1
|
Thompson MK, Poortmans P, Chalmers AJ, Faivre-Finn C, Hall E, Huddart RA, Lievens Y, Sebag-Montefiore D, Coles CE. Practice-changing radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie? Br J Cancer 2018; 119:389-407. [PMID: 30061587 PMCID: PMC6117262 DOI: 10.1038/s41416-018-0201-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 12/18/2022] Open
Abstract
As we mark 150 years since the birth of Marie Curie, we reflect on the global advances made in radiation oncology and the current status of radiation therapy (RT) research. Large-scale international RT clinical trials have been fundamental in driving evidence-based change and have served to improve cancer management and to reduce side effects. Radiation therapy trials have also improved practice by increasing quality assurance and consistency in treatment protocols across multiple centres. This review summarises some of the key RT practice-changing clinical trials over the last two decades, in four common cancer sites for which RT is a crucial component of curative treatment: breast, lung, urological and lower gastro-intestinal cancer. We highlight the global inequality in access to RT, and the work of international organisations, such as the International Atomic Energy Agency (IAEA), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the United Kingdom National Cancer Research Institute Clinical and Translational Radiotherapy Research Working Group (CTRad), that aim to improve access to RT and facilitate radiation research. We discuss some emerging RT technologies including proton beam therapy and magnetic resonance linear accelerators and predict likely future directions in clinical RT research.
Collapse
Affiliation(s)
- Mareike K Thompson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Anthony J Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, G61 1QH, UK
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester; The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, London, SM2 5NG, UK
| | - Robert A Huddart
- Section of Radiotherapy and Imaging, The Institute of Cancer Research, London, SM2 5NG, UK
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, C. Heymanslaan, 9000, Ghent, Belgium
| | - David Sebag-Montefiore
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds; Leeds Cancer Centre, St James's University Hospitals, Leeds, LS9 7TF, UK
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, CB2 0QQ, UK.
| |
Collapse
|
2
|
Donker M, van Tienhoven G, Straver ME, Meijnen P, van de Velde CJH, Mansel RE, Cataliotti L, Westenberg AH, Klinkenbijl JHG, Orzalesi L, Bouma WH, van der Mijle HCJ, Nieuwenhuijzen GAP, Veltkamp SC, Slaets L, Duez NJ, de Graaf PW, van Dalen T, Marinelli A, Rijna H, Snoj M, Bundred NJ, Merkus JWS, Belkacemi Y, Petignat P, Schinagl DAX, Coens C, Messina CGM, Bogaerts J, Rutgers EJT. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014; 15:1303-10. [PMID: 25439688 PMCID: PMC4291166 DOI: 10.1016/s1470-2045(14)70460-7] [Citation(s) in RCA: 1113] [Impact Index Per Article: 111.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND If treatment of the axilla is indicated in patients with breast cancer who have a positive sentinel node, axillary lymph node dissection is the present standard. Although axillary lymph node dissection provides excellent regional control, it is associated with harmful side-effects. We aimed to assess whether axillary radiotherapy provides comparable regional control with fewer side-effects. METHODS Patients with T1-2 primary breast cancer and no palpable lymphadenopathy were enrolled in the randomised, multicentre, open-label, phase 3 non-inferiority EORTC 10981-22023 AMAROS trial. Patients were randomly assigned (1:1) by a computer-generated allocation schedule to receive either axillary lymph node dissection or axillary radiotherapy in case of a positive sentinel node, stratified by institution. The primary endpoint was non-inferiority of 5-year axillary recurrence, considered to be not more than 4% for the axillary radiotherapy group compared with an expected 2% in the axillary lymph node dissection group. Analyses were by intention to treat and per protocol. The AMAROS trial is registered with ClinicalTrials.gov, number NCT00014612. FINDINGS Between Feb 19, 2001, and April 29, 2010, 4823 patients were enrolled at 34 centres from nine European countries, of whom 4806 were eligible for randomisation. 2402 patients were randomly assigned to receive axillary lymph node dissection and 2404 to receive axillary radiotherapy. Of the 1425 patients with a positive sentinel node, 744 had been randomly assigned to axillary lymph node dissection and 681 to axillary radiotherapy; these patients constituted the intention-to-treat population. Median follow-up was 6·1 years (IQR 4·1-8·0) for the patients with positive sentinel lymph nodes. In the axillary lymph node dissection group, 220 (33%) of 672 patients who underwent axillary lymph node dissection had additional positive nodes. Axillary recurrence occurred in four of 744 patients in the axillary lymph node dissection group and seven of 681 in the axillary radiotherapy group. 5-year axillary recurrence was 0·43% (95% CI 0·00-0·92) after axillary lymph node dissection versus 1·19% (0·31-2·08) after axillary radiotherapy. The planned non-inferiority test was underpowered because of the low number of events. The one-sided 95% CI for the underpowered non-inferiority test on the hazard ratio was 0·00-5·27, with a non-inferiority margin of 2. Lymphoedema in the ipsilateral arm was noted significantly more often after axillary lymph node dissection than after axillary radiotherapy at 1 year, 3 years, and 5 years. INTERPRETATION Axillary lymph node dissection and axillary radiotherapy after a positive sentinel node provide excellent and comparable axillary control for patients with T1-2 primary breast cancer and no palpable lymphadenopathy. Axillary radiotherapy results in significantly less morbidity. FUNDING EORTC Charitable Trust.
