Prognosis of local recurrence in giant cell tumour of bone: what can we do?

Giant cell tumour of bone (GCTB) is classified as an intermediate tumour with rare metastasis, but is challenged by local recurrence. This review focuses on the role of radiological evaluation in terms of prognosis of local recurrence in GCTB. We hope to highlight the value of radiological evaluation by integrating studies on the impact of surgical treatments and non-surgical factors on local recurrence of GCTB and the current statuses of genetic and molecular prognostic factors of GCTB. Radiological evaluation can provide diverse information on tumours. As a non-invasive method, magnetic resonance imaging (MRI) is especially valuable for the diagnosis and evaluation of bone tumours due to its heightened sensitivity to soft tissue disease and multiplanar image acquisition. Imaging findings should be integrated with clinical characteristics, pathology and genetic and molecular prognostic factors to direct clinical approach and reduce the local recurrence of GCTB. Therefore, it is necessary to establish a multi-perspective evaluation system by which prognostic factors can be reliably determined. We further advocate more large-scale prospective studies. With the help of radiological evaluation, the clinic treatment of GCTB can be guided and local recurrence might be reduced; additionally, MR imaging can identify local recurrence of GCTB after surgical treatment in the early stage.

A prospective study on predicting local recurrence of giant cell tumour of bone by evaluating preoperative imaging features of the tumour around the knee joint

PURPOSE

To evaluate the role of medical imaging in predicting local recurrence of giant cell tumour of bone (GCTB) by assessing the preoperative imaging features of GCTB around the knee.

METHODS

Forty-eight consecutive GCTBs in the proximal tibia and distal femur treated with curettage were prospectively enrolled. Patients were grouped in terms of their imaging features on radiography, computed tomography (CT) and magnetic resonance imaging (MRI). All patients were followed up for at least two years after surgery. The association between preoperative imaging features and local recurrence was investigated. Imaging features were retrospectively studied by correlation analysis. The differences between rates were tested by the Chi square and Fisher exact tests; independent factors were determined by multivariate logistic regression analysis.

RESULTS

Cystic change and adjacent soft tissue invasion were associated with a higher rate of local recurrence compared to the negative groups (P < 0.05). Cystic change was identified as an independent risk factor for local recurrence of GCTB (P < 0.05). Expansibility was correlated with the "soap bubble" sign and the fluid-fluid level (P < 0.05); the "soap bubble" sign was correlated with osteosclerosis and the fluid-fluid level (P < 0.05); cortical bone involvement was correlated with adjacent soft tissue invasion (P < 0.05); and cystic change was correlated with the fluid-fluid level (P < 0.05).

CONCLUSION

Cystic change was an independent risk factor for local recurrence of GCTB. Adjacent soft tissue invasion might indirectly relate to local relapse. A cluster of association relationships between imaging features was revealed.

Clonal analysis as a prognostic factor in multiple oral squamous cell carcinoma

OBJECTIVES

A novel classification based on molecular methods to assess clonality defines three types of secondary oral squamous cell carcinoma (OSCC): second primary tumour (SPT) independent from the index tumour, local recurrence (LR), clonally related to the primary tumour, and second field tumour (SFT), derived from the same genetically altered mucosal field as the primary tumour. The present study applied mtDNA analysis in a group of patients experiencing a second loco-regional neoplastic manifestation. The purpose was to differentiate secondary tumours into LRs, SPTs and SFTs and evaluate the prognostic impact in terms of survival rate.

MATERIAL AND METHODS

The study population comprised 23 patients who experienced a second neoplastic lesion after a surgical resection of primary OSCC. mtDNA D-loop analysis was applied in paired neoplastic lesions and in clinically and histologically normal mucosa. On the basis of mtDNA results, the second OSCC was classified as LR or SPT or SFT. Disease-free survival was defined as the duration between the appearance of the second neoplastic lesion and death of disease, or last follow-up visit.

RESULTS

Seven secondary tumours were classified as LR, 12 as SFT, 4 as SPT. An altered mucosal field proved a variable significantly related to a better survival rate (p<0.05); 2/12 (16.6%) SFT events failed as compared to 5/7 LRs (71.4%) and 3/4 SPTs (75%).

CONCLUSION

mtDNA analysis may be considered a useful tool to differentiate secondary tumours and might influence the choice of the most appropriate treatment in patients with multiple OSCCs.

Risk factors for local recurrence of fibromatosis

OBJECTIVE

To evaluate the clinical, radiological and histological factors that can predict local recurrence of fibromatosis.

METHODS

A retrospective study was conducted on 51 patients diagnosed with fibromatosis in this hospital from 1983 to 2014. The mean follow-up was 83 months. A study was made of the clinical parameters, location, depth, size, surgical margins, and proliferation index (Ki-67). An evaluation was also made of the risk of recurrence depending on the adjuvant treatment and the relationship between treatment and patient functionality.

RESULTS

Tumour location and depth were identified as risk factors for local recurrence, showing statistically significant differences (P<.001 and P=.003, respectively). There were no statistically significant differences in age, gender, size, surgical margins, or adjuvant treatments, or in the Musculoskeletal Tumour Society Score according to the treatment received. The mean Ki-67 was 1.9% (range 1-4), and its value was not associated with the risk of recurrence.

DISCUSSION

Deep fibromatosis fascia tumours, and those located in extremities are more aggressive than superficial tumours and those located in trunk. The Ki-67 has no predictive value in local recurrence of fibromatosis. Radiotherapy, chemotherapy, or other adjuvant treatments such as tamoxifen have not been effective in local control of the disease. Given the high recurrence rate, even with adequate margins, a wait and see attitude should be considered in asymptomatic patients and/or stable disease.

Safety and efficacy of a China-made cryoablation device in treatment of hepatocellular carcinoma smaller than 5 cm

AIM

To assess the safety and efficacy of a China-made cryoablation device in the treatment of hepatocellular carcinoma (HCC) smaller than 5 cm.

METHODS

A total of 33 patients with HCC smaller than 5 cm were treated by cryoablation using a China-made cryoablation device under the guidance of computed tomography. Operation-associated complications within and after procedures were evaluated. The efficacy of target lesions within procedures and local recurrence rate after procedures were evaluated with imaging modalities.

RESULTS

All 37 lesions of the 33 patients were successfully treated with a China-made cryablation device. Upon the finish of procedures, complete ablation was achieved in 83.78% (31/37) of lesions, and partial ablation was achieved in 16.22% (6/37). In a median follow-up period of 10.8 mo, 32 patients remained alive and 1 was lost to follow-up. The rate of local recurrence for target lesions was 30.3% (10/33), which is equal to that achieved with imported devices.

CONCLUSION

Our findings suggest that the China-made cryoablation device is safe and effective for HCC smaller than 5 cm with the capability of destroying the whole tumor lesion.

Long-term outcomes after salvage radiotherapy for postoperative locoregionally recurrent non-small-cell lung cancer

Purpose

The outcomes and toxicities of locoregionally recurrent non-small-cell lung cancer (NSCLC) patients treated with curative radiotherapy were evaluated in the modern era.

Materials and Methods

Fifty-seven patients receiving radical radiotherapy for locoregionally recurrent NSCLC without distant metastasis after surgery from 2004 to 2014 were reviewed. Forty-two patients were treated with concurrent chemoradiotherapy (CCRT), and 15 patients with radiotherapy alone. The median radiation dose was 66 Gy (range, 45 to 70 Gy). Lung function change after radiotherapy was evaluated by comparing pulmonary function tests before and at 1, 6, and 12 months after radiotherapy.

