Female adnexal tumor of probable wolffian origin: a clinicopathological case report and a possible new treatment

Female adnexal tumors of probable wolffian origin (FATWOs) are rare tumors arising in the broad ligament from the remnants of the mesonephric duct. We report a case of recurrent disease. A 15-year-old girl who presented with a painful pelvic mass underwent a laparotomy with tumor resection. Pathology findings confirmed a FATWO. The tumor recurred within 2 years and was treated with multiple chemotherapy regimens, including a platinum-based drug, and surgery for progressive disease. The tumor was positive for c-kit oncogene (CD 117). Gleevac therapy, a tyrosine kinase inhibitor, was prescribed, and she developed severe persistent lower abdominal pain 2 months later. She underwent a hysterectomy and debulking of retroperitoneal masses. Pathology showed evidence of tumor necrosis, suggesting a possible beneficial effect, and she was recommenced on Gleevac in an effort to prevent recurrences. She is currently asymptomatic, without evidence of disease 10 months after surgery, continuing on Gleevac therapy. FATWOs are very rare tumors. Most cases are benign but have the potential to recur and metastasize. There is limited knowledge about the optimal treatment for this neoplasm. Our patient's favorable response to Gleevac therapy supports the concept of targeted molecular therapy in patients with c-kit-positive FATWO tumors.

Feasibility of laparoscopic debulking with electrosurgical loop excision procedure and argon beam coagulator at recurrence in patients with previous laparotomy debulking

OBJECTIVES

Our purpose is to assess the feasibility and success of laparoscopic ovarian debulking with electrosurgical loop excision procedure (LEEP) and argon beam coagulator (ABC).

METHODS

Thirty-six consecutive asymptomatic patients with chemosensitive stage III or IV ovarian cancer who had undergone prior laparotomy debulking and chemotherapy, underwent laparoscopic debulking at the time of elevated CA 125. Preoperative abdominal/pelvic computed tomography was negative. Operative laparoscopy was performed through an open technique in the left upper quadrant. Tumors were debulked laparoscopically by using the LEEP and the ABC.

RESULTS

Of 36 patients, 34 (94%) underwent successful laparoscopic debulking without requiring laparotomy. Of 34 patients, 32 (94%) had all visible disease resected at laparoscopy; 6% had surgical complications. Median time for surgery was 2.6 hours, median blood loss 70 mL, and median hospital stay 1 day. Seventy-four percent had a complete response after laparoscopic debulking and chemotherapy with a median progression free survival of 1.1 years.

CONCLUSION

We present the first report of laparoscopic ovarian debulking using LEEP and ABC after elevation of CA 125 in chemosensitive, asymptomatic patients who had undergone prior laparotomy debulking. Laparoscopic debulking appears feasible (94%), successful (94%), and safe (6% complications). Prospective randomized trials are needed to determine the optimal management of asymptomatic, chemosensitive patients with elevated CA 125.

Management of patients with an increasing prostate-specific antigen after radical prostatectomy

Since the late 1980s, early detection and monitoring of men for prostate cancer by serum prostate-specific antigen (PSA) measurement has resulted in an increase in the number of men presenting with a potentially curable disease. During the same time, in an attempt to provide a definitive cure, radical prostatectomy has been performed increasingly and now is regarded as the management option of choice for many patients with clinically localized prostate cancer. Radical prostatectomy involves the removal of all of the prostate tissue resulting in the serum PSA level to steadily decline to an undetectable level within 4 to 6 weeks after surgery. Despite improvements in surgical technique and a marked downward stage shift brought about by serum PSA testing, approximately 25% of men ultimately will experience a subsequent increase in serum PSA to a detectable level indicating disease recurrence after radical prostatectomy within 15 years. In this brief review, the factors associated with a high risk for disease recurrence after radical prostatectomy are discussed. Factors indicating whether the increasing serum PSA is caused by local recurrence or metastatic disease and the management options available to address serum PSA recurrence also are discussed.

Non hodgkin's lymphoma seven years following remission of acute lymphoblastic leukemia

The authors describe a case of extramedullary relapse in lymph node presenting as lymphoblastic lymphoma seven years following remission of acute lymphoblastic leukemia. To the best of our knowledge, this is the first reported case of an isolated lymph node relapse with hematopoietic remission of leukemia. We have discussed cases of large cell lymphoma and other unusual areas of extramedullary relapse complicating acute lymphoblastic leukemia in hematopoietic remission.

