who have shown a favorable response to sunitinib to achieve complete and sustained remission or durable control of previously progressive disease beyond that expected for sunitinib treatment alone.

Surgical treatment of patients with initially inoperable and/or metastatic gastrointestinal stromal tumors (GIST) during therapy with imatinib mesylate

The aim of the study was to analyze the surgical possibilities of unresectable and/or metastatic GIST CD117(+) patients during imatinib treatment. We analyzed the results of surgery in 141 patients treated with imatinib for initially inoperable and/or metastatic GIST CD117(+). Median follow-up time was 12 months (range: 3-26). Surgery was performed as subsequent treatment in 24 patients (Group I, 17%) for resection of residual disease after complete/partial response and lack of further response to imatinib and as salvage therapy in eight patients (Group II, 6%), who progressed on initially successful imatinib therapy. In Group I, the viable GIST cells were not detected histologically in only three resection specimens. The first five patients in Group I did not receive imatinib further and we observed four recurrences. In next 19 patients, continuing imatinib after surgery, we observed only one relapse. In Group II, we continued imatinib therapy after high-risk surgical procedures, but in five patients we observed subsequent progression. Surgical removal of residual disease during imatinib treatment may allow for complete remission in selected GIST patients after response to therapy, theoretically prolonging durable remission, but it is necessary to continue imatinib for its maintenance.

Surgical treatment of patients (pts) with gastrointestinal stromal tumors (GIST) after imatinib mesylate (IM) therapy

9037 Background: Complete response (CR) during IM therapy due to unresectable/metastatic GIST is restricted to a few pts and progression rate is about 10%/year. The aim of the study was to analyze the surgical possibilities of unresectable/metastatic GIST CD117(+) pts during IM treatment. Methods: We analyzed the results of surgery in 118 consecutive pts (69 male - M, 49 female - F, median age 55) treated with IM for inoperable/metastatic GIST CD117(+) between 09/2001 and 09/2004 in 1 center. Median follow-up time was 7 months [m] (range: 1 - 18 m). Results: Surgery was used as adjuvant treatment in 16 pts (group I - 14%, 9M, 7F, median age 56) for R0/R1 resection of residual disease after CR/partial response (PR - according to RECIST) no longer responding to IM treatment (median duration of IM treatment 14 m, range: 4–30 m) and as salvage therapy in 7 pts (group II: 5M, 2F, median age 52), who progressed on initially successful IM (median duration of IM treatment 20 m, range: 10–31m). In group I the viable GIST cells were not detected histologically in resection specimens in only 3 pts. Surgical procedures in group I consisted of 5 extensive liver resections (in 2 cases combined with radiofrequency ablation), 7 resections of intraperitoneal lesions with omentectomy, 1 partial gastrectomy and 3 explorative laparotomies only (in CR). Initially 5 pts in group I did not received further IM and we observed 3/5 recurrences (IM reintroduction demonstrated again PR). In other 11 pts, who continue IM after surgery, we do not observe disease relapse. Complications comprised 3 prolonged ileus treated conservatively. In group II after resection of progressive lesions (resistant to IM) we continued IM therapy, but in 4/7 pts we observed subsequent progression. In this group surgery was associated with a high risk of complications: 1 perioperative death due to uncontrolled bleeding and 1 ileus treated surgically. Conclusions: Surgical removal of residual disease during IM treatment may allow for CR in selected GIST pts after PR, theoretically prolonging durable remission, but it is necessary to continue IM after R0/R1 surgery for maintaining CR. In case of progression during IM the indications for surgery should be individualized. No significant financial relationships to disclose.

Cis-Diamminedichloroplatinum, Vinblastine, and Bleomycin Combination Chemotherapy in Disseminated Testicular Cancer

Fifty patients with disseminated testicular cancer were treated with a three-drug combination consisting of cis-diamminedichloroplatinum, vinblastine, and bleomycin. Three patients were considered inevaluable due to early death. This chemotherapy regimen produced 74% complete and 26% partial remissions. Furthermore, five patients with partial remission became disease-free after surgical removal of residual disease, producing an overall 85% disease-free status. Toxicity, although significant during remission induction with cis-platinum, vinblastine, and bleomycin, was usually manageable, although there were two drug-related deaths during this period. Thirty-eight of these patients remain alive and 32 remain alive and disease-free at 6+ to 30+ months. We believe this regimen represents a major advance in the management of patients with disseminated testicular cancer.

