Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01

BACKGROUND

The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients.

METHODS

At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04).

CONCLUSION

In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Early complications of a reduction mammoplasty technique in the treatment of macromastia with or without breast cancer

This study was planned to investigate the early postoperative complications of reduction mammoplasty done for benign or malignant reasons on 286 patients. Minor and major complication rates were 16.3% and 1.9%, respectively.There was no significant difference in terms of complications between the patients with and those without breast cancer. Body mass index was found to be the only factor associated with the complication rates.

BACKGROUND

This study was planned to investigate the early postoperative complications after reduction mammoplasty applied either for benign or malignant reasons and reliability of the technique with respect to wound healing.

PATIENTS AND METHODS

Two hundred and eighty-six reduction procedures were evaluated prospectively. Fifty-two patients underwent reduction mammoplasty for macromastia and 101 for macromastia with breast cancer. The wound complications were evaluated in 2 groups, as minor and major complications. Seroma, hematoma, surgical site infection, delayed wound healing, and minor wound dehiscence were included in the minor complication group. Severe complications, such as necrosis of nipple-areola complex and major incisional wound dehiscence, were included in the major complications group.

RESULTS

Mean (SD) age of the patients was 48.8 ± 10.3 years, mean (SD) body mass index was 29 ± 3.3 kg/m(2), and mean (SD) weight of resected specimen was 958 ± 72 g. Mean (SD) preoperative and postoperative volumes for each breast were 1245 ± 75 cm(3) and 436 ± 27 cm(3), respectively. Minor and major complication rates were 25/153 (16.3%) and 3/153 (1.9%), respectively. There was no significant difference in terms of complications between the patients with and without breast cancer. Body mass index was found to be the only factor associated with the complication rates.

DISCUSSION

Reduction mammoplasty is a surgical technique that has satisfactory cosmetic results in the treatment of macromastia. This technique also is safe in the treatment of breast cancer patients with macromastia and does not increase complication rates.

Prognostic factors affecting survival and disease-free survival in lymph node-negative breast carcinomas

BACKGROUND AND OBJECTIVES

The objective of this study was to identify the patients who are at low or high-risk by defining the prognostic factors in node-negative breast carcinomas.

METHODS

Medical records of 384 consecutive breast cancer patients with negative axillary lymph nodes who had been operated on between January 1994 and January 1997 at our hospital were retrospectively reviewed. Several clinical and pathological characteristics of patients were categorized. Univariate analyses of survival and disease-free survival (DFS) were performed by the Kaplan-Meier method and the log-rank test. Independent prognostic and predictive factors affecting survival and DFS were assessed by Cox proportional hazard method.

RESULTS

5-year survival and DFS were 91.4 and 85.7%, respectively. Size, grade, age, and lymphovascular invasion (LVI) were the prognostic factors that independently affected survival and DFS. Tamoxifen improved survival and DFS. While age younger than 35 was an adverse factor for both survival and DFS, age older than 49 was a detrimental factor for DFS.

CONCLUSIONS

Patients who have a tumor with size greater than 2 cm, with histologic grade 3, with LVI, and patients with age under 35 or older than 49 have poorer prognosis among node-negative breast carcinomas, and are candidates for adjuvant therapy.

Prognostic factors determining survival in differentiated thyroid cancer

BACKGROUND

Differentiated thyroid cancer (DTC) is among the most curable cancers. We evaluated the prognoses of patients with DTC from an iodine-deficient area.

MATERIALS AND METHODS

Four hundred twenty-two patients with thyroid cancer who underwent surgery between 1992 and 2000 at the Ankara Oncology Hospital were evaluated. Three hundred eighty-two patients with DTC were included. Gender, age, histopathological type, tumor size, capsular invasion and vascular invasion, distant metastasis, TNM, and AMES-MACIS scoring were analyzed.