Results

Median follow-up was 53.6 months (range, 12.0 to 107.5 months) among the survivors. The median overall survival (OS) and progression-free survival (PFS) were 54.8 months (range, 3.0 to 116.9 months) and 12.2 months (range, 0.8 to 100.2 months), respectively. Multivariate analyses revealed that single locoregional recurrence focus and use of concurrent chemotherapy were significant prognostic factors for OS (p = 0.048 and p = 0.001, respectively) and PFS (p = 0.002 and p = 0.026, respectively). There was no significant change in predicted forced expiratory volume in one second after radiotherapy. Although diffusing lung capacity for carbon monoxide decreased significantly at 1 month after radiotherapy (p < 0.001), it recovered to pretreatment levels within 12 months. Acute grade 3 radiation pneumonitis and esophagitis were observed in 3 and 2 patients, respectively. There was no chronic complication observed in all patients.

Conclusion

Salvage radiotherapy showed good survival outcomes without severe complications in postoperative locoregionally recurrent NSCLC patients. A single locoregional recurrent focus and the use of CCRT chemotherapy were associated with improved survival. CCRT should be considered as a salvage treatment in patients with good prognostic factors.

External radiotherapy for breast cancer in the elderly

BACKGROUND

Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients.

AIMS

The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population.

MATERIALS AND METHODS

Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost.

DISCUSSION

The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care.

CONCLUSIONS

New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.

Analysis of local recurrences after transanal endoscopic microsurgery for low risk rectal carcinoma

AIM

Rates of local recurrence (LR) after transanal endoscopic microsurgery (TEM) for rectal carcinoma vary; the reasons remain unclear. We analyzed LR after TEM for low-risk pT1 (G1/2/X, L0/X) rectal carcinoma to investigate the influence of completeness of resection and occult lymph node metastasis on risk of LR.

METHOD

LR location and stage, completeness of resection of primary carcinoma (minimal distance between tumor and resection line ≤1 mm vs >1 mm), and incidence of involved lymph nodes in resected LR specimens were collected, and tumor characteristics of LR were compared with primary carcinoma. Distant metastasis and overall and cancer-specific survival were determined.

RESULTS

LR developed in 14 patients; in 2/4 with R1/X resection, in 3/8 (38%) with clear margins (R0) but a minimal distance of ≤1 mm, and in 9/88 (10%) with formally complete resection. Six of nine patients with formally complete resection underwent radical surgery for LR; in five out of these six, lymph nodes were not involved. In 5/14 patients, LR was poorly differentiated compared to primary carcinoma. Main LR causes were incomplete tumor resection or tumor persistence after formally complete resection. Overall (p = 0.008) and cancer-specific (p < 0.001) survival was lower in LR patients compared to non-LR patients, even if lymph nodes were uninvolved.

CONCLUSIONS

The results suggest that most LRs after TEM for low-risk rectal cancer were caused by residual tumor at the previous excision site and not by undetected lymph node metastases. By improved standardization of surgical techniques to ensure complete resection of carcinomas and thorough pathological assessments, most LRs seem to be avoidable.

A meta-analysis of randomized control trials of surgical methods with osteosarcoma outcomes

Background

Osteosarcoma is a high malignant neoplasm, and conflicting findings have been reported on the survival and function recovery of osteosarcoma patients experiencing limb salvage or amputation. In the present study, we compared limb salvage surgery (LSS) with amputation in clinical outcomes of osteosarcoma patients by a meta-analysis.

Methods

The survival rate of osteosarcoma patients was collected from research reports from CNKI, MEDLINE, EMBASE, the Cochrane Database, and Google Scholar till April 30, 2016. The quality of including articles was evaluated by two independent reviewers. Differences between patients undergoing limb salvage surgery and amputation were analyzed based on postoperative survival rates.

Results

Ten articles were included according to selection criteria. There were 1343 patients in total from these studies. Our results showed that there was no significant difference between limb salvage surgery and amputation according to local recurrence; however, patients with limb salvage surgery had a higher 5-year overall survival.

Conclusions

LSS results in higher 5-year survival rates and better survival, while not increasing the risk of local recurrence. This study provided more evidences to support limb salvage surgery as a considerable treatment of osteosarcoma patients.

Radiotherapy in desmoid tumors : Treatment response, local control, and analysis of local failures

BACKGROUND

Desmoid tumors (aggressive fibromatosis) are rare soft tissue tumors which frequently recur after surgery. Desmoid tumors arise from musculoaponeurotic tissue in the extremities, head and neck, abdominal wall, or intra-abdominally. Our aim was to examine the outcome of radiotherapy of desmoid tumors in a single institution series.

PATIENTS AND METHODS

We evaluated 41 patients with desmoid tumors treated with 49 radiotherapies between 1987 and 2012. Radiologic images for response evaluation were reassessed and responses to treatment registered according to RECIST criteria 1.1. For patients with local failures radiation dose distribution was determined in each local failure volume using image co-registration. Recurrences were classified as in-target, marginal, or out-of-target. Prognostic factors for radiotherapy treatment failure were evaluated.

RESULTS

Radiotherapy doses varied from 20-63 Gy (median 50 Gy) with a median fraction size of 2 Gy. The objective response rate to definitive radiotherapy was 55% (12/22 patients). Median time to response was 14 months. A statistically significant dose-response relation for definitive and postoperative radiotherapy was observed both in univariate (p-value 0.002) and in multivariate analysis (p-value 0.02) adjusted for potential confounding factors. Surgery before radiotherapy or surgical margin had no significant effect on time to progression. Nine of 11 (82%) local failures were classified as marginal and two of 11 (18%) in-target. None of the recurrences occurred totally out-of-target.

CONCLUSIONS

Radiotherapy is a valuable option for treating desmoid tumors. Radiotherapy dose appears to be significantly associated to local control.

Abdominosacral resection for locally recurring rectal cancer

AIM

To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.

METHODS

A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.

RESULTS

At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.

CONCLUSION

Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Evaluation of hepatocellular carcinoma tumor vascularity using contrast-enhanced ultrasonography as a predictor for local recurrence following radiofrequency ablation

PURPOSE

The purpose of this study was to evaluate whether the hypervascularity of hepatocellular carcinomas (HCCs) on contrast-enhanced ultrasonography (CEUS) prior to radiofrequency ablation (RFA) is a significant risk factor for local recurrence after RFA.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. Overall, 208 patients (mean age, 71.7 years; range, 50-87 years; 137 men, 71 women) with 282 HCCs treated with RFA were analyzed retrospectively. The mean maximum tumor diameter was 15.7mm. We compared the abilities of CEUS and contrast-enhanced computed tomography (CECT) to detect hypervascularity in HCCs. We then classified the HCCs into two groups according to the arterial-phase CEUS findings: a "hypervascular group" with whole or partial hypervascular areas within the lesions compared with the surrounding liver parenchyma, and a "non-hypervascular group" with isovascular or hypovascular areas within the lesions. We assessed the cumulative rate of local recurrence after RFA, and we also evaluated the risk factors for local recurrence using a univariate analysis.

RESULTS

The detection rate for hypervascular HCCs was significantly higher using CEUS (78%, 221/282) than that using CECT (66%, 186/282) (P<0.001). Using the CEUS findings, the cumulative rate of local recurrence was significantly higher in the hypervascular group (41.2%, 56/221) than in the non-hypervascular group (18.4%, 6/61) (P=0.007). A univariate analysis revealed that hypervascularity on CEUS was an independent risk factor for local recurrence (P=0.010).