Surgery in testis cancer: laparoscopic and open techniques.

The review focuses on the current developments of the management of patients with testis cancer regarding surgery. For clinical stage I and stage II disease, the pros and cons of surgery as a diagnostic and therapeutic tool are updated. Additionally, the emerging role of laparoscopic techniques in the staging of the disease is critically discussed. The review presents the currently changing indications for surgery in addition to chemotherapy in metastatic disease. The complication rates of primary retroperitoneal lymph node dissection have recently been assessed by the German Testicular Cancer Study Group. These data confirm the excellent results of the Indiana series published some years ago. Laparoscopic surgery has been performed in a larger cohort of patients in specialized centers, and, concomitantly, operative times and complication rates have dropped. Indications for surgery in the post-chemotherapy setting have been more clearly defined recently. Seminoma patients usually do not need surgical removal of the residual tumor after chemotherapy, whereas patients with non-seminoma disease probably need surgery even in cases of complete radiological remission after chemotherapy. In view of the recent data on late relapse, complete surgical removal of residual disease for non-seminoma seems of the utmost importance. Larger series of surgical procedures, laparoscopic as well as open, have helped to define the role of this approach in the management of testis cancer. Long-term data on patients with complete response to initial treatment and late relapse have shown the danger of limiting the treatment of metastatic disease to chemotherapy alone. These data have also shown the importance of proper surgical techniques for all stages of testis cancer.

The treatment of neuroblastoma with intraspinal extension with chemotherapy followed by surgical removal of residual disease: A prospective study of 42 patients‐‐Results of the NBL 90 study of the French Society of Pediatric Oncology

The treatment of neuroblastoma with intraspinal extension with chemotherapy followed by surgical removal of residual disease: A prospective study of 42 patients‐‐Results of the NBL 90 study of the French Society of Pediatric Oncology

The treatment of neuroblastoma with intraspinal extension with chemotherapy followed by surgical removal of residual disease: A prospective study of 42 patients--Results of the NBL 90 study of the French Society of Pediatric Oncology

Neuroblastoma is the most common malignant cause of spinal compression in the pediatric population. More than 30% of patients who are impaired prior to treatment remain impaired after the completion of therapy. Those who do not improve after decompressive laminectomy may go on to develop severe delayed spinal deformities. To decrease the long term sequelae of routine neurosurgical intervention for all intraspinal extensions of neuroblastoma, the French NBL 90 Study was formulated to use chemotherapy as a first-line treatment for all nonmetastatic neuroblastomas with intraspinal extension. Neurosurgical decompression and excision was recommended only for patients demonstrating rapid neurologic deterioration. The overall survival of the 42 patients registered was 97%. Initial neurologic impairment was present in 27 patients (64%), including 11 with paraplegia. Thirty-two patients received chemotherapy as first-line treatment. Complete regression of the intraspinal component was observed in 13 patients and partial regression of greater than 50% of the initial volume in 5 patients. Of 19 evaluable patients presenting with a neurologic deficit and treated with primary chemotherapy, recovery was completed in 11 and partial in 3. Four patients failed to recover from long-standing pretreatment paraplegia. Only one patient worsened during therapy, and recovered completely after emergent neurosurgical intervention. Seven patients underwent initial neurosurgical procedures; six had a neurologic deficit and five recovered completely, including all three who presented with acute onset of paraplegia. Three patients had extraspinal surgery as exclusive treatment. Six patients (15%) suffered severe neurologic sequelae. Only one of the patients who underwent surgery required spinal stabilization for progressive deformity, but follow-up is limited. By treating patients with dumbbell neuroblastoma initially with chemotherapy, the authors were able to reduce the size of the intraspinal mass in 58% of patients, improve partial neurologic deficits in 92%, and avoid neurosurgical decompression in 60%. Neurologic deficits also improved in 83% of patients requiring emergent neurosurgical intervention.