Collapse
Affiliation(s)
- Mila Donker
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Marieke E Straver
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Philip Meijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | | | | | | | - Willem H Bouma
- Department of Surgery, Gelre Hospital, Apeldoorn, Netherlands
| | | | | | - Sanne C Veltkamp
- Department of Surgery, Amstelland Hospital, Amstelveen, Netherlands
| | - Leen Slaets
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Nicole J Duez
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Peter W de Graaf
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | - Thijs van Dalen
- Department of Radiation Oncology, University Medical Center, Utrecht, Netherlands
| | - Andreas Marinelli
- Department of Surgery, Medical Center Haaglanden, Westeinde, Den Haag, Netherlands
| | - Herman Rijna
- Department of Surgery, Kennemer Gasthuis, Haarlem, Netherlands
| | - Marko Snoj
- Department of Surgery, Institute of Oncology, Ljubljana, Slovenia
| | - Nigel J Bundred
- Department of Surgery, Manchester University Hospital, Manchester, UK
| | - Jos W S Merkus
- Department of Surgery, Haga Hospital, Den Haag, Netherlands
| | - Yazid Belkacemi
- Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Patrick Petignat
- Division of Gynecology, University Hospitals of Geneva, Geneva, Switzerland
| | - Dominic A X Schinagl
- Department of Radiation Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Corneel Coens
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Carlo G M Messina
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Jan Bogaerts
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Emiel J T Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.
| |
Collapse
|
3
|
Comparison of the sentinel node procedure between patients with multifocal and unifocal breast cancer in the EORTC 10981-22023 AMAROS Trial: identification rate and nodal outcome. Eur J Cancer 2013; 49:2093-100. [PMID: 23522754 DOI: 10.1016/j.ejca.2013.02.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/13/2013] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Multifocal breast cancer is associated with a higher risk of nodal involvement compared to unifocal breast cancer and the drainage pattern from multifocal localisations may be different. For this reason, the value of the sentinel node biopsy (SNB) procedure for this indication is debated. The aim of the current analysis was to evaluate the sentinel node identification rate and nodal involvement in patients with a multifocal tumour in the EORTC 10981-22023 AMAROS trial. PATIENTS AND METHODS From the first 4000 registered patients, 342 were identified with a multifocal tumour on histological examination and compared to a randomly selected control group of 684 patients with a unifocal tumour. The outcome of the SNB was assessed. RESULTS The sentinel node was identified in 96% of the patients with a multifocal tumour and in 98% of those with unifocal disease. In the multifocal group, 51% had a metastasis in the sentinel node compared to 28% in the unifocal group; and further nodal involvement after a positive sentinel node was found in 40% (38/95) and 39% (39/101) respectively. CONCLUSION In this prospective international multicentre study, the 96% detection rate indicates that the SNB procedure can be highly effective in patients with a multifocal tumour. Though the tumour-positive rate of the sentinel node was twice as high in the multifocal group compared to the unifocal group, further nodal involvement after a positive sentinel node was similar in both groups. This suggests that the SNB procedure is safe in patients with multifocal breast cancer.