CONCLUSION

Hypervascularity in HCCs as observed using CEUS is a significant risk factor for local recurrence after RFA.

Radiofrequency Ablation Combined with Hepatic Arterial Chemoembolization Using Degradable Starch Microsphere Mixed with Mitomycin C for the Treatment of Liver Metastasis from Colorectal Cancer: A Prospective Multicenter Study

PURPOSE

This phase II prospective study investigates possible benefits of radiofrequency ablation (RFA) combined with hepatic arterial chemoembolization using degradable starch microsphere (DSM) mixed with mitomycin C (MMC) in non-surgical candidates with colorectal liver metastases.

MATERIALS AND METHODS

This study, approved by the respective institutional review board, included non-surgical candidates with 3 or fewer liver tumors of 3 cm or smaller, or a single lesion 5 cm or smaller. Percutaneous RFA was performed immediately after chemoembolization using DSM-MMC. Primary and secondary endpoints were the local tumor control rate, safety, and 2-year recurrence-free and overall survival rates.

RESULTS

This study examined 25 patients (22 males, 3 females) with 38 tumors of mean maximum diameter of 2.2 ± 0.9 cm (standard deviation) (range 1.0-4.2 cm). Their mean age was 70.2 ± 8.2 years (range 55-82 years). Local tumor progression developed in 3 tumors (7.9%, 3/38) of 3 patients (12%, 3/25) during the mean follow-up of 34.9 ± 9.2 months (range 18.3-50.1 months). The 2-year local tumor control rates were 92.0% [95% confidence interval (CI), 81.4-100%] on a patient basis and 94.6% (95% CI, 87.3-100%) on a tumor basis. The respective 2-year overall and recurrence-free survival rates were 88.0% (95% CI, 75.3-98.5%) and 63.3% (95% CI, 44.2-82.5%), with median survival time of 48.4 months. Fever was the only adverse event requiring treatments in 2 patients (8%).

CONCLUSIONS

This combination therapy is safe, exhibiting strong anticancer effects on colorectal liver metastasis, which might contribute to patient survival.

Local recurrence of prostate cancer after radical prostatectomy is at risk to be missed in 68Ga-PSMA-11-PET of PET/CT and PET/MRI: comparison with mpMRI integrated in simultaneous PET/MRI

PURPOSE

The positron emission tomography (PET) tracer ⁶⁸Ga-PSMA-11, targeting the prostate-specific membrane antigen (PSMA), is rapidly excreted into the urinary tract. This leads to significant radioactivity in the bladder, which may limit the PET-detection of local recurrence (LR) of prostate cancer (PC) after radical prostatectomy (RP), developing in close proximity to the bladder. Here, we analyze if there is additional value of multi-parametric magnetic resonance imaging (mpMRI) compared to the ⁶⁸Ga-PSMA-11-PET-component of PET/CT or PET/MRI to detect LR.

METHODS

One hundred and nineteen patients with biochemical recurrence after prior RP underwent both hybrid ⁶⁸Ga-PSMA-11-PET/CT_low-dose (1 h p.i.) and -PET/MRI (2-3 h p.i.) including a mpMRI protocol of the prostatic bed. The comparison of both methods was restricted to the abdomen with focus on LR (McNemar). Bladder-LR distance and recurrence size were measured in axial T2w-TSE. A logistic regression was performed to determine the influence of these variables on detectability in ⁶⁸Ga-PSMA-11-PET. Standardized-uptake-value (SUV_mean) quantification of LR was performed.

RESULTS

There were 93/119 patients that had at least one pathologic finding. In addition, 18/119 Patients (15.1%) were diagnosed with a LR in mpMRI of PET/MRI but only nine were PET-positive in PET/CT and PET/MRI. This mismatch was statistically significant (p = 0.004). Detection of LR using the PET-component was significantly influenced by proximity to the bladder (p = 0.028). The PET-pattern of LR-uptake was classified into three types (1): separated from bladder; (2): fuses with bladder, and (3): obliterated by bladder). The size of LRs did not affect PET-detectability (p = 0.84), mean size was 1.7 ± 0.69 cm long axis, 1.2 ± 0.46 cm short-axis. SUV_mean in nine men was 8.7 ± 3.7 (PET/CT) and 7.0 ± 4.2 (PET/MRI) but could not be quantified in the remaining nine cases (obliterated by bladder).

CONCLUSION

The present study demonstrates additional value of hybrid ⁶⁸Ga-PSMA-11-PET/MRI by gaining complementary diagnostic information compared to ^{the 68}Ga-PSMA-11-PET/CT_low-dose for patients with LR of PC.

Multimodality imaging of locally recurrent and metastatic cervical cancer: emphasis on histology, prognosis, and management

The management of recurrent and metastatic cervical cancer is evolving in concert with the available advanced imaging techniques and molecular targeted therapy. The purpose of this review is to provide an overview of imaging and treatment of cervical cancer patients with locoregional recurrence and metastatic disease, with emphasis on characteristic patterns of spread based on histology (squamous cell carcinoma and other subtypes), prognostic factors, diagnosis, and treatment response assessment, as well as updated therapeutic options.

Locally Recurrent Disease Related to Anal Canal Cancers

Surgery for anal cancer is usually reserved for patients with persistent disease or local recurrence after definitive chemoradiation therapy. Patients with local recurrence should be re-evaluated for evidence of metastatic disease using positron emission tomography-computed tomography, and the local anatomy should be delineated with MRI. Eligible patients should undergo tailored surgery with the aim of achieving an R0 resection. Management is best undertaken within a specialized multidisciplinary setting. Careful patient selection and shared decision making are paramount for achieving acceptable patient-centered outcomes.

Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

BACKGROUND

The aim of our study was to assess various predictors for local recurrence (LR) in patients undergoing breast conservation surgery (BCS) for ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

An audit was performed of 582 consecutive patients with DCIS between Jan 1975 to June 2008. In patients undergoing BCS, local guidelines reported a margin of ≥10 mm during the above period. Guideline with regard to margin of excision changes soon after this period. We retrospectively analysed clinical and pathological risk factors for local recurrence in patients undergoing BCS. Statistical analysis was carried out using SPSS version 19, and a cox regression model for multivariate analysis of local recurrence was used.

RESULTS

Overall 239 women had BCS for DCIS during the above period. The actuarial 5-year recurrence rate was 9.6%. The overall LR rate was 17% (40/239. LR was more common in patients ≤50 years: (10/31 patients, 32%) compared to patients > 50 years (30/208, 14%, P = 0.02). Forty three per cent of patients (6/14) with <5 mm margin developed LR which was significantly higher compared to patients with 5-9 mm margin (12%, 3/25) and with ≥10 mm margin (14%, 27/188, P = 0.01). On multivariate analysis age ≤50 years, <5 mm pathological margin were independent prognostic factors for local recurrence.

CONCLUSION

Our study shows that younger age (≤50 years) and a margin < 5 mm are poor prognostic factors for LR in patients undergoing breast conservation surgery for DCIS.

Breast-cancer subtype, age, and lymph node status as predictors of local recurrence following breast-conserving therapy

PURPOSE/OBJECTIVES

Advances in breast-conserving therapy (BCT) have yielded local control rates comparable or superior to those of mastectomy. In this study, we sought to identify contemporary risk factors associated with local recurrence (LR) following BCT.