Neoadjuvant Cisplatin and Interferon-α2B in the Treatment and Organ Preservation of Penile Carcinoma

We investigated the antitumor activity and toxicity of cisplatin and interferon-α2B as the primary treatment of penile carcinoma. A total of 13 consecutive patients with nonmetastatie, histologically confirmed invasive squamous cell carcinoma of the penis underwent treatment consisting of 20mg./m.2 cisplatin intravenously and 5 × 106μ./m. interferon-α2B subcutaneously daily for 5 consecutive days. An equivalent dose of interferon was then administered subcutaneously every 2 days for 3 weeks and the regimen was repeated at 28-day intervals. Of 12 evaluable patients 9 responded: 4 achieved a pathologically confirmed complete remission of 38+, 21+, 10 and 7 months in duration (2 with relapse were treated with local therapy and remain with no evidence of disease), and 5 achieved a partial response, underwent surgical removal of residual disease and remained disease-free for 14+ to 24+ months. The most significant toxicities were anemia in 5 patients and reversible renal impairment in 3 but no patient had neutropenic fever or required platelet transfusion. We conclude that primary treatment with cisplatin and interferon-α2B induced responses in 75% of 12 patients with penile carcinoma and allowed for a less radical operation than originally scheduled. A larger number of patients and longer followup will be required to confirm these encouraging preliminary results.

MANAGEMENT OF ADVANCED AND EXTRAGONADAL GERM-CELL TUMORS

The management of patients with advanced and extragonadal germ-cell tumors is similar in many respects to that of the group with minimal or moderate disease. Initial chemotherapy consisting of a cisplatin-based regimen followed by surgical removal of residual disease or teratoma is utilized. The principal reason for failure of therapy is the presence of bulky disease not responding completely to chemotherapy. Unresectable residual teratoma after chemotherapy may also be responsible for therapeutic failure in this patient group. Additionally, the presence of non-germ-cell elements that are chemoresistant may be a third reason for failure. Despite previous reports and these recognized problems, recent studies indicate that this group of patients can be rendered disease free in more than 65% to 70% of instances. Therefore, these patients should be considered potentially curable, and aggressive multimodality therapy employed. Clinical trials of newer agents such as ifosfamide and procedures such as autologous bone marrow transplantation after intensive chemotherapy are under way to define their roles in patients with advanced disease.

High failure rate of carboplatin-etoposide combination in good risk non-seminomatous germ cell tumours

24 patients with good risk non-seminomatous germ cell tumours (GR-NSGCT) were enrolled in a phase II trial combining carboplatin (C) and etoposide (E). Carboplatin was given at a fixed dose of 450 mg/m 2 at d2, and E 120 mg/m 2, d1-3, every 4 weeks × 4 cycles (cy). Myelosuppression was the major toxicity with neutropenia grade 4 in 18 cy (19%) and grade 3 in 26 cy (27%). Thrombocytopenia grade 3 and 4 occurred in 7 and 1 cy, respectively. Responses included: 20 complete responses (CR) (83%) with 16 clinical CR and 4 pathological CR; 3 additional patients had complete surgical removal of residual disease (SRRD) with viable tumour (surgical CR); 1 patient progressed during C + E therapy. 5 of the 16 clinical CR relapsed, and all the 3 surgical CR progressed despite post-operative salvage chemotherapy. Adverse events occurred in 9 patients (37.5%; 95% C.I., 19–59%). After a median follow-up of 24 m (range 14 to 38) 4 patients had died [3 progressive disease (PD), 1 suicide while in CR], 3 were alive with PD, and 17 had no evidence of disease. No significant correlation between area under the curve values of carboplatin, overall treatment failure and the platelet nadirs was observed. We conclude that the efficacy of the C + E regimen as given in our protocol is inferior to the standard cisplatin-containing regimens. The low dose-density (D/I) of carboplatin could be responsible for the high failure rate.

Primary chemotherapy in the management of low stage (IIA and IIB) non-seminomatous germ cell testicular tumours.

In a prospective study a total of 65 patients in clinical stages IIA and IIB nonseminomatous testicular tumours were treated by primary chemotherapy followed by retroperitoneal lymphadenectomy in cases with residual disease. The patients were given a combination of cisplatin, vinblastine and bleomycin, or also etoposide. Sixty-two patients (95.4%) achieved complete response: 39 (60%) by chemotherapy alone and 23 (35.4%) following surgical removal of residual disease. Three patients died; there were two drug-related deaths during PVB chemotherapy, one patient had progression of disease following chemotherapy and died as a result of disease dissemination. Three patients relapsed from complete response following chemotherapy, two of them died within 19 and 29 months after the onset of therapy. The third patient received second-line chemotherapy and gained complete response again. Of the 65 patients, 60 (92.3%) survive with no evidence of disease. The follow-up period ranged from 6 to 79 months (mean 39.4 months, median 39 months).

High-dose melphalan with autologous marrow for treatment of advanced neuroblastoma.