RESULTS

The 10-year disease-free survival rate was 72% and the overall survival rate was 88%. Age >/=45 years at presentation, follicular thyroid cancer, tumor extension beyond the thyroid capsule, vascular invasion, distant metastasis, increasing tumor size, stage, and high MACIS-AMES scores were found to be statistically significant adverse prognostic factors in univariate analysis for DFS and OAS. Multivariate analysis for DFS and OAS confirmed that distant metastasis, follicular thyroid cancer, tumor extension beyond the thyroid capsule, vascular invasion, primary tumor size, TNM stage, and high MACIS score were independent prognostic factors.

CONCLUSION

In DTC patients, in addition to traditional risk factors, prognostic factors, such as vascular invasion and capsular invasion, need to be evaluated; not only for achieving an adequate therapeutic approach, but also for avoiding overtreatment of low-risk patients.

The incidence of hyperthyroidism in patients with thyroid cancer in an area of iodine deficiency

BACKGROUND

The incidence of hyperthyroidism among thyroid malignancy varies greatly depending on the geographical area and iodine intake. The aim of the study was to evaluate the association of hyperthyroidism and thyroid cancer (TC) in an iodine deficient area.

PATIENTS AND METHODS

Medical records of 422 patients who underwent operation for TC between 1992 and 2000 in Ankara Oncology Hospital were reviewed. The characteristics of TC patients with hyperthyroidism were analyzed in respect to gender, age, histopathological type, thyroid function status, tumor size, extrathyroidal invasion, local recurrences, distant metastasis, AMES and MACIS scoring.

RESULTS

In the present patient series, among 422 patients with TC, hyperthyroidism was found in 12 patients (2.8%). None of the patients had Graves' disease. Of 12 patients with hyperthyroidism, 9 patients had papillary carcinoma, 1 patient had follicular carcinoma and 2 patients had follicular variant of papillary carcinoma. The tumor was in the active nodule in 5 patients.

CONCLUSION

The existence of hyperthyroidism among patients with differentiated TC is a clinical entity. Patients with hyperthyroidism and nodules require a careful approach in order to establish or exclude the possibility of TC especially in formerly iodine deficient areas.

Effect of different enteral nutrients on bacterial translocation in experimental obstructive jaundice

Obstructive jaundice leads to bacterial translocation (BT) by disruption of the gut barrier, intestinal microecology, and impaired host immune defence. The objective of the present study is to investigate the effects of different enteral nutrients on BT that is induced by obstructive jaundice in rats. Eighty male Wistar-Albino rats were randomly assigned into 4 groups. Group 1: 20 rats underwent laparotomy, common bile duct (CBD) was not actually ligated and transected, but sham ligation of CBD was performed. Groups 2-4: 60 rats underwent laparotomy, CBD ligation and transection. Group 1 and 2 rats were given rat chow, group 3 rats were fed a glutamine and arginine supplemented enteral diet, and group 4 rats were fed an arginine, m-RNA and omega-3 supplemented enteral diet, an immunonutrient. Rats in groups 3 and 4 had significantly less BT to mesenteric lymph nodes compared to rats in group 2 (p = 0.001). These findings suggest that oral administration of an arginine and glutamine supplemented diet and immunonutrition reduce BT in rats with obstructive jaundice.

Locally applied granulocyte-macrophage colony-stimulating factor improves the impaired bowel anastomoses in rats with long-term corticosteroid treatment

Inflammation is an essential component of the first phase of anastomotic wound healing, and it is suppressed by corticosteroids. The anti-inflammatory effect of corticosteroids is largely responsible for the impairment of wound healing in bowel anastomosis. It has been reported that local application of granulocyte-macrophage colony-stimulating factor (GM-CSF) improves the healing process in dermal wounds. In the present study, we investigated the effects of locally injected GM-CSF on anastomotic wound healing in long-term corticosteroid treated rats. Eighty male Sprague-Dawley rats were randomized into four groups. (1) control, (2) steroid, (3) steroid + local GM-CSF, (4) steroid + systemic GM-CSF. In groups 2, 3, and 4, methylprednisolone (5 mg/kg) was injected IM daily for 14 days. After 14 days, following anesthesia and laparotomy, colonic anastomosis was performed 3 cm away from the peritoneal reflection. In group 3, 50 mg GM-CSF was injected into the perianastomotic area. In group 4, 50 mg GM-CSF was applied subcutaneously. On postoperative day 3, repeat laparotomies were performed and bursting pressures, hydroxyproline levels, and histopathology examinations were studied. The mean values of bursting pressures and hydroxyproline levels in group 3, treated with steroid + local GM-CSF, were significantly higher than that of the group 2 and group 4 values. In the histopathology examination, the mean score of group 3 was significantly higher than that of groups 2 and 4. Our study indicates that local application of GM-CSF significantly improves the impaired anastomotic wound healing in rats treated with long-term corticosteroid.