Autologous natural killer cell therapy for human recurrent malignant glioma

BACKGROUND

Natural killer (NK) cells are highly efficient in the cellular immune response against malignant tumors without restriction of major histocompatibility complex. However clinical studies using autologous NK cells have been reported in only a very limited number of cases, due to the fact that selective NK expansion is difficult to achieve in this patient population. Here, we report the results of adoptive immunotherapy in patients with recurrent malignant gliomas using autologous NK cells that were expanded ex vivo by a novel method.

PATIENTS AND METHODS

Peripheral blood mononuclear cells (PBMCs) were prepared from patients with malignant gliomas, and were co-cultured with an irradiated human feeder cell line (HFWT) in RHAM-alpha medium supplemented with 5% autologous plasma and interleukin-2. The resulting NK cell-rich effector cells were injected into 9 patients (16 courses) with recurrent malignant glioma (6 cases of WHO grade-3 glioma and 3 cases of grade-4 glioma).

RESULTS

The mean frequency of NK cells among lymphocytes was 82.2 +/- 10.5%. A combination of focal and intravenous injections was peformed in 10 courses. Intravenous injection alone was performed in 6 courses. Further, intravenous injection of low-dose interferon beta (6x10(6) IU/week) was performed as an adjuvant therapy in all courses to achieve maximum benefit for enrolled patients. Clinical evaluation demonstrated 3 PR, 2 MR, 4 NC and 7 PD in a total of 16 courses of treatment. Severe neurological toxicity was not observed in any of the patients.

CONCLUSION

It was demonstrated that NK cell-rich effector cells were expanded ex vivo from PBMCs in all nine cases of recurrent malignant glioma and that NK cell therapy was safe and partially effective in patients with recurrent malignant gliomas.

Donor lymphocyte infusions for relapse of chronic myeloid leukemia after allogeneic stem cell transplantation: prognostic significance of the dose of CD3 + and CD4 + lymphocytes

Between December 1993 and November 2001, 30 patients with chronic myeloid leukemia who relapsed after stem cell transplantation were studied. Seventeen patients were not treated before donor lymphocyte infusion (DLI), eight patients received interferon-alpha (IFN-alpha), and five underwent chemotherapy. The method of DLI was the bulk dose regimen. The median time between DLIs was 6 weeks. The median number of infusions was three; the median time from transplant to relapse was 17 months and from relapse to DLI 2 months. Eleven patients (37%) were in molecular/cytogenetic relapse, 14 (47%) in chronic phase, and five (16%) in accelerated or blastic phase. Seventeen patients (57%) developed acute graft-versus-host disease (GVHD). Chronic GVHD was observed in 15 of 24 (62%) patients. Four (13%) patients developed cytopenia after a median of 30 days. Nineteen (63%) patients achieved response, 15 of them developed GVHD. The response rate according to the disease phase was molecular or cytogenetic relapse: 91%, chronic phase: 57%, and accelerated or blastic phase: 20%. The median time to response was 6 months. Patients treated with IFN-alpha or no treatment as well as those who were in molecular/cytogenetic relapse and those who received a CD3(+) cell dose <1 x 10(8)/kg and CD4(+) <8 x 10(7)/kg had better survival. We conclude that patients who receive lower doses of lymphocytes have better survival. In some patients IFN-alpha seems to be a good choice to potentiate the graft-versus-leukemia (GVL) effect.

Overview of recurrent respiratory papillomatosis

PURPOSE OF REVIEW

The purpose of this article is to review recent literature regarding pediatric recurrent respiratory papillomatosis (RRP) published within the last year. By reviewing and assessing these articles, a more clear understanding regarding the etiology and management of pediatric RRP can be obtained, allowing physicians to better care for their pediatric RRP patients.