METHODS

We analyzed a multi-institutional cohort of 2233 consecutive breast-cancer patients who underwent BCT between 1998 and 2007. Patients were stratified by age, biologic subtype (as approximated by receptor status and tumor grade), and nodal status. Patients who received HER2/neu-directed therapy were excluded due to variations in practice over the study period. The association of clinicopathologic features with LR was evaluated using Cox proportional hazards regression models.

RESULTS

With a median follow-up of 106 months, 69 LRs (3 %) were observed. On univariate analysis, LR was associated with non-luminal-A subtype (hazard ratio [HR] for luminal-B = 3.01, HER2 = 6.29, triple-negative [TNBC] = 4.72; p < 0.001 each), younger age (HR of oldest vs. youngest quartile = 0.43; p = 0.005), regional nodal involvement (HR for 4-9 involved nodes = 3.04; >9 nodes = 5.82; p < 0.01 for each), positive margins (HR 2.43; p = 0.005), and high grade (HR 5.37; p < 0.001). Multivariate Cox regression demonstrated that non-luminal-A subtypes (HR for luminal-B = 2.64, HER2 = 5.42, TNBC = 4.32; p < 0.001 for each), younger age (HR for age >50 = 0.56; p = 0.01), and nodal disease (HR 1.06 per involved node; p < 0.004) were associated with LR. The 8-year risk of LR was 2.8 % for node-negative patients and 5.2 % for node-positive patients.

CONCLUSION

BCT yields favorable outcomes for the large majority of patients, although increased LR was observed among those with non-luminal-A subtypes, younger age, and increasing lymph node involvement. Risk factors for LR after BCT appear to be converging with those after mastectomy in the current era.

Surgical margin-negative endoscopic mucosal resection with simple three-clipping technique: a randomized prospective study (with video)

BACKGROUND

Although endoscopic mucosal resection is an established colorectal polyp treatment, local recurrence occurs in 13 % of cases due to inadequate snaring. We evaluated whether pre-clipping to the muscularis propria resulted in resected specimens with negative surgical margins without thermal denaturation.

METHODS

Of 245 polyps from 114 patients with colorectal polyps under 20 mm, we included 188 polyps from 81 patients. We randomly allocated polyps to the conventional injection group (CG) (97 polyps) or the pre-clipping injection group (PG) (91 polyps). The PG received three-point pre-clipping to ensure ample gripping to the muscle layer on the oral and both sides of the tumor with 4 mL local injection. Endoscopic ultrasonography was performed to measure the resulting bulge. Outcomes included the number of instances of thermal denaturation of the horizontal/vertical margin (HMX/VMX) or positive horizontal/vertical margins (HM+/VM+), the shortest distance from tumor margins to resected edges, and the maximum bulge distances from tumor surface to the muscularis propria.

RESULTS

The numbers of HMX and HM+ in the CG and PG were 27 and 6, and 9 and 2 (P = 0.001), and VMX and VM+ were 8 and 5, and 0 and 0 (P = 0.057). The shortest distance from tumor margin to resected edge [median (range), mm] in polyps in the CG and PG was 0.6 (0-2.7) and 4.7 (2.1-8.9) (P = 0.018). The maximum bulge distances were 4.6 (3.0-8.0) and 11.0 (6.8-17.0) (P = 0.005).

CONCLUSIONS

Pre-clipping enabled surgical margin-negative resection without thermal denaturation.

Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer

PURPOSE

Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE.

METHODS

After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n = 36) or ELAPE (n = 36) for LARC ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival.

RESULTS

Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, p = 0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7 % in the conventional APE group (p = 0.025). Cumulative local recurrence rate at 5 years was 18.2 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.153). Local recurrence without distant metastases occurred in 15.5 % in the APE group but was not observed in the ELAPE group (p = 0.039). We did not detect significant differences in cause-specific nor in overall survival.

CONCLUSION

ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.

Reoperations after primary breast conserving surgery in women with invasive breast cancer in Catalonia, Spain: a retrospective study

BACKGROUND

Although complete tumor resection is accepted as the best means to reduce recurrence, reoperations after lumpectomy are a common problem in breast cancer. The aim of this study was to assess the reoperation rates after primary breast conserving surgery in invasive breast cancer cases diagnosed in Catalonia, Spain, between 2005 and 2011 and to identify variations based on patient and tumour characteristics.

METHODS

Women with invasive incident breast cancer identified from the Patient's Hospital Discharge Database [174.0-174.9 codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as the primary diagnosis] and receiving primary breast conserving surgery were included in the study and were followed up to 3 and 12 months by collecting information about repeat breast cancer surgery.

RESULTS

Reoperation rates after primary breast conserving surgery decreased from 13.0 % in 2005 to 11.7 % in 2011 at 3 months and from 14.2 % in 2005 to 12.9 % in 2011 at 12 months' follow-up. While breast conservation reoperations saw a slight, non-significant increase in the same period (from 5.7 to 7.3 % at 3 months, and from 6.0 to 7.5 % at 12 months), there was a significant decrease in radical reoperation (from 7.3 to 4.4 % at 3 months and from 8.2 to 5.4 % at 12 months). Overall, additional breast surgeries decreased among younger women.

CONCLUSIONS

Despite the rise of breast conserving surgery, reoperation rates following initial lumpectomy in Catalonia decreased by 10 % at 3 and 12 months' follow-up, remaining low and almost unchanged. Ultimately, there was also a significant decrease in mastectomies.

[What is the role of intraoperative radiotherapy in breast cancer treatment?]

Breast-conserving surgery followed by whole breast postoperative irradiation is considered to be the current standard treatment for patients with early stage breast cancer. It allows an excellent local tumour control with 6% of local recurrence. Over the last years, partial breast radiotherapy has been developed to reduce treatment volume and duration. Intraoperative radiotherapy is one of the techniques. It offers an excellent delineation of the tumour bed and high normal tissue sparing. This purpose of this review is to describe the different intraoperative radiotherapy techniques available, to assess their potential clinical efficiency and tolerance, the recommendations for new practice with a selected population of patients and for future research.

Utility of Examination of Biopsy Tracts in Osteosarcoma Resection Specimens

OBJECTIVES

To determine the utility and necessity of submitting tissue sections from the biopsy tracts of osteosarcoma resection specimens.

METHODS

The prevalence of residual tumor in representative sections of osteosarcoma biopsy tracts was assessed in a series of 97 osteosarcoma resection specimens.

RESULTS

No residual tumor cells were identified in 97 sampled biopsy tracts (0%; 95% confidence interval, 0%-2.5%).

CONCLUSIONS

Pathologists do not need to submit sections of resected biopsy tracts unless there is clinical or gross evidence that would warrant further examination.

Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter?

BACKGROUND

There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC.

METHODS

A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance.

RESULTS

Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]).

CONCLUSIONS

This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.

Pre-treatment double- or triple-positive tumor markers are predictive of a poor outcome for patients undergoing radiofrequency ablation for hepatocellular carcinoma

PURPOSES

We evaluated the therapeutic effect of radiofrequency ablation (RFA) on hepatocellular carcinoma (HCC) according to the number of positive tumor markers.

METHODS

The subjects of this study were 160 patients who underwent percutaneous and surgical RFA for HCC. Patients were divided into negative (n = 51), single- (n = 69), double- (n = 31), and triple-positive (n = 9) tumor marker groups according to the pre-treatment expression of these markers. We looked for any relationships among clinical parameters, outcomes, and tumor markers.