Prognostic significance of axillary node and infraclavicular lymph node status after mastectomy

AIMS

The American Joint Committee on Cancer staging system for breast carcinomas has been revised. According to this revised staging system, metastasis to infraclavicular lymph nodes and number of positive axillary nodes have prognostic significance and a new stage, stage IIIC, has been introduced. The aim of this study is to investigate the association of positive axillary nodes by level and number with survival and stage migration between the old and the new stages in a large series of mastectomy patients.

METHODS

Data from 1277 consecutive breast cancer patients treated by mastectomy were studied, retrospectively. Prognostic value of number of positive axillary nodes and entirely invasion of apex axillary nodes were analysed. Survival curves were generated by Kaplan-Meier method, and multivariate analysis was performed by Cox proportional hazard model.

RESULTS

Five-year survival rates for metastasis to axillary level III and for stage IIIC breast cancer were 35.4 and 38.2%, respectively. Metastases to apex axillary nodes, 4-9 and 10 or more positive lymph nodes were found to be adverse and independent prognostic factors for survival in lymph node positive patients.

CONCLUSION

Invasion of infraclavicular nodes and 4-9 and > or =10 positive axillary lymph nodes were independent predictors for survival in node positive breast carcinomas in this series. Patients with the new stage IIIC had the worst survival among breast cancer patients.

Local granulocyte-macrophage colony-stimulating factor improves incisional wound healing in adriamycin-treated rats

PURPOSE

Neoadjuvant treatment is often given for locally advanced malignancies; however, clinical and experimental studies have shown that some chemotherapeutic agents impair wound healing. It has been reported that granulocyte-macrophage colony-stimulating factor (GM-CSF) applied locally improves dermal wound healing. Thus, we investigated the effects of locally injected GM-CSF on abdominal wounds impaired by adriamycin, a widely used chemotherapeutic agent.

METHODS

We divided 120 female Sprague-Dawley rats into five treatment groups of 24 rats. Group 1 received saline 8 mg/kg intravenously (i.v.) + laparotomy 14 days later (control); group 2 received 8 mg/kg i.v. adriamycin + laparotomy 14 days later; group 3 received adriamycin 8 mg/kg i.v. + laparotomy + local GM-CSF 50 microg 14 days later; group 4 received saline 8 mg/kg i.v. + laparotomy + local GM-CSF 50 microg 14 days later; and group 5 received adriamycin 8 mg/kg i.v. + laparotomy + systemic GM-CSF 50 microg 14 days later. Sutures were removed on postoperative day (POD) 7 in all five groups, and the abdominal bursting pressures were measured and recorded. Tissue samples were taken from the incision line for histopathological evaluation and hydroxyproline content measurement.

RESULTS

The bursting pressure was significantly lower in groups 2 and 5 than in groups 1, 3, and 4. The hydroxyproline content and histopathological findings supported this result.

CONCLUSION

The local injection of GM-CSF improved impaired wound healing in adriamycin-treated rats.

Granulocyte macrophage-colony stimulating factor improves impaired anastomotic wound healing in rats treated with intraperitoneal mitomycin-C

PURPOSE

Intraperitoneal chemotherapy (IPCT) delivers higher local concentrations of cytotoxic drugs than intravenous (i.v.) chemotherapy, but it can adversely affect the healing of intestinal anastomoses if given in the early postoperative period. Intestinal anastomotic leakage is a serious surgical complication. Experimental and clinical studies have shown that the local administration of granulocyte macrophage-colony stimulating factor (GM-CSF) improves would healing. Therefore, we evaluated the effects of locally applied GM-CSF on anastomotic wound healing in rats treated with intraperitoneal mitomycin-C immediately after surgery.