RECENT FINDINGS

Pediatric RRP continues to be an extremely difficult management problem for otolaryngologists. This disease process continues to be a significant burden on the health care system and is a significant cause of morbidity in affected patients and their families. The incidence of RRP continues to be approximately 3.96 per 100,000 in the pediatric population. It has been noted recently that approximately 7 of every 1000 children born to mothers with vaginal condyloma develop pediatric RRP. Although the mainstay of surgical management has traditionally been the CO2 laser, newer surgical techniques have demonstrated efficacy in the management of pediatric RRP patients, including powered instrumentation and the pulse-dye laser. The traditional adjuvant medical therapies used for pediatric RRP continue to be commonly used, including interferon-alpha2a, retinoic acid, and indol-3-carbinol/diindolylmethane (I3C/DIM). Recently cidofovir has demonstrated efficacy in selected patients. In addition, current research regarding vaccine therapy for pediatric RRP has shown promise. Basic science research in the field of immunology has demonstrated multiple defects in cell-mediated immunity, which has shed further light on the etiology of pediatric RRP.

SUMMARY

Pediatric RRP continues to be a highly morbid disease process. New surgical and medical therapies offer hope for better control of this disease in affected patients. Recent advances in immunologic research offer the hope of immune system modulation and augmentation as potential future treatment modalities to better control this disease process.

A Case of Aorto-Bronchial Fistula After Insertion of Left Main Bronchial Self-Expanding Metallic Stent in a Patient with Recurrent Esophageal Cancer

We report a case of aorto-bronchial fistula (ABF) caused by a self expanding metallic stent (EMS) 51 days after insertion into the left main bronchus. The patient presented with left main bronchial stenosis caused by post-operative local recurrence of esophageal cancer. Post-operative radio therapy totaling 40 Gy and post-recurrence radiotherapy totaling 34 Gy were administered, with daily fractions of 2 Gy. Stenosis of the left main bronchus improved slightly, and was followed with insertion of EMS to prevent restenosis. The patient experienced massive hemoptysis for 3 days before sudden death. Autopsy revealed the EMS edge perforating the descending aortic lumen. Tumor infiltration and bacterial infection were observed on the wall of the left bronchus, and atherosclerosis was present on the aortic wall around the fistula. It should be noted that the left main bronchus was at considerable risk of ABF after insertion of EMS for malignant stenosis, and prophylactic sent insertion into the left bronchus without imperative need must be avoided.

Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis

PURPOSE

To determine survival and relapse rates by T and N stage and treatment method in five randomized phase III North American rectal adjuvant studies.

PATIENTS AND METHODS

Data were pooled from 3,791 eligible patients enrolled onto North Central Cancer Treatment Group (NCCTG) 79-47-51, NCCTG 86-47-51, US Gastrointestinal Intergroup 0114, National Surgical Adjuvant Breast and Bowel Project (NSABP) R01, and NSABP R02. Surgery alone (S) was the treatment arm in 179 patients. The remaining patients received adjuvant treatment as follows: irradiation (RT) alone (n = 281), RT + fluorouracil (FU) +/- semustine bolus chemotherapy (CT; n = 779), RT + protracted venous infusion CT (n = 325), RT + FU +/- leucovorin or levamisole bolus CT (n = 1,695), or CT alone (n = 532). Five-year follow-up was available in 94% of surviving patients, and 8-year follow-up, in 62%.

RESULTS

Overall (OS) and disease-free survival were dependent on TN stage, NT stage, and treatment method. Even among N2 patients, T substage influenced 5-year OS (T1-2, 67%; T3, 44%; T4, 37%; P <.001). Three risk groups of patients were defined: (1) intermediate (T1-2/N1, T3/N0), (2) moderately high (T1-2/N2, T3/N1, T4/N0), and (3) high (T3/N2, T4/N1, T4/N2). For intermediate-risk patients, those receiving S plus CT had 5-year OS rates of 85% (T1-2/N1) and 84% (T3/N0), which was similar to results with S plus RT plus CT (T1-2/N1, 78% to 83%; T3/N0, 74% to 80%). For moderately high-risk lesions, 5-year OS ranged from 43% to 70% with S plus CT, and 44% to 80% with S plus RT plus CT. For high-risk lesions, 5-year OS ranged from 25% to 45% with S plus CT, and 29% to 57% with S plus RT plus CT.

CONCLUSION

Different treatment strategies may be indicated for intermediate-risk versus moderately high- or high-risk patients based on differential survival rates and rates of relapse. Use of trimodality treatment for all patients with intermediate-risk lesions may be excessive, since S plus CT resulted in 5-year OS of approximately 85%; however, 5-year disease-free survival rates with S plus CT were 78% (T1-2/N1) and 69%(T3/N0), indicating room for improvement.

Pooled analysis of fluorouracil-based adjuvant therapy for stage II and III colon cancer: who benefits and by how much?