RESULTS

The 3-year recurrence-free and overall survival rates of the negative, single-, double-, and triple-positive groups were 30, 19, 16, and 11 % (P = 0.02), and 94, 88, 67, and 37 % (P < 0.001), respectively. The 2-year local recurrence rates were 6.5, 0, 41.2, and 61.9 %, respectively (P < 0.001). Multivariate analysis revealed that a double- or triple-positive pre-treatment tumor marker profile was independently associated with local recurrence [hazard ratio (HR) 5.48, 95 % confidence interval (CI) 2.44-12.33, P < 0.001] and overall survival (HR 4.21, 95 % CI 1.89-9.37, P < 0.001).

CONCLUSION

RFA may not be suitable for patients with HCC who have pre-treatment expression of ≥two of these tumor markers.

[Not Available]

REFLEXIONS ABOUT NEW STRATEGIES OF RADIOTHERAPY FOR EARLY BREAST CANCER: Radiotherapy (RT) remains a major treatment element in early breast cancer, with a major impact on local control and survival. For ductal carcinoma in situ (DCIS), RT reduces local recurrence (LR) rates by 50 to 60 % after conservative surgery (both in situ and invasive). This was confirmed by four randomized trials and one meta-analysis. For infiltrating breast cancers (IBC), RT also reduces LR rates by 65 to 75 % after conservative surgery. Boost allows an additional reduction of LR. RT is efficient in all age categories, but hypofractionated schemes are particularly adapted to elderly women. Partial breast irrradiation techniques are very much heterogeneous and lack follow-up. They should be used in LR low-risk patients only and in the frame of controlled studies. Locoregional RT for high-risk patients (especially in pN+) remains essential to reduce the locoregional recurrence rate and to increase survival, as confirmed in several meta-analyses. Four studies showed a survival benefit (2-3 %), thanks to internal mammary chain irradiation in LR high-risk patients. Moreover, axillary RT seems to be a likely valuable alternative to axillary dissection in case of sentinel node invasion. Finally, with the modern techniques and dosimetric optimization, RT toxicity was reduced, or even cancelled, arousing hope for a better increased benefit for the patients in the future.

Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter?

BACKGROUND

There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC.

METHODS

A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance.

RESULTS

Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]).

CONCLUSIONS

This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery in the Spanish Rectal Cancer Project

INTRODUCCIóN: The purpose of this prospective multicentre multilevel study was to investigate the influence of hospital caseload on long-term outcomes following standardization of rectal cancer surgery in the Rectal Cancer Project of the Spanish Society of Surgeons.

METHODS

Data relating to 2910 consecutive patients with rectal cancer treated for cure between March 2006 and March 2010 were recorded in a prospective database. Hospitals were classified according to number of patients treated per year as low-volume, intermediate-volume, or high volume hospitals (12-23, 24-35, or ≥36 procedures per year).

RESULTS

After a median follow-up of 5 years, cumulative rates of local recurrence, metastatic recurrence and overall survival were 6.6 (CI95% 5.6-7.6), 20.3 (CI95% 18.8-21.9) and 73.0 (CI95% 74.7 - 71.3) respectively. In the multilevel regression analysis overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients (HR 0,727 [CI95% 0,556-0,951]; P=.02). The risk of local recurrence and metastases were not related to the caseload. Moreover, there was a statistically significant variation in overall survival (median hazard ratio [MHR] 1.184 [CI95% 1.071-1,333]), local recurrence (MHR 1.308 [CI95% 1.010-1.668]) and metastases (MHR 1.300 [CI95% 1.181; 1.476]) between all hospitals.

CONCLUSIONS

Overall survival was higher for patients treated at hospitals with an annual caseload of 36 or more patients. However, local recurrence was not influenced by caseload.

Background and Current Treatment of Squamous Cell Carcinoma of the Anus

In this review, a summary of our current understanding of squamous cell carcinoma of the anus (SCCA) and the advances in our knowledge of SCCA regarding screening, prevention, the role of the immune system, current treatment and the potential for novel targets are discussed. The present standard of care in terms of treatment is 5-fluorouracil (5-FU) and mitomycin C (MMC) concurrently with radiation, which results in a high level of disease control for small early cancers. Preservation of the anal sphincter is achieved in the majority, although anorectal function is often impaired. Although evidence from prospective studies to support a change in the treatment strategy is lacking, patients with HPV-negative SCCA appear to be less responsive to chemoradiation (CRT) and relapse more frequently. In contrast, HPV-positive tumours usually fare better, but oncological outcomes are modified by smoking and immune incompetence. There is current interest in escalating the radiotherapy dose for larger, more advanced tumours, and de-escalating treatment for HPV-positive tumours. The use of novel immunological treatments to target the underlying different molecular pathways of HPV-positive cancers is exciting.

Clinical outcome of recurrent giant cell tumor of the extremity in the era before molecular target therapy: the Japanese Musculoskeletal Oncology Group study

BACKGROUND

Giant cell tumor of the bone (GCTB) is classified as an intermediate, locally aggressive but rarely metastasizing tumor. The mainstay of treatment for the treatment of GCTB had been the surgical removal until an anti- receptor activator of nuclear factor-kappa B ligands (RANKL) antibody denosumab was developed. And favorable responses and the possibility of surgical downstaging have been reported. However, the long-term outcome of denosumab has not yet been confirmed and moreover the long-term clinical outcome after the recurrence of GCTB in the era before molecular target therapy is still uncertain. The aim of this study was to evaluate the long-term clinical outcome of recurrent GCTB of the extremity in the era before molecular target therapy and to determine the factors that affect the repetitive recurrence and sacrifice of adjacent joints.

METHODS

This multicenter study focused only recurrent GCTB of the extremity with no medical treatment and included 103 patients treated from 1980 to 2008.

RESULTS

Thirty-two (31.1 %) patients developed repetitive recurrences after salvage surgery. Second curettage and venue of initial surgery (non-cancer hospital) were both significantly correlated with repetitive recurrence in univariate (P = 0.034 and P = 0.002) and multivariate (P = 0.004 and P = 0.001) analyses. Seventy-two (76.6 %) of 94 patients achieved successful preservation of adjacent joints. Campanacci Grade III was significantly correlated with sacrifice of the adjacent joint by univariate statistical analysis (P = 0.019), although its impact was only marginally significant by multivariate analysis (P = 0.059). Seventeen patients (16.5 %) developed distant metastasis, and one patient (0.97 %) developed malignant transformation. Finally, 94/103 patients (91.3 %) with recurrent GCTB were successfully rendered NED by further surgical treatment.

CONCLUSIONS

We concluded that repetitive, thorough curettage with surgical adjuvant treatment resulted in a favorable rate of adjacent joint preservation (76.6 %), but recurettage inferred a risk of repetitive recurrences. Although the treatment strategy against the recurrent GCTB is being updated with denosumab, we believe that our data will be useful for future comparisons with the long-term clinical benefit of denosumab.

Percutaneous Radiofrequency Ablation Versus Robotic-Assisted Partial Nephrectomy for the Treatment of Small Renal Cell Carcinoma

Introduction

The authors compared the oncologic outcomes of radiofrequency ablation (RFA) with robotic-assisted partial nephrectomy (RPN) for the treatment of T1 stage renal cell carcinoma (RCC).