METHODS

We performed colon anastomoses in albino rats, which were then divided into three treatment groups. Group A was a control group that received no treatment, Group B was given intraperitoneal mitomycin-C postoperatively, and Group C was given intraperitoneal mitomycin-C with a local injection of GM-CSF postoperatively. We measured bursting pressures and hydroxyproline content, and histologically examined the resected anastomoses on postoperative day (POD) 3.

RESULTS

Anastomotic healing was impaired after intraperitoneal mitomycin-C, but this was overcome by the injection of GM-CSF into the perianastomotic area.

CONCLUSION

Local GM-CSF administration counteracts the detrimental effects of intraperitoneal mitomycin-C treatment on intestinal anastomoses in rats.

Effects of locally applied recombinant human granulocyte-macrophage colony-stimulating factor on ischemic bowel anastomoses in rat

BACKGROUND

Ischemia is one of the most common causes of anastomosis disruption. In the present study we investigated the effect of locally injected recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on ischemic bowel anastomosis in rats.

METHODS

144 male Sprague-Dawley rats were randomized into four groups: in group 1, colon anastomoses were performed; in group 2, anastomoses were performed then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area; in group 3, anastomoses were performed on ischemic colon segments, and in group 4, colon anastomoses were performed on ischemic segments and then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area. On the 3rd and 7th post-operative days, the rats were sacrificed and anastomotic bursting pressures were measured. Hydroxyproline contents were studied on the tissues from the anastomotic line. Three anastomotic segments were saved from each group for histopathological studies before bursting pressure measurement.

RESULTS

The bursting pressure in group 3 was significantly weaker than in the other groups. There were no significant differences between the bursting pressures in groups 1 and 4. The levels of hydroxyproline content in group 4 were significantly greater than in group 3.

CONCLUSIONS

These data suggest that the local injection of rhGM-CSF improves the healing of ischemic and even normal colon anastomoses.

Optimal timing for surgery after adriamycin treatment in rats

PURPOSE

To determine the optimal timing of surgery after adriamycin treatment, we investigated the time-related effect of adriamycin on wound healing over a long period.

METHODS

We divided 119 female Sprague-Dawley rats into seven treatment groups. Group 1 was subjected to laparatomy only. All the other groups were given 8 mg/kg adriamycin intravenously followed by laparotomy on the same day (group 2), 7 days later (group 3), 14 days later (group 4), 21 days later (group 5), 28 days later (group 6), or 35 days later (group 7). On postoperative day 7, the sutures were removed, abdominal bursting pressure was measured, and tissue samples were taken for histopathological evaluation and analysis of hydroxyproline content.

RESULTS

Bursting pressures were significantly lower in groups 3, 4, 5, and 6 than in group 1. The hydroxyproline content and histopathological evaluation supported these findings.

CONCLUSIONS

Our results showed that the optimal timing for surgery after adriamycin treatment is before the 7th day or after the 35th day. If surgery is performed between these days, there is a high risk of impaired wound healing.

Results of breast conserving surgery in clinical stage I-II breast carcinoma

BACKGROUND

The role of breast conserving surgery with radiotherapy is well established and has become a widely used procedure in breast cancer. Patient selection, a multidisciplinary approach, and expert surgical technique are important factors to avoid locoregional recurrence. The aim of this study was to analyse the outcomes of patients treated with breast conserving surgery in stage I-II breast cancer.

METHODS

In this study, the results of 135 breast conserving surgery cases are reported. The majority of patients received radiotherapy and adjuvant systemic treatment.

RESULTS

At a median follow-up period of 54 months, 5 patients (3.7%) developed locoregional recurrence. The 5 years overall and disease-free survival rates were 90% and 84%, respectively. Young age, lymph node involvement, and oestrogen receptor negativity were independent predictors for overall survival.

CONCLUSION

In selected patients, breast conserving surgery using good surgical technique in conjunction with radiotherapy can achieve a high survival rate with a low locoregional recurrence rate.