A group of 12 children with advanced neuroblastoma (7 Stage IV and 5 Stage III), selected by their initial response to chemotherapy with pulsed cyclophosphamide/vincristine/Adriamycin (CVA), were given consolidation therapy with high-dose melphalan (140 mg/m2) and then surgical removal of residual disease. Twenty-two high-dose melphalan procedures were combined with autologous marrow grafting to offset myelotoxicity and were well tolerated. In each of 2 additional children, procedures carried out without marrow autografting led to serious marrow and mucosal toxicity. There were no treatment-related deaths. In 7/11 patients with evaluable computerized tomographic (CT) scans there was a decrease in maximum diameter of the primary tumour after melphalan. Complete response was achieved in 6 patients, of whom 3 are well and have no evidence of disease at 35, 33 and 18 months from completion of all treatment; however, although survival (median 23 months) of all 12 autografted patients is longer than that of 28 comparable children treated between 1970-77 with conventional chemotherapy (median 14 months) the difference is not statistically significant. High-dose melphalan is a safe and tolerable treatment in children when combined with autologous marrow grafting, but further study is required to determine whether the procedure can improve prognosis for patients with advanced neuroblastoma.

Chemotherapy for Disseminated Testicular Cancer

Fifty patients with disseminated testicular cancer were treated with a three-drug combination consisting of cis-diaminedichloroplatinum, vinblastine, and bleomycin. Three patients were considered unevaluable due to early death. This chemotherapy regimen produced 74 per cent complete and 26 per cent partial remissions. Furthermore, five patients in partial remission became disease-free following the surgical removal of residual disease, producing an overall 85 per cent disease-free status. Toxicity, although significant during remission induction with cis-platinum, vinblastine, and bleomycin, was usually manageable. Maintenance therapy with vinblastine and BCG was very well tolerated, and only two patients in complete remission have experienced a relapse on maintenance therapy, one of whom had a central nervous system relapse. Thirty eight of these patients remain alive, and 32 remain alive and disease-free 6+ to 30+ months. We feel that this regimen represents a major advance in the management of patients with disseminated testicular cancer.

Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy in disseminated testicular cancer.

Fifty patients with disseminated testicular cancer were treated with a three-drug combination consisting of cis-diamminedichloroplatinum, vinblastine, and bleomycin. Three patients were considered inevaluable due to early death. This chemotherapy regimen produced 74% complete and 26% partial remissions. Furthermore, five patients with partial remission became disease-free after surgical removal of residual disease, producing an overall 85% disease-free status. Toxicity, although significant during remission induction with cis-platinum, vinblastine, and bleomycin, was usually manageable, although there were two drug-related deaths during this period. Thirty-eight of these patients remain alive and 32 remain alive and disease-free at 6 + to 30 + months. We believe this regimen represents a major advance in the management of patients with disseminated testicular cancer.

Improved Chemotherapy in Disseminated Testicular Cancer

Two combination chemotherapy regimens for disseminated testicular cancer are described. Our present regimen of platinum vinblastine and bleomycin has been highly successful, producing 16 complete (80 per cent) and 4 partial (20 per cent) remissions. Furthermore, 2 patients have been rendered free of disease by the surgical removal of residual disease, making the effective complete remission rate in these 20 patients 90 per cent. Of these patients 16 are alive and 14 are free of disease for more than 8 to more than 20 months. Despite the significant toxicity during the first 12 weeks of this therapeutic regimen it usually was manageable and maintenance therapy produced minimal toxicity. We believe that this regimen is a major advance in the management of patients with disseminated testicular cancer.

Retrospective critical review and analysis of bilateral staged pulmonary resections for treatment of pulmonary tuberculosis.

A critical retrospective analysis of 14 cases of bilateral staged pulmonary resections for the treatment of pulmonary tuberculosis is described. Lobectomies with or without segmentectomies were the preferred procedures. The four positive cases had mostly cavitary disease (85%) with positive bacteriologic culture from the specimens (75%). The ten negative cases had less cavitary disease (65%) with negative bacteriologic culture of the specimens (90%). Positive residual bacteriologic specimen activity (10%) of the negative group favors the surgical removal of residual disease, despite the fact that 45% have no culture or bacterial stain obtained. Negative residual bacteriologic specimen activity (25%) of the positive group indicates the limitations of inadequate surgery. Thus the indications of surgery may gradually reestablish their own crieteria in this era of massive chemotherapy.