Materials and methods

This was a retrospective data analysis of a high-volume single tertiary centre. Patients were treated with RFA or RPN following multidisciplinary decision making. Only histologically proven RCCs were included. Baseline demographics were collected, and PADUA scores of tumour features were calculated to standardize baseline anatomy. Peri-operative complications, kidney function and oncological outcomes were compared.

Results

Sixty-three cases were included in each group. Baseline renal function was poorer in RFA, and 16/63 RFA patients had tumours in single kidneys compared to 1/63 RPN cases (p < 0.001). Length of stay was shorter in RFA (1 vs. 3 days, p < 0.0001). Post-procedure renal function decline at 30 days was significantly less in RFA [(−0.8) ± 9.6 vs. (−16.1) ± 19.5 mls/min/1.73 m²; p < 0.0001]. More minor complications were recorded in RPN (10/63 vs. 4/63, p = 0.15), but local recurrence was numerically higher in RFA (6/63 vs. 1/63, p = 0.11). Disease-free survival (DFS) was not significantly different (adjusted HR = 0.6, 95 % Cl 0.1–3.7; p = 0.60). Increasing tumour size was an independent predictor of local recurrence (adjusted HR = 1.7; 95 % Cl 1.1–2.6 per cm; p = 0.02).

Conclusions

Both RPN and RFA offer very good oncological outcomes for the treatment of T1 RCC with low peri-operative morbidity and similar oncologic outcomes. RFA demonstrated fewer peri-operative complications and better preservation of renal function, whereas RPN had an insignificantly lower local recurrence rate. RFA should be offered alongside RPN for selected cases.

Proton Beam Therapy for Locally Recurrent Parotid Gland Cancer

The aim of this study was to evaluate the efficacy and safety of proton beam therapy for patients with locally recurrent parotid cancer. Between 2009 and 2012, ten patients with locally recurrent parotid gland cancer were treated with proton beam therapy (70.2 Gy equivalents in 32 fractions) with or without intra-arterial infusion chemotherapy of cisplatin (50 mg/body/week, for a total of 5-8 weeks). The median follow-up was 24 months (range 10-49 months). The 1-year overall survival and local control rates were 80 %, and the 3-year overall survival and local control rates were 60 %. None of the patients experienced grade 3-5 toxicities in the treatment or the follow-up periods. These findings suggest that proton beam therapy could be applied effectively and safely for patients with locally recurrent parotid gland cancer.

Lymph Node Ratio as a Risk Factor for Locoregional Recurrence in Breast Cancer Patients with 10 or More Axillary Nodes

PURPOSE

We analyzed the association of lymph node ratio (LNR) wth locoregional control (LRC) in breast cancer patients with ≥10 involved axillary lymph nodes who underwent multimodality treatment.

METHODS

We retrospectively analyzed 234 breast cancer patients with ≥10 involved axillary lymph nodes between 2000 and 2011. All patients received adjuvant chemotherapy and radiotherapy (RT) after radical surgery. The cutoff value of LNR was obtained using receiver operating characteristic curve analysis. The majority of patients (87.2%) received chemotherapeutic regimen including taxane. RT consisted of tangential fields to the chest wall or intact breast, delivered at a median dose of 50 Gy, and a single anterior port to the supraclavicular lymph node area, delivered at a median dose of 50 Gy. For patients who underwent breast-conserving surgery, an electron boost with a total dose of 9 to 15 Gy was delivered to the tumor bed.

RESULTS

Within a median follow-up period of 73.5 months (range, 11-183 months), locoregional recurrence (LRR) occurred in 30 patients (12.8%) and the 5-year LRC rate was 88.8%. After multivariate analysis, LNR ≥0.7 was the only independent factor significantly associated with LRC (hazard ratio, 2.06; 95% confidence interval, 0.99-4.29; p=0.05).

CONCLUSION

An aggressive multimodal treatment approach showed favorable locoregional outcome in patients with ≥10 involved axillary lymph nodes. However, patients with a high LNR ≥0.7 still had an increased risk for LRR, even in the setting of current local treatments.

Breast-conserving treatment for ductal carcinoma in situ: Impact of boost and tamoxifen on local recurrences

PURPOSE

Ductal carcinoma in situ represents 15 to 20% of all breast cancers. Breast-conserving surgery and whole breast irradiation was performed in about 60% of the cases. This study reports local recurrence rates in patients with ductal carcinoma in situ treated by breast-conserving surgery and whole breast irradiation with or without boost and/or tamoxifen and compares different therapeutic options in two European countries.

PATIENTS AND METHODS

From 1998 to 2007, 819 patients with pure ductal carcinoma in situ were collected, both in France (266) and Italy (553). Median age was 56. All underwent breast-conserving surgery and whole breast irradiation; 391 (48%) received a boost (55% in France and 45% in Italy, P=0.017) and 173 (22.5%) tamoxifen (4.5% in France and 32% in Italy, P<0.0001).

RESULTS

With a 90-month median follow-up, there were 51 local recurrences (6.2%), including 27 invasive (53%). The 5- and 10-year local recurrence rates were 4% and 8.6%. Two patients developed axillary recurrence and 12 (1.5%) metastases (seven after invasive local recurrence); 41 (5%) patients had contralateral breast cancer. In the multivariate analysis, high nuclear grade and lack of tamoxifen are the most powerful predictors of local recurrence, with 2.6 (95% confidence interval [95% CI]: 1.74-3.89, P=0.0012) and 2.85 (95% CI: 1.42-5.72, P=0.04) odds ratio (OR) estimates, respectively. Age, margin status and boost did not influence local recurrence rates.

CONCLUSIONS

This study confirms the ductal carcinoma in situ treatment heterogeneity among countries and the unfavourable prognostic role of nuclear grade. Tamoxifen reduces local recurrence rates and might be considered for some subgroups of patients, but further confirmation is required. The boost usefulness still remains unclear.

A Rare Case of a Recurrent Giant Solitary Fibrous Tumor of the Ciliary Body of the Orbit

Solitary fibrous tumors (SFTs) are uncommon spindle-cell tumors of mesenchymal origin initially described in the pleura and subsequently in other extra-pleural sites. These tumors are categorized as tumors of 'intermediate malignancy' under the World Health Organization classification of soft tissue tumors. SFT was virtually non-existent or misdiagnosed until its characteristic features, particularly the strong and diffuse immuno-reactivity to CD 34 were described. Extra-pleural manifestations of SFT, particularly in the head and neck region are rare. Although a number of isolated case reports of orbital SFTs have been described ever since its initial description in 1994, cases of recurrent SFTs have been very few. Recurrences of these tumors following surgery are considered unusual and metastasis exceptional. We describe clinical presentation and the management challenges of recurrent giant orbital SFT in a 15-year old girl along with a brief review of literature.

Seroma Cytology in Breast Cancer: An Underappreciated Issue

BACKGROUND

The presence of malignant cells in postoperative seroma has been ignored in current breast cancer treatment. We aimed to assess the presence of malignant seroma cytology and to evaluate its relationship with the known prognostic factors for breast cancer.

PATIENTS AND METHODS

The solution from irrigation of the operation field and postoperative drainage fluid from 68 patients were prospectively collected and examined for malignant cytology. The results were evaluated according to the tumor characteristics and patient demographics.

RESULTS

Malignant cytology was found in none of the intraoperative samples but was found in the postoperative samples from 4 patients. Of these 4 patients, 3 were free of axillary metastasis. None of the common risk factors for breast cancer was associated with the finding of malignant cytology.