Temporal variation in the recovery from impairment in adriamycin-induced wound healing in rats

Background

An adriamycin-induced impairment of wound healing has been demonstrated experimentally in rats. The purpose of this study is to investigate a possible temporal variation in recovery from the impairment of wound healing caused by adriamycin administration.

Methods

The subjects were 120 female Spraque-Dawley rats. They were divided into eight groups, undergoing adriamycin administration (8 mg/kg, i.v.) at 9 a.m. or 9 p.m. on day 0 and laparotomy on day 0, 7, 14 or 21. Blast pressures were recorded after the incision line had been opened, and tissue samples were kept at -30°C for later measurement of hydroxyproline levels.

Results

Adriamycin treatment in rats at 9 p.m. resulted in significantly lower blast pressure levels than treatment at 9 a.m. between days 7 and 21, indicating a lag effect of healing time in wounded tissues. However the decreased hydroxyproline levels were not changed at these days and sessions.

Conclusion

It is concluded that adriamycin-induced impairment of wound healing in adult female rats exhibits nycthemeral variation.

Effects of beta-D-glucan on steroid-induced impairment of colonic anastomotic healing

BACKGROUNDS/AIMS

Inflammation during the early phase of anastomotic wound healing is an essential cellular response and is suppressed by corticosteroids. The anti-inflammatory effect of corticosteroids is largely responsible for its impairment of wound healing in bowel anastomosis. Beta-D-glucan, a commonly used macrophage activator, has been shown to improve anastomotic wound healing under normal conditions. In the present study, we have investigated the effects of beta-D-glucan on anastomotic wound healing in rats treated with long-term corticosteroid.

METHODOLOGY

92 male Sprague-Dawley rats were randomized into four groups. 1 : control, 2: control + beta-D-glucan, 3 : steroid, 4 : steroid + beta-D-glucan. Methylprednisolone (5mg/kg) was injected IM daily for 14 days in groups 3 and 4. After 14 days, following anaesthesia and laparotomy, colonic anastomosis was performed 3 cm away from the peritoneal reflection of rectum. In groups 2 and 4, 100mg/kg beta-D-glucan was administered orally for 7 days before laparotomy. On postoperative day 3, relaparotomies were performed and bursting pressures, hydroxyproline levels and histopathological specimens were studied.

RESULTS

The mean values of bursting pressures groups were 50.8 (95% CI 46.99-56.50), 58.2 (95% CI 54.49-61.90), 32.0 (95% CI 29.21-34.98), 45.9 (95% CI 43.09-48.80) respectively. The differences of the mean values of the groups between group 1 and 2 and also 3 were significant (p = 0.002, p < 0.001). The mean values of hydroxyproline of the groups were 3.8 (95% CI 3.56-4.06), 4.7 (95% CI 4.50-5.04), 2.9 (95% CI 2.73-3.20), 3.9 (95% CI 3.65-4.22) respectively. The differences of the values of the groups between control (group1) and group 2 and also group 3 were significant (p = 0.001, p < 0.001). In histopathological examination, increased macrophages and fibroblast population were observed in specimens from beta-D-glucan-treated animals.

CONCLUSION

The results indicate that in rat model, oral administration of beta-D-glucan causes a significant improvement in the healing of anastomotic wound impaired by long-term corticosteroid administration.

Prognostic Significance of Apex Axillary Invasion for Locoregional Recurrence and Effect of Postmastectomy Radiotherapy on Overall Survival in Node-Positive Breast Cancer Patients

Postmastectomy irradiation substantially reduces the risk of locoregional recurrences (LRR) of breast carcinoma. However, debates continue on the prognostic factors for radiotherapy and the effect of radiotherapy on overall survival. The present study was undertaken to investigate the prognostic significance of level III positive nodes, along with the other factors for LRR, and to evaluate the effect of postmastectomy radiotherapy on overall survival among node-positive breast carcinoma treated systemically. Data from 549 consecutive node-positive breast cancer patients who underwent modified radical mastectomy and received adjuvant systemic therapy were studied retrospectively. Prognostic factors for LRR and the effect of postmastectomy radiotherapy on overall survival were analyzed. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model. The 5-year locoregional recurrence rate is 7%. Apical invasion was found to be an independent prognostic factor for LRR (HR 2.6, CI 1.29-5.35) along with a finding of 4 or more positive nodes and T3 tumor. Adjuvant radiotherapy decreased LRR and improved survival significantly. Apical invasion, 4 or more positive axillary lymph nodes, and T3 tumor are the predictors of LRR, and patients with these adverse factors are candidates for adjuvant radiotherapy. Postmastectomy radiotherapy improves overall survival.

Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p&gt;0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size&lt;5cm (p&lt;0.0001), and high histologic grade (HG III, p&lt;0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Application of sentinel node biopsy in breast cancer patients with clinically negative and positive axilla and role of axillary ultrasound examination to select patients for sentinel node biopsy

PURPOSE

To evaluate the identification rate and the false-negative (FN) rate of sentinel lymph node biopsy (SLNB) using preoperative axillary ultrasound (AU) in patients with clinically negative and positive axilla and to prove that SLNB could also be performed in clinically axillary positive patients.

METHODS

Three hundred and fifty seven consecutive T1-2 invasive breast cancer patients with clinically negative or positive axilla were enrolled in our Institution between 2006 and 2011. All patients had preoperative AU, and underwent SLNB followed by breast conserving surgery or mastectomy with level 1, 2 axillary dissection. SLNB was performed using 5 mL of 1% methylene blue. The identification (ID) rate and the FN rate of SLNB were calculated for patients with clinically negative and positive axilla, and for patients with negative AU.

RESULTS

Two hundred thirty two patients (65%) were clinically axillary-negative and 125 (35%) were clinically axillary-positive. The ID rates of SLNB were 91 and 89% and the FN rates were 7 and 9%, respectively, in patients with clinically negative and positive axilla. The ID rate of SLNB increased to 94% and the FN rate decreased to 4% after the exclusion of 85 patients (24%) with metastatic lymph nodes on AU.

CONCLUSION

SLNB can be safely applied to T1 tumors regardless of the clinical status of the axilla. Use of AU before SLNB significantly increases the ID rate and decreases the FN rate of SLNB in clinically axillary negative as well as in positive patients.

Efficacy of granulocyte-macrophage colony-stimulating factor on the survival of ischaemic skin flaps in rats

Our objective was to find out whether granulocyte-macrophage colony-stimulating factor (GM-CSF) improves the survival of skin flaps in rats. Random skin flaps were raised in 30 male Sprague-Dawley rats, and recombinant GM-CSF 50 microg in 0.5 ml saline solution (n=15) or 0.5 ml saline solution alone (n=15) was injected intradermally into the area of the flap after it had been raised. Surviving areas were measured after seven days, and the median area surviving in the group treated with GM-CSF was greater than that in the control group (728 mm2 (range 565-1120) compared with 985 mm2 (range 636-1368), p=0.005). These results suggest that in this model, GM-CSF given postoperatively improves the viability of ischaemic skin flaps.

Locally applied molgramostim improves wound healing at colonic anastomoses in rats after ligation of the common bile duct

BACKGROUND

Several systemic factors, including jaundice, long-term corticosteroid therapy, diabetes and malnutrition, increase the risk of anastomotic dehiscence. The local application of molgramostim (recombinant human granulocyte-macrophage colony stimulating factor) has been reported to improve impaired dermal wound healing. Since jaundice, one of the systemic risk factors for anastomotic dehiscence, causes significant impairment of anastomotic healing, we hypothesized that locally injected molgramostim could improve the healing of bowel anastomoses in bile-duct-ligated rats used as an experimental model for jaundice.