Collapse
|
4
|
Blessing JA, Bialy SA, Whitney CW, Stonebraker BL, Stehman FB. Gynecologic Oncology Group quality assurance audits: analysis and initiatives for improvement. Clin Trials 2010; 7:390-9. [DOI: 10.1177/1740774510372535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Gynecologic Oncology Group (GOG) is a multi-institution, multi-discipline Cooperative Group funded by the National Cancer Institute (NCI) to conduct clinical trials which investigate the treatment, prevention, control, quality of survivorship, and translational science of gynecologic malignancies. In 1982, the NCI initiated a program of on-site quality assurance audits of participating institutions. Each is required to be audited at least once every 3 years. In GOG, the audit mandate is the responsibility of the GOG Quality Assurance Audit Committee and it is centralized in the Statistical and Data Center (SDC). Each component (Regulatory, Investigational Drug Pharmacy, Patient Case Review) is classified as Acceptable, Acceptable, follow-up required, or Unacceptable. Purpose To determine frequently occurring deviations and develop focused innovative solutions to address them. Methods A database was created to examine the deviations noted at the most recent audit conducted at 57 GOG parent institutions during 2004—2007. Cumulatively, this involved 687 patients and 306 protocols. Results The results documented commendable performance: Regulatory (39 Acceptable, 17 Acceptable, follow-up, 1 Unacceptable); Pharmacy (41 Acceptable, 3 Acceptable, follow-up, 1 Unacceptable, 12 N/A): Patient Case Review (31 Acceptable, 22 Acceptable, follow-up, 4 Unacceptable). The nature of major and lesser deviations was analyzed to create and enhance initiatives for improvement of the quality of clinical research. As a result, Group-wide proactive initiatives were undertaken, audit training sessions have emphasized recurring issues, and GOG Data Management Subcommittee agendas have provided targeted instruction and training. Limitations The analysis was based upon parent institutions only; affiliate institutions and Community Clinical Oncology Program participants were not included, although it is assumed their areas of difficulty are similar. Conclusions The coordination of the GOG Quality Assurance Audit program in the SDC has improved data quality by enhancing our ability to identify frequently occurring deviations and develop innovative solutions to avoid or minimize their occurrence in the future. Clinical Trials 2010; 7: 390—399. http://ctj.sagepub.com
Collapse
Affiliation(s)
- John A Blessing
- Gynecologic Oncology Group Statistical & Data Center, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, USA,
| | - Sally A Bialy
- Gynecologic Oncology Group Statistical & Data Center, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, USA
| | | | - Bette L Stonebraker
- Gynecologic Oncology Group Statistical & Data Center, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, NY, USA
| | - Frederick B Stehman
- Section of Gynecologic Oncology, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
5
|
You YN, Jacobs L, Martinez E, Ota DM. The audit process and how to ensure a successful audit. Cancer Treat Res 2007; 132:179-97. [PMID: 17305022 DOI: 10.1007/978-0-387-33225-3_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Y Nancy You
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | |
Collapse
|
6
|
Rutgers EJT. Guidelines to assure quality in breast cancer surgery. Eur J Surg Oncol 2005; 31:568-76. [PMID: 16023942 DOI: 10.1016/j.ejso.2005.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Revised: 09/20/2004] [Accepted: 02/11/2005] [Indexed: 12/22/2022] Open
Abstract
The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.
Collapse
Affiliation(s)
- E J Th Rutgers
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| |
Collapse
|
7
|
Rutgers EJT, Meijnen P, Bonnefoi H. Clinical trials update of the European Organization for Research and Treatment of Cancer Breast Cancer Group. Breast Cancer Res 2004; 6:165-9. [PMID: 15217489 PMCID: PMC468675 DOI: 10.1186/bcr906] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The present clinical trial update consists of a review of two of eight current studies (the 10981-22023 AMAROS trial and the 10994 p53 trial) of the European Organization for Research and Treatment of Cancer Breast Cancer Group, as well as a preview of the MIND-ACT trial. The AMAROS trial is designed to prove equivalent local/regional control for patients with proven axillary lymph node metastasis by sentinel node biopsy if treated with axillary radiotherapy instead of axillary lymph node dissection, with reduced morbidity. The p53 trial started to assess the potential predictive value of p53 using a functional assay in yeast in patients with locally advanced/inflammatory or large operable breast cancer prospectively randomised to a taxane regimen versus a nontaxane regimen.