CONCLUSION

Malignant cells can be seen in the drainage fluids from breast cancer patients independent of any contamination occurring during surgery, even in those without axillary metastasis.

Oncological Safety of Breast Conservation Surgery in Young Females

Breast conservation surgery (BCS) is the standard of care in early breast cancer. The oncological safety of this procedure has been proven beyond doubt in several randomised control trials. But there are concerns regarding the safety of this procedure in young females. The concern is regarding increased risk of local recurrence. This issue has not been addressed in any major trial. In this prospective study we intend to look into the oncological safety of BCS in young patients who are less than forty years of age.

Management of recurrent head and neck cancer: variables related to salvage surgery

After a local and/or regional recurrence of head and neck squamous cell carcinoma (HNSCC) not all patients are candidates to salvage treatment. The objective of this study was to identify the variables related to performance of salvage surgery with curative intent in these patients. We performed a retrospective study of 1088 HNSCC patients with a local and/or regional recurrence. According to a multivariate analysis, the variables related to performance of salvage surgery were the Karnofsky index, the location and extension of the primary tumor, the initial treatment, the disease-free interval between treatment of the initial tumor and diagnosis of the recurrence, and the year the recurrence was diagnosed. Considering salvage surgery as the dependent variable, the results of a recursive partitioning analysis defined four categories of patients in function of the category of local and regional extension of the initial tumor, the location of the primary tumor, the initial treatment and the disease-free interval between treatment of the initial tumor and diagnosis of the recurrence.

Early detection of local recurrence after soft tissue sarcoma resection and flap reconstruction

PURPOSE

Flap reconstruction has become an essential component in soft tissue sarcoma treatment. However, the clinical features of local recurrence after soft tissue sarcoma resection and flap reconstruction remain unclear. The present study aimed to establish effective follow-up strategies after soft tissue sarcoma resection and flap reconstruction.

METHODS

Data from patients who underwent soft tissue sarcoma resection and immediate flap reconstruction were retrospectively reviewed. Follow-up after surgery included history taking and physical examination during every visit to the hospital. Magnetic resonance imaging to evaluate the primary site was performed six months after the end of treatment then annually for ten years. The methods of detection of local recurrence were assessed.

RESULTS

A total of 229 consecutive patients were included in the present study. During a median follow-up period of 40 months, 33 patients (14.4%) developed local recurrence. Twenty-three recurrences that occurred on the margin of the transferred flap were detected as palpable mass prior to radiological assessment; among the remaining ten recurrences that occurred in the deep layer of the transferred flap, six were detected by abnormal clinical findings and four were clinically occult and detected by surveillance radiological assessment.

CONCLUSIONS

Surveillance radiological assessment has an important role in early detection of local recurrence that develops in the deep layer of the transferred flap. Therefore, meticulous clinical assessment combined with routine radiological study should be performed during follow-up evaluation for local recurrence after soft tissue sarcoma resection and flap reconstruction.

Management of recurrent head and neck cancer: variables related to salvage surgery

After a local and/or regional recurrence of head and neck squamous cell carcinoma (HNSCC) not all patients are candidates to salvage treatment. The objective of this study was to identify the variables related to performance of salvage surgery with curative intent in these patients. We performed a retrospective study of 1088 HNSCC patients with a local and/or regional recurrence. According to a multivariate analysis, the variables related to performance of salvage surgery were the Karnofsky index, the location and extension of the primary tumor, the initial treatment, the disease-free interval between treatment of the initial tumor and diagnosis of the recurrence, and the year the recurrence was diagnosed. Considering salvage surgery as the dependent variable, the results of a recursive partitioning analysis defined four categories of patients in function of the category of local and regional extension of the initial tumor, the location of the primary tumor, the initial treatment and the disease-free interval between treatment of the initial tumor and diagnosis of the recurrence.

Surgery methods and soft tissue extension are the potential risk factors of local recurrence in giant cell tumor of bone

Background

Various treatments of giant cell tumor of bone (GCTB) included in curettages and resections and with adjuvant are exerted, but the best treatment is controversial. The aim of the study was the identification of individual risk factors after various treatments in GCTB.

Methods

A total of 179 patients treated for GCTB between 1998 and 2010 were concluded in the retrospective study. All patients were treated with intralesional curettage, extensive curettage, or wide resection. Mean follow-up was 60.2 ± 18.7 months (36~112 months). Age, gender, tumor location, Campanacci grade, soft tissue extension, pathological features, and surgical methods were performed to univariate Kaplan-Meier survival analysis and multivariate Cox regression analysis.

Results

The local recurrence rates of intralesional curettage (41.9 %) and extensive curettage (19.0 %) were significantly higher than that of wide resection (7.7 %). The higher risk of local recurrence was found for soft tissue extension (hazard = 7.921, 95 % CI 1.107~56.671), compared with no statistical significances between gender, location, Campanacci grade, pathologic fracture, and local recurrences, which were shown by Kaplan-Meier analysis. However, recurrence-free survival (RFS) of patients younger than 30 was significantly lower than that of patients older than 30. The RFS of pathologic fracture patients with soft tissue extension was significantly lower than that of pathologic fracture patients without soft tissue extension. Multivariate Cox regression analysis indicated that the independent variable that contributed to recurrence-free survival was soft tissue extension and surgical methods. The RFS of extensive curettage had no statistically significant difference with wide resection and was significantly higher than that of intralesional curettage. Use of high-speed burring and bone cement significantly decreased the local recurrence rate.

Conclusions

Age (below 30 years), gender, tumor location, Campanacci grade, and pathologic fracture have no statistically significant influence on local recurrences. Soft tissue extension and intralesional curettage of surgical methods increased the RFS. The results of the present study suggested that compared with curettage and wide section, treatment of GCTB by extensive curettage could provide the favorable local control and functional recovery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0871-z) contains supplementary material, which is available to authorized users.

The width of resection margins influences local recurrence in soft tissue sarcoma patients

BACKGROUND

Patients with soft tissue sarcoma (STS) being treated following the standardized guidelines can still not be guaranteed to remain free from local recurrence (LR). A complete tumour resection has been accepted as a major prognostic factor for LR. This retrospective study was designed to analyse the influence of two different classifications of resection margins (R-classification and UICC-classification) on LR in STS patients.

MATERIALS AND METHODS

Of 411 patients treated at our institution for STS, 265 were eligible for statistical analysis. Kaplan-Meier curves and Cox regression models were used to assess the impact of an R0 resection according to the R-classification (resection margin clear but allowing <1 mm) and according to the UICC-classification (minimal resection margin ≥1 mm) on LR.

RESULTS

Survival curves showed a lower LR rate for R0 resections in the UICC-classification, namely 1.3%, 12% and 12% as compared to 2.1%, 9.5% and 16.5% for the R-classification. In multivariate analysis calculated separately for each classification, R1 resection as defined by the R-classification (HR: 11.214; 95%CI: 2.394-52.517; p = 0.002) as well as by UICC-classification (HR: 15.634; 95%CI: 2.493-98.029; p = 0.003) remained significant.

CONCLUSION

In our study, margin status according to both classifications represents an independent prognostic factor for LR in patients with STS following curative surgery. Local control rates were superior after a minimal resection margin of 1 mm (R0 by UICC-classification) compared to R0 resections after the R-classification.

Is breast conservative surgery a reasonable option in multifocal or multicentric tumors?