METHODS

Eighty-six Sprague-Dawley rats were randomized into 4 groups of 20-22 animals each as follows: group 1--colonic anastomosis only; group 2--laparotomy followed 7 days later by colonic anastomosis; group 3--common-bile-duct ligation (CBDL) followed 7 days later by colonic anastomosis (control group); group 4--CBDL followed by colonic anastomosis with locally applied molgramostim. Laparotomy was performed under anesthesia in group 2 rats. In groups 3 and 4, laparotomy was followed by ligation and dissection of the common bile duct. After 7 days, colonic anastomosis was performed; in group 4 rats, molgramostim (50 microg) was injected into the perianastomotic area. On postoperative day 3, rats were killed, and the bursting pressures and hydroxyproline levels measured. Two rats from each group were selected for histopathological examination.

RESULTS

The mean bursting pressure in group 4 was significantly higher than that in group 3 (37.8 v. 30.5 mm Hg [p < 0.01]). The mean hydroxyproline level in group 3 was significantly lower than that of the other groups (2.7 v. 3.1-3.5 mg/g tissue [p < 0.01]). On histopathological examination, specimens from group 4 rats showed an increased mononuclear cell population and a smaller gap on the anastomotic line than those from group 3.

CONCLUSION

The local injection of molgramostim improves healing of the impaired wound in rats subjected to CBDL.

Methylene blue prevents surgery-induced peritoneal adhesions but impairs the early phase of anastomotic wound healing

OBJECTIVES

Adhesion formation continues to be an important problem in gastrointestinal surgery. In recent years, methylene blue (MB) has been reported to be an effective agent for preventing peritoneal adhesions. However, its effects on the wound healing process are unknown. In the present study, we investigated the effects of MB on the early and late phases of anastomotic wound healing and on adhesion formation.

METHODS

We randomly categorized 92 rats into 2 groups in bursting pressure measurements and 50 rats into 3 groups in the adhesion model. We divided the animals into saline-treated (n = 46) or MB-treated (n = 46) groups. Bursting pressures of the anastomoses were measured on postoperative days 3 and 7. In biochemical studies, tissue hydroxyproline levels, total nitrite/nitrate levels and nitric oxide synthase activity were measured on postoperative days 3 and 7. In the adhesion model, we randomly categorized rats into sham (n = 10), saline-treated (n = 20) and MB-treated (n = 20) groups, and the formation of intraperitoneal adhesions was scored on postoperative day 14. We compared the measurement of bursting pressure and biochemical measurements of tissue hydroxyproline levels, total nitrite/nitrate levels and nitric oxide synthase activity. Histopathological findings of specimens were presented.

RESULTS

During the early phase of wound healing (postoperative day 3), bursting pressures, tissue hydroxyproline, total nitrite/nitrate levels and nitric oxide synthase activity in the MB-treated group were significantly lower than those of the saline-treated group. On postoperative day 7, there was no significant difference in these parameters between MB and saline-treated groups. In the adhesion model, MB caused a significant reduction in the formation of peritoneal adhesions.

CONCLUSION

MB prevents peritoneal adhesions but causes a significant impairment of anastomotic bursting pressure during the early phase of the wound healing process by its transient inhibitory effect on the nitric oxide pathway.

The effects of locally injected granulocyte macrophage-colony stimulating factor on the healing of intraoperatively irradiated intestinal anastomoses in rats

Intraoperative irradiation is used to reduce the number of local recurrences and to increase disease free survival in the treatment of intestinal malignancies. Irradiation for the local control of tumours diminishes the wound healing in the intestine as in any other tissues. For many surgeons, it seems too risky to make resection and anastomosis in an irradiated intestine. Granulocyte Macrophage-Colony Stimulating Factor (Gm-csf) had been successfully used in chronic and incisional dermal wounds. In this study, we evaluated the effect of locally applied Gm-csf on intraoperatively irradiated rat small intestinal anastomosis. 160 male Sprague-Dawley rats were randomized into 4 groups. In group 1 (control), ileal resection was made (1 cm. in length) and anastomosis was performed. In group 2, ileal resection and anastomosis were performed and 50 microgr. rHu Gm-csf was injected subserosally in the perianastomotic area. In group 3, intraoperatively 2000 cGy irradiation was applied to the intestine following ileal resection and anastomosis. In group 4, ileal resection and anastomosis were performed, and 50 microgr. rHu Gm-csf was injected subserosally in the perianastomotic area, then intraoperatively 2000 cGy irradiation was applied to the intestine. On the 3rd and 7th days, relaparotomies were made in order to measure the bursting pressures of the anastomotic segments. The measurement of hydroxyproline levels were evaluated to determine the amount of anastomotic collagen. Histopathological evaluations were also performed. The bursting pressure values in gm-csf given groups were significantly higher than their control groups. The hydroxyproline content of group 4 was significantly higher than group 3 on the 3rd day. In conclusion, these data indicate that local injection of Gm-csf improves the wound healing of intraoperatively irradiated bowel anastomosis.