Collapse
Affiliation(s)
- Emiel J T Rutgers
- Department of Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
| | | | | |
Collapse
|
8
|
Abstract
Sentinel lymph node (SLN) biopsy is rapidly emerging as a minimally invasive alternative to standard axillary dissection for nodal staging in breast cancer. So far only data from case-control trials are available documenting SLN biopsy to be highly predictive of axillary node status, with a false-negative rate of less than 5%. The procedure has the potential to identify those patients most likely to be helped by axillary dissection (ie, those with positive nodes) and to spare node-negative patients, who cannot benefit, from the morbidity of an operation. No data exist from randomized trials focusing on the oncologic safety of the SLN biopsy alone or the expected reduced postoperative morbidity. Therefore, results from randomized trials validating SLN biopsy in breast cancer are required before accepting the procedure as the standard of care. This review discusses the European multicenter randomized trials addressing the pros and cons of SLN dissection, either as a surrogate for conventional axillary dissection or to examine aspects of the procedure itself. The trials identified are the ALMANAC trial (Axillary Lymphatic Mapping Against Nodal Axillary Clearance); the AMAROS-EORTC trial (After Mapping of the Axilla: Radiotherapy or Surgery); the KiSS study (German Clinical Interdisciplinary Sentinel Study); the Milan trial (European Institute of Oncology); the Fransenod study (French Randomised Sentinel Node Study); and the IBCSG 23-01 trial (International Breast Cancer Study Group Trial 23-01).
Collapse
Affiliation(s)
- Robert E Mansel
- Department of Surgery, University of Wales College of Medicine, Cardiff, UK
| | | |
Collapse
|
9
|
Weigelt B, Verduijn P, Bosma AJ, Rutgers EJ, Peterse HL, van't Veer LJ. Detection of metastases in sentinel lymph nodes of breast cancer patients by multiple mRNA markers. Br J Cancer 2004; 90:1531-7. [PMID: 15083181 PMCID: PMC2409726 DOI: 10.1038/sj.bjc.6601659] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Disseminated breast tumour cells in sentinel lymph nodes (SNs) were evaluated by quantitative real-time PCR and the sensitivity of this assay was compared to the routine histological analysis. First, several candidate marker genes were tested for their specificity in axillary lymph nodes (ALN) of 50 breast cancer patients and 43 women without breast cancer. The marker gene panel selected, designed to detect the mRNA of CK19, p1B, EGP2 and SBEM, was subsequently applied to detect metastases in 70 SNs that were free of metastases as determined by standard histological evaluation. Remarkably, seven negative SNs showed increased marker gene expression, suggesting the presence of (micro) metastases. Four of these seven SNs positive by real-time PCR proved to contain tumour deposits after careful review of the slides or further sectioning of the paraffin-embedded material. In three PCR positive SNs, however, no tumour cells were found by haematoxylin and eosin staining (H&E) and immunohistologically analysis. The quantitative real-time PCR assay with multiple mRNA markers for the detection of disseminated breast cancer cells in SNs thus resulted in an upstaging of SNs containing metastastic disease of 10% compared to the routine histological analysis. The application of this technique may be of clinical relevance, as it is suggested that micrometastatic disease in SNs are associated with further nodal non-SN metastases in breast cancer.
Collapse
Affiliation(s)
- B Weigelt
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - P Verduijn
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - A J Bosma
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - E J Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - H L Peterse
- Division of Diagnostic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - L J van't Veer
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Division of Diagnostic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. E-mail:
| |
Collapse
|
10
|
van der Hage JA, Putter H, Bonnema J, Bartelink H, Therasse P, van de Velde CJH. Impact of locoregional treatment on the early-stage breast cancer patients: a retrospective analysis. Eur J Cancer 2003; 39:2192-9. [PMID: 14522378 DOI: 10.1016/s0959-8049(03)00572-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although adequate locoregional treatment improves local and regional control in early-stage breast cancer, uncertainty still exists about the role of locoregional therapy with respect to survival. To study the impact of surgery and radiotherapy on locoregional control and survival, we combined the data of three European Organisation for Research and Treatment of Cancer (EORTC) Breast Cancer Group trials including early-stage breast cancer patients with long-term follow-up. Risk ratios (RR) were estimated for locoregional recurrence and overall survival using Cox regression models. All analyses were adjusted for tumour size, nodal status, age, adjuvant radiotherapy, adjuvant chemotherapy and trial. The combined data-set consisted of 3648 patients. The median follow-up period was 11 years. 5.9% of the patients who underwent mastectomy and 10.8% of the patients who underwent breast-conserving therapy had a locoregional recurrence (P<0.0001). The risk of death after breast-conserving therapy was similar compared with mastectomy (RR 1.07, P=0.37). Adjuvant radiotherapy after mastectomy was associated with a lower risk for locoregional recurrence (RR 0.43, P<0.001) and death (RR 0.73, P=0.001). Patients with 1-3 positive nodes benefited the most from radiotherapy after mastectomy. Breast-conserving therapy was associated with an impaired locoregional control. However, breast-conserving therapy was not associated with a worse overall survival. Adjuvant radiotherapy in mastectomised patients was associated with both a significantly superior locoregional control and overall survival. The effect of adjuvant radiotherapy was most profound in patients who had 1-3 positive nodes.