PURPOSE

Although it is well-established that fluorouracil- (FU-) based adjuvant therapy improves survival for patients with resected high-risk colon cancer, the magnitude of adjuvant therapy benefit across specific subgroups and for individual patients has been uncertain.

PATIENTS AND METHODS

Using a pooled data set of 3,302 patients with stage II and III colon cancer from seven randomized trials comparing FU + leucovorin or FU + levamisole to surgery alone, we performed an analysis based on a Cox proportional hazards regression model. Treatment, age, sex, tumor location, T stage, nodal status, and grade were tested for both prognostic and predictive significance. Model derived estimates of 5-year disease-free survival and overall survival (OS) for surgery alone and surgery plus FU-based therapy were calculated for a range of patient subsets.

RESULTS

Nodal status, T stage, and grade were the only prognostic factors independently significant for both disease-free survival and OS. Age was significant only for OS. In a multivariate analysis, adjuvant therapy showed a beneficial treatment effect across all subsets. Treatment benefits were consistent across sex, location, age, T-stage, and grade. A significant stage by treatment interaction was present, with treatment benefiting stage III patients to a greater degree than stage II patients.

CONCLUSION

Patients with high-risk resected colon cancer obtain benefit from FU-based therapy across subsets of age, sex, location, T stage, nodal status, and grade. Model estimates of survival stratified by T stage, nodal status, grade, and age are available at http://www.mayoclinic.com/calcs. This information may improve patients' and physicians' understanding of the potential benefits of adjuvant therapy.

Late relapse of testicular cancer

Due to its unique biological behavior, late relapse (LR) of testicular cancer has recently been described as an own tumor entity. It is currently defined as tumor recurrence more than 2 years after complete remission following primary treatment including chemotherapy. The incidence ranges from 2 to 6%, with a median relapse-free interval of 5.4-7.1 years from the initial treatment. Although histology shows a germ cell tumor (GCT) origin, the clinical biology is different. The dominant characteristics are slow tumor growth and chemoresistance. Molecular analysis currently focuses on the mechanisms of drug resistance. The initial response to chemotherapy is less than 30% and in most cases complete surgical resection remains the only treatment option with favorable long-term results. The most common site of LR is the retroperitoneum, with undifferentiated cancer (yolk sac) being the most frequent histology. In most cases, patients have already undergone previous retroperitoneal surgery. The overall cure rate is only about 50%, hence, adequate treatment of the primary tumor is essential to prevent the development of LR.

An update on the management of relapsed and primary refractory Hodgkin’s disease

With the use of combined modality therapy for early stage disease and a risk-adapted approach for advanced stage disease, nearly 90% of patients with Hodgkin's lymphoma are cured with initial therapy. However, in patients who have primary refractory or relapsed disease, high-dose therapy and autologous stem cell transplantation is the best curative option. The use of peripheral blood progenitor cells has decreased transplant related mortality to less than 3%; but long-term progression-free survival as increased minimally. Although prognostic factors have been used to tailor therapy in de novo Hodgkin's lymphoma their utility in the relapsed-refractory setting has not been exploited. This update will discuss these important prognostic factors and try to guide oncologists in treatment decisions in this setting.

The influence of resection and aneuploidy on mortality in oral leukoplakia

BACKGROUND

Although the standard treatment of oral leukoplakia ranges from watchful waiting to complete resection, the value of these approaches is unknown.

METHODS

We studied the relations among resection, ploidy status, and death from cancer in 103 patients with diploid dysplastic oral leukoplakia, 20 patients with tetraploid lesions, and 27 patients with aneuploid lesions. Data on cancer-specific mortality and treatment were obtained from the Cancer Registry of Norway, Statistics Norway, and chart reviews.

RESULTS

Primary oral carcinoma developed in 47 of the 150 patients with leukoplakia (31 percent)--5 with diploid, 16 with tetraploid, and 26 with aneuploid leukoplakia--during a mean follow-up of 80 months (range, 4 to 237). The margin status of the initial leukoplakia resection had no relation to the development of oral cancer (P=0.95). Twenty-six of the 47 patients in whom cancer developed (4 with prior tetraploid and 22 with prior aneuploid lesions) had recurrences (55 percent); the recurrences were more frequently multiple and distant (within the oral cavity) among patients with aneuploid lesions than among those with tetraploid or diploid lesions. All 47 patients underwent a standard regimen of surgery and radiation, followed by chemotherapy in the 26 with recurrent cancer. Only patients with aneuploid leukoplakia died of oral cancer; the five-year rate of death from cancer was 72 percent. Aneuploidy-related first carcinomas were diagnosed at a more advanced stage than were carcinomas originating from diploid or tetraploid leukoplakia (P=0.03) and were more likely to be lethal regardless of the stage.