Prognostic factors for survival in breast cancer patients who developed distant metastasis subsequent to definitive surgery

INTRODUCTION

The present study was undertaken to define the prognostic factors for overall survival subsequent to definitive surgery, and for survival after the development of distant metastasis in breast cancer patients who developed distant metastasis subsequent to definitive surgery.

METHODS

The records of 470 breast cancer patients with T1-3 tumours and distant metastasis following surgery were reviewed. Prognostic factors were compared to the first metastatic sites as solitary skeletal, multiple skeletal, and visceral metastases, and were analysed for overall survival following surgery and survival after metastasis. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model.

RESULTS

79 patients (17 percent) had a solitary skeletal metastasis, 105 (22 percent) had multiple skeletal metastases, and 286 (61 percent) had a visceral metastasis. The five-year overall survival was significantly better for patients with a solitary bone metastasis (73 percent) compared to patients who had multiple bone metastases (46 percent), or a visceral metastasis (22 percent) (p-value is less than 0.0001). Pathological lymph node status 3, stage IIIC, grade 3, oestrogen receptor negativity, and visceral metastases were found to have independent detrimental influence on overall survival following surgery and survival after metastasis. A long-term metastasis-free interval affected post-metastatic outcome favourably. Radiotherapy improved overall survival.

CONCLUSION

Pathological lymph node status, stage, grade, and oestrogen receptor status predicted survival after surgery as well as after the development of metastasis. Solitary bone metastasis has a more favourable prognosis than multiple bone metastases, and compared to visceral metastasis, skeletal metastasis has a more favourable prognosis.

A comparison of the outcomes of non-randomised chemotherapy regimens in node positive breast cancer

Adjuvant chemotherapy increases disease-free survival (DFS) and overall survival (OS) following surgery for breast cancer. However, debates concerning the type of adjuvant chemotherapy continue. The effect of adjuvant chemotherapy on loco-regional recurrence-free survival (LFS) was also reported. The present study was undertaken to compare the results of adjuvant FAC (5-fluorouracil, Doxorubicin, Cyclophosphamide) and CMF (Cyclophosphamide, Methotrexate, 5-fluorouracil) chemotherapy on DFS, OS and LFS for node positive breast carcinoma treated with mastectomy in a non-randomised setting. Data from 688 consecutive lymph node positive breast cancer patients who underwent radical or modified radical mastectomy and received adjuvant FAC (600/60/600 mgr/m2 for 6 cycles every three weeks) or CMF (600/40/600 mgr/m2 for 6 cycles on days land 8 every four weeks) chemotherapy were reviewed. The effect of FAC on DFS, OS and LFS as compared with CMF was analysed. Survival curves were generated by the Kaplan-Meier method, and a multivariate analysis was performed by the Cox proportional hazard model. Adjuvant FAC was found to improve DFS, OS and LFS. 5-year DFS, OS and LFS were longer for patients treated with FAC as compared to CMF (67% versus 53%, p < 0.001; 77% versus 66%, p < 0.001, and 97% versus 91%). Adjusted hazard ratio (HR) for potential risk factors and tamoxifen treatment showed that FAC treated patients much benefitted in terms of survival as compared to CMF treated patients (HR 0.53, CI 0.40-0.69 for DFS; HR 0.48, CI 0.35-0.65 for OS, and HR 0.33, CI 0.16-0.65 for LFS). In conclusion, adjuvant FAC improves DFS, OS and LFS as compared to CMF in node positive breast carcinoma patients treated with mastectomy.