Collapse
Affiliation(s)
- J A van der Hage
- Department of Surgery, D6-43, Leiden University Medical Center, PO box 9600, 2300 RC Leiden, The Netherlands
| | | | | | | | | | | |
Collapse
|
11
|
Hoekstra HJ, van Ginkel RJ. Hyperthermic isolated limb perfusion in the management of extremity sarcoma. Curr Opin Oncol 2003; 15:300-3. [PMID: 12874508 DOI: 10.1097/00001622-200307000-00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
High local drug concentrations can be achieved in a limb with minimal systemic toxicity with the technique of hyperthermic isolated limb perfusion (HILP). The currently most successful drugs are still Tumor Necrosis Factor alpha (TNFalpha) and melphalan. With HILP, as an induction chemotherapy treatment of locally advanced primarily irresectable soft tissue sarcomas of a limb, a limb salvage rate of 71% can be achieved, with a minimal treatment related morbidity. For the HILP is no upper age limit. Systemic inflammatory response syndrome is currently seldom seen. The exact working mechanisms of TNFalpha are still unknown. Experimental work is now directed to the development of drugs sensitizing the tumor vasculature to the effects of TNFalpha. In the clinical HILP setting are currently lower doses of TNFalpha in combination with melphalan investigated. Although multidrug resistance (MDR) is a major issue in effectiveness of chemotherapy in human cancer treatment, HILPs with TNFalpha and melphalan did not induce MDR in sarcomas. The future research in HILP with TNFalpha is directed in increasing tumor sensitivity for TNF with lowering the dosage without decreasing tumor response.
Collapse
Affiliation(s)
- H J Hoekstra
- Division of Surgical Oncology, Department of Surgery, Groningen University Hospital, PO Box 30.001, 9700 RB Groningen, The Netherlands.
| | | |
Collapse
|
12
|
Abstract
The concept of sentinel lymph node (SLN) biopsy in breast cancer patients is simple, attractive and rapidly emerging as a new standard of care. Several aspects of the technique of lymphatic mapping, case selection, pathologic analysis and the finding of micrometastases, and the accuracy of the technique are important subjects of study and debate in the literature and will be discussed in this review. High identification rates can be attained by the use of both radioguided and blue dye lymphatic mapping. Intradermal injection of tracers has reported to be successful, suggesting that dermal and parenchymal lymphatics drain to the same SLN. Extra axillary drainage is only seen after peri- or intratumoural injection. SLN biopsy is most widely used for both palpable and non-palpable T1 and T2 tumours, and limited experience exists for other indications. Accuracy is high only in experienced hands. The impact of failure of the procedure on regional disease control and survival will be assessed in a trial of the NSABP (National Adjuvant Breast and Bowel Project). The influence of a positive SLN biopsy with and without axillary dissection on survival and local control will be studied in trials of the BASO (British Association of Surgical Oncology), ACOSOG (American College of Surgeons Oncology Group) and EORTC (European Organisation for Research and Treatment of Cancer). These phase III trials and related studies on the importance of micrometastases in the SLN will give new insights in the safety of the SLN procedure and in the importance of treatment of regional lymph nodes in relation to local disease control and survival.
Collapse
Affiliation(s)
- J Bonnema
- Leids Universitair Medisch Centrum, Leiden, The Netherlands.
| | | |
Collapse
|