CONCLUSIONS

Complete resection of aneuploid leukoplakia does not reduce the high risk of aggressive carcinoma and death from oral cancer.

15-Year Experience on Intravesical Therapy of T1G3 Urinary Bladder Cancer: a Conservative Approach

OBJECTIVE

To report the recurrence, progression and survival in patients with T1G3 transitional cell carcinoma (TCC) of the urinary bladder treated with sequential intravesical bacillus Calmette-Guérin (BCG) and chemotherapeutic agents (doxorubicin or epirubicin) on long-term follow up.

METHODS

Between July 1988 and September 1999, all patients in a single center with T1G3 bladder TCC, after complete transurethral resection (TURBT), received either 81 mg of Connaught strain BCG or 50 mg of doxorubicin or epirubicin as adjuvant therapy. A conservative approach was adopted whereby those with superficial recurrences were eligible to crossover, even repeatedly, until progression to muscle invasion. Recurrence, progression and disease-specific survival were analyzed.

RESULTS

There were 36 patients included, with 26 males and 10 females. The mean age was 71.6 years (range 53-85 years). Final analysis was made at a median follow-up of 23.5 months (range 0-125 months) for recurrence, 33 months (range 0-125 months) for progression and 45.5 months (range 3-125 months) for survival. Sixteen (44.4%) patients showed recurrence. Nine (25%) of these 16 patients progressed. Five (13.9%) of those who progressed died of TCC. The 10 year Kaplan-Meier estimates for recurrence-free survival, progression-free survival and disease-specific survival were 48, 68 and 81%, respectively. Figures with this conservative approach were comparable to those with more aggressive approaches reported in the literature.

CONCLUSIONS

Adjuvant intravesical therapy with either BCG or a chemotherapeutic agent (doxorubicin or epirubicin) and crossover on recurrence was an effective conservative treatment for T1G3 bladder TCC.

Is cidofovir a useful adjunctive therapy for recurrent respiratory papillomatosis in children?

OBJECTIVE

To assess the usefulness of cidofovir in treating recurrent respiratory papillomatosis in children. Cidofovir is an acyclic nucleoside phosphonate that has been reported to be effective in the treatment of respiratory papillomatosis in several small series of patients.

METHODS

A prospective study was conducted in 11 children (mean, 2.1 years; range, 0.5-3 years at diagnosis) with recurrent respiratory papillomatosis who at the start of the study were requiring debridement of papillomas at least every 6 weeks. After microlaryngoscopy with powered microdebridement of papillomas patients received intralesional injection of cidofovir (5mg/ml). The severity of papillomatosis was rated at each visit using a standardized papilloma severity scoring system. The success of therapy was measured by the trend in the patient's papilloma severity scores before and after cidofovir therapy and by whether the frequency of operative interventions decreased in the period after treatment began.

RESULTS

Three patients had impressive improvements in severity scores and a decrease in the frequency of required operative interventions after cidofovir, two patients had a partial response, and for six patients cidofovir was considered ineffective.

CONCLUSIONS

Intralesional cidofovir did not decrease the severity or frequency of operative intervention for recurrent respiratory papillomas in the majority of children in this study. The drug did improve papillomatosis in the minority of patients without causing notable morbidity. A large multi-institutional controlled study is needed to better assess the efficacy of this treatment.

Local recurrence of prostate cancer after external beam radiotherapy: early experience of salvage therapy using high-intensity focused ultrasonography

OBJECTIVES

To evaluate the efficacy and safety of a salvage therapy using transrectal high-intensity focused ultrasonography (HIFU) for locally recurrent prostate cancer after external beam radiotherapy.

METHODS

All patients were treated with HIFU under general or spinal anesthesia. Specific parameters were progressively defined to avoid any rectal damage. Patient follow-up included sextant biopsy and prostate-specific antigen (PSA) measurement.