The incidence of multifocal (MF) and multicentric (MC) carcinomas varies widely among clinical studies, depending on definitions and methods for pathological sampling. Magnetic resonance imaging is increasingly used because it can help identify additional and conventionally occult tumors with high sensitivity. However, false positive lesions might incorrectly influence treatment decisions. Therefore, preoperative biopsies must be performed to avoid unnecessary surgery. Most studies have shown higher lymph node involvement rates in MF/MC tumors than in unifocal tumors. However, the rate of local recurrences is usually low after breast conservative treatment (BCT) of MC/MF tumors. It has been suggested that BCT is a reasonable option for MC/MF tumors in women aged 50-69 years, with small tumors and absence of extensive ductal carcinoma in situ. A meta-analysis showed an apparent decreased overall survival in MC/MF tumors but data are controversial. Surgery should achieve both acceptable cosmetic results and negative margins, which requires thorough preoperative radiological workup and localization of lesions. Boost radiotherapy techniques must be evaluated since double boosts might result in increased toxicity, namely fibrosis. In conclusion, BCT is feasible in selected patients with MC/MF but the choice of surgery must be discussed in a multidisciplinary team comprising at least radiologists, surgeons and radiotherapists.

Factors associated with the location of local rectal cancer recurrence and predictors of survival

PURPOSE

The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC.

METHODS

Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980-2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database.

RESULTS

One hundred and fifty-seven patients were identified with a mean follow-up 59.8 ± 50.1 months and time to LRRC of 31.7 ± 30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P = 0.019) and lateral (P = 0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P = 0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2-8.4; P < 0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3-2.7, P < 0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1-2.1; P = 0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2-2.7; P = 0.008) were associated with reduced LRRC 5-year survival.

CONCLUSIONS

The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

FXYD-3 expression in relation to local recurrence of rectal cancer

Purpose

In a previous study, the transmembrane protein FXYD-3 was suggested as a biomarker for a lower survival rate and reduced radiosensitivity in rectal cancer patients receiving preoperative radiotherapy. The purpose of preoperative irradiation in rectal cancer is to reduce local recurrence. The aim of this study was to investigate the potential role of FXYD-3 as a biomarker for increased risk for local recurrence of rectal cancer.

Materials and Methods

FXYD-3 expression was immunohistochemically examined in surgical specimens from a cohort of patients with rectal cancer who developed local recurrence (n = 48). The cohort was compared to a matched control group without recurrence (n = 81).

Results

Weak FXYD-3 expression was found in 106/129 (82%) of the rectal tumors and strong expression in 23/129 (18%). There was no difference in the expression of FXYD-3 between the patients with local recurrence and the control group. Furthermore there was no difference in FXYD-3 expression and time to diagnosis of local recurrence between patients who received preoperative radiotherapy and those without.

Conclusion

Previous findings indicated that FXYD-3 expression may be used as a marker of decreased sensitivity to radiotherapy or even overall survival. We were unable to confirm this in a cohort of rectal cancer patients who developed local recurrence.

Local recurrence risk after previous salvage mastectomy

INTRODUCTION

Breast-conserving surgery is a standard treatment for early breast cancer. For ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery, salvage mastectomy is the current standard surgical procedure. However, it is not rare for patients with IBTR who have received salvage mastectomy to develop local recurrence. In this study, we examined the risk factors of local recurrence after salvage mastectomy for IBTR.

PATIENTS AND METHODS

A total of 118 consecutive patients who had histologically confirmed IBTR without distant metastases and underwent salvage mastectomy without irradiation for IBTR between 1989 and 2008 were included from eight institutions in Japan. The risk factors of local recurrence were assessed.

RESULTS

The median follow-up period from salvage mastectomy for IBTR was 4.6 years. Patients with pN2 or higher on diagnosis of the primary tumor showed significantly poorer local recurrence-free survival than those with pN0 or pN1 at primary tumor (p < 0.001). Multivariate analysis showed that the lymph node status of the primary tumor was a significantly independent predictive factor of local recurrence-free survival (p = 0.02).

CONCLUSION

The lymph node status of the primary tumor might be a predictive factor of local recurrence-free survival after salvage mastectomy for IBTR. Further research and validation studies are needed. (UMIN-CTR number UMIN000008136).

Inflammatory Myofibroblastic Tumors: Current Update

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate biological potential with a predilection for the lung and abdominopelvic region. IMT represents the neoplastic subset of the family of inflammatory pseudotumors, an umbrella term for spindle cell proliferations of uncertain histogenesis with a variable inflammatory component. IMTs show characteristic fasciitis-like, compact spindle cell and hypocellular fibrous histologic patterns and distinctive molecular features. Imaging findings reflect pathologic features and vary from an ill-defined, infiltrating lesion to a wellcircumscribed, soft tissue mass owing to variable inflammatory, stromal, and myofibroblastic components.

Positive frozen section margins predict local recurrence in R0-resected squamous cell carcinoma of the head and neck

OBJECTIVES

The purpose of this study was to analyse the impact of surgical margins on tumour recurrence and survival of patients with carcinomas of the head and neck.

MATERIAL AND METHODS

A cohort of 156 patients with primary squamous cell carcinoma of the head and neck treated by local resection with negative margins and neck dissection between 2004 and 2012 was investigated. Margin status in frozen sections and permanent paraffin tissues were analysed and compared to clinical and histopathological parameters as well as to tumour recurrence (local, regional and distant) and disease-specific survival (DSS).

RESULTS

Close margins (<5mm) on permanent sections were correlated to high-grade differentiation (p=0.070), lymphangiosis (p=0.009) and positive neck nodes (p=0.025) implicating regional and distant recurrence (p=0.001) as well as unfavorable DSS (p=0.002). Positive margins on initial frozen section analysis revised into negative margins during further surgery were the strongest predictor for local recurrence in uni- and multivariate analysis (p<0.001, hazard ratio 3.34). However, positive frozen section margins were not significantly predictive for DSS (p=0.150). Significant predictors for DSS in univariate analysis were local recurrence (p=0.026), T-stage (p=0.02), N-stage (p<0.001), grading (p=0.02) and lymphangiosis (p=0.001). Multivariate DSS analysis revealed lymph node metastasis (p=0.005) and local recurrence (p=0.017) as significant negative predictors.

CONCLUSION

Close margins on permanent sections are associated with aggressive tumour characteristics, regional and distant metastasis implicating worse DSS. The accuracy of frozen section analysis seems limited as positive frozen section margins revised into negative margins bear a high risk of local recurrence.

Cervical Lymph Node Metastasis in High-Grade Transformation of Head and Neck Adenoid Cystic Carcinoma: A Collective International Review

Adenoid cystic carcinoma (AdCC) is among the most common malignant tumors of the salivary glands. It is characterized by a prolonged clinical course, with frequent local recurrences, late onset of metastases and fatal outcome. High-grade transformation (HGT) is an uncommon phenomenon among salivary carcinomas and is associated with increased tumor aggressiveness. In AdCC with high-grade transformation (AdCC–HGT), the clinical course deviates from the natural history of AdCC. It tends to be accelerated, with a high propensity for lymph node metastasis. In order to shed light on this rare event and, in particular, on treatment implications, we undertook this review: searching for all published cases of AdCC-HGT. We conclude that it is mandatory to perform elective neck dissection in patients with AdCC-HGT, due to the high risk of lymph node metastases associated with transformation.