RESULTS

A total of 71 patients were included in this series. The main baseline characteristics before HIFU were mean age 67 +/- 5.86 years, mean prostate volume 21.4 +/- 11.1 cm(3), and mean PSA level 7.73 +/- 8.10 ng/mL. All biopsies were positive, with a pre-HIFU Gleason score of 2 to 6 in 24 patients, 7 in 13 patients, and 8 to 10 in 34 patients. The mean patient follow-up was 14.8 months (range 6 to 86). After HIFU treatment, 57 (80%) of the 71 patients had negative biopsies, and 43 (61%) of 71 had a nadir PSA level of less than 0.5 ng/mL. The nadir level was obtained within 3 months. At the last follow-up, 44% of the patients had no evidence of any disease progression. The adverse events related to HIFU included rectourethral fistula in 6%, grade 3 incontinence in 7%, and bladder neck stenosis in 17%. No rectal injury occurred with the use of specific parameters.

CONCLUSIONS

HIFU appears to be a promising treatment option with a curative chance for patients with local recurrence after external beam radiotherapy. The HIFU-related morbidity was lower than the morbidity reported after other types of salvage therapy, leading to a favorable risk/benefit ratio.

Whole-body hyperthermia in combination with platinum-containing drugs in patients with recurrent ovarian cancer

BACKGROUND

Patients with advanced ovarian cancer have an enormous risk of relapse after primary therapy, and the prognosis for these patients remains bleak. Primary and acquired resistance of tumor cells to antineoplastic drugs is a major cause of the limited effectiveness of chemotherapy. The effect of whole-body hyperthermia (WBH) combined with platinum-containing chemotherapy in the treatment of recurrent ovarian cancer was examined in this study.

METHODS

Patients studied were those with pathologically verified epithelial ovarian cancer after operation who had had first-line chemotherapy with cisplatin or carboplatin, and relapsed. All 21 patients were treated with WBH and platinum-based chemotherapy. During the WBH, a core temperature of 41.5 degrees C-42 degrees C was attained in the rectum. We combined the WBH with 300-400 mg/dl artificial hyperglycemia. The plateau temperature was held over a period of, on average, 90 +/- 30 min, and the artificial hyperglycemia, on average, 240 +/- 30 min. WBH was repeated at the beginning of each new chemotherapy cycle.

RESULTS

One patient (4.8%) had a complete remission, 7 patients (33.3%) had a partial remission, stable disease was noted in 10 patients (47.6%), and 3 (14.3%) patients did not respond and had progressive disease. Median time to progression was 6.5 months, and median survival time, 16.5 months.

CONCLUSION

Our results validate the efficacy of WBH in the treatment of patients with recurrent platinum-resistant ovarian cancer. The overall tolerance of this treatment was good. The priority for all patients was an improvement in life quality; this was seen 3-4 days after WBH. The encouraging results should be confirmed in randomized studies. Patients with advanced ovarian cancer have an enormous risk of relapse after primary therapy, and the prognosis for these patients remains bleak. Primary and acquired resistance of tumor cells to antineoplastic drugs is a major cause of the limited effectiveness of chemotherapy. The effect of whole-body hyperthermia (WBH) combined with platinum-containing chemotherapy in the treatment of recurrent ovarian cancer was examined in this study.

Recurrent carcinoma of the head and neck: treatment strategies and survival analysis in a 20-year period

Following clinical diagnosis of a recurrent tumor, curative treatment is seldom available. Depending on the size of the recurrent tumor and the patient's general health condition extensive surgical resections and reconstructions are avoided in favor of non-surgical palliative intended treatment modalities. According to the literature location of the tumor, tumor size, as well as R-1- and R-2-resection rates are the most frequent reasons for the development of recurrent tumors. In a retrospective evaluation a population of 1000 patients who were treated for a primary head and neck cancer during the period from 1979 to 1996 were analysed descriptively. Survival probabilities of patients with recurrent tumors were calculated according to the product-limit method by Kaplan-Meier, different treatment concepts were compared and analysed with the log-rank test for significant differences. The largest proportion of primary tumors involved the floor of mouth ( n = 369, 36.9%). A total of 198 patients (19.8%) developed a recurrent cancer; 79.8% of patients experienced a recurrent cancer within two years following primary treatment. Within the group of T1/T2 tumors the incidence of recurrent tumors was 28.9%, whereas the incidence in the T3/T4 group was 44.6%. Tumor infiltration of the resection margins was detected in 12.9%. In line with the literature, tumor infiltration of the resection margins is a relevant prognostic factor, therefore intraoperative frozen section must be recommended. Treatment with curative intention, in particular extensive surgical resections, is seldom possible, and requires always a very intensive discussion with the patient.

Challenging cases in thyroid cancer: a multidisciplinary approach

Recurrent thyroid cancer can present many complex management problems. Unfortunately, recurrent thyroid cancer is often refractory to radioiodine therapy. The proper use of external beam irradiation and surgical interventions can provide regional control of localized recurrences. Because of the complex nature of these patients, a multidisciplinary team approach to management which includes specialists in thyroid medicine and surgery, head and neck radiotherapy, and nuclear medicine often is required to provide individualized, optimal multimodality treatment recommendations. In this article we review a multidisciplinary team approach to a patient with widespread, radioiodine-refractory bone metastases from follicular thyroid cancer and to a patient with unresectable central neck recurrence of papillary thyroid cancer.

[Chemoprophylaxis and endoscopical treatment of upper urinary tract tumors recurrences]

OBJECTIVES

Upper urinary tract tumors are a rare condition. We review our experience in the diagnosis of upper urinary tract tumors and their recurrences, emphasizing the management of recurrences.

METHODS

From January 1980 to June 2002 139 endourological procedures were carried out in 94 patients with the working diagnosis of upper urinary tract tumor.

RESULTS

The overall treatment failure rate was 18.7 with ureteroscopy being the least efficient technique.

CONCLUSIONS

In our experience, there is an indication for conservative endourological treatment in superficial low grade G1-2 tumors smaller than 2 cm.

Right gastroepiploic artery occlusion test for resection of recurrent lesion after esophageal reconstruction using a gastric tube

BACKGROUND

Blood supply to a reconstructed gastric tube after esophagectomy is mainly through the right gastroepiploic artery (RGEA); therefore, a recurrent lesion involving the RGEA is thought to be unresectable, or if possible, resectable combined with a whole gastric tube.

METHODS

We developed a new method of right gastroepiploic artery occlusion test for evaluation of the blood circulation of a reconstructed gastric tube in a patient who has a recurrent lesion involving the RGEA. A balloon occlusion catheter is inserted into the RGEA through the celiac trunk through a 7 Fr angiographic catheter, and the balloon is inflated. Celiac angiography and color Doppler endoscopic ultrasonography can evaluate intragastric blood flow from the right gastric artery during occlusion of the RGEA.

RESULTS

We present a case of successful resection of celiac lymph node metastasis invading the RGEA and the celiac trunk after esophageal reconstruction using a gastric tube.

CONCLUSIONS

When ligation of the right gastroepiploic artery is needed, the test is safe and simple to perform; and findings can be reliably evaluated by angiography and color Doppler endoscopic ultrasonography.

Retrospective analysis of 25 women with malignant cystosarcoma phyllodes--treatment results

PURPOSE

Mastectomy without axillary dissection should be the standard treatment in patients with malignant form of cystosarcoma phyllodes. The role of postoperative radiotherapy and chemotherapy remains to be fully established. We evaluate treatment results in a group of patients with cystosarcoma phyllodes (CP) treated at our Institute.

PATIENTS AND METHODS

In this report we analyze treatment outcome in 25 patients with malignant cystosarcoma phyllodes treated at Masaryk Memorial Cancer Institute between 1970 and 1995. Mean tumor size was 10 cm in diameter. All patients underwent surgery. Subsequently, 17 patients (68%) received radiotherapy on the breast or chest wall.

RESULTS

Median follow-up was 139.5 months. Local recurrence was observed in 16% of all patients and all patients with local recurrence died. Time to local relapse after surgery was 4-11 months. Distant metastases occurred in 5 patients. All patients with local recurrence had distant metastases. Dissemination occurred 3-19 months after local recurrence. Five-year survival of all patients was 80%.

CONCLUSION

A specific protocol for the treatment of cystosarcoma phyllodes is missing, probably due to rarity of the disease. The treatment of local recurrent disease remains unsuccessful in most CP patients. We recommend postoperative irradiation on the chest wall in patients with malignant form of CP, because adjuvant radiotherapy decreased the incidence of local relapse in our group of patients.