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PubMed2006

Clinicopathological features of recurrence after radical cystectomy for patients with transitional cell carcinoma of the bladder.

BACKGROUND: The objective of this study was to investigate the clinicopathological features of recurrent transitional cell carcinoma (TCC) of the bladder in patients who had previously undergone radical cystectomy. MATERIALS AND METHODS: This study included 124 patients who underwent radical cystectomy for transitional cell carcinoma (TCC) of the bladder in our institution. Several clinicopathological factors were analyzed to characterize differences between patients with and without disease recurrence, and determined predictive factors for disease recurrence using multivariate analysis. We further analyzed prognostic parameters that affect survival after disease recurrence was diagnosed. RESULTS: Of the 124 patients, 24 (19.5%) developed recurrence, and the median time to recurrence was 9.5 months (range, 1-44 months). The 5-year recurrence-free survival in these 124 patients was 75.6%. The incidence of disease recurrence was significantly associated with gender, pathological stage, lymph node metastasis, lymphatic invasion and blood vessel invasion. Multivariate analysis identified gender, pathological stage and lymph node metastasis as independent predictors of disease recurrence following radical cystectomy. After disease recurrence, the 1-year cancer-specific survival of the 24 patients was 16.7%; that is, 23 of the 24 patients had died of progressive recurrent diseases, while the remaining 1 who survived had developed recurrence in the upper urinary tract. CONCLUSIONS: These findings suggest that careful follow-up should be performed after radical cystectomy for TCC of the bladder considering gender, pathological stage and nodal involvement; however, once recurrent disease develops, the prognosis of such patients is extremely poor. Therefore, it would be potentially important to establish a multimodal therapeutic approach targeting recurrent TCC of the bladder.

Aged↗
PubMed1992

Recurrent focal glomerulosclerosis: natural history and response to therapy.

PURPOSE: Recurrent focal glomerulosclerosis (FGS) has been well documented since it was first reported in 1972. However, the course of the disease after transplantation and the optimal treatment regimen have not been well defined since the introduction of newer treatment modalities. PATIENTS AND METHODS: We reviewed all the charts of patients with biospy-proven FGS who received renal transplants at our institution from January 1980 through December 1990. Case histories consistent with diagnoses other than primary FGS (such as reflux nephropathy or intravenous drug use) were eliminated from the study. During this time period, 78 allografts were received by 71 patients with FGS. Independent variables that were analyzed included sex, race, time in months between the diagnosis of FGS and end-stage disease (dialysis or transplantation), age at time of transplantation, type of dialysis, source of allograft (cadaveric or living related), haplotype matching, donor-specific transfusions, age and sex of the donor, post-transplantation acute tubular necrosis, rejection episodes, immunosuppression regimen, use of plasmapheresis and angiotensin converting enzyme (ACE) inhibitors, and outcome. RESULTS: FGS recurred in 25 allografts (32%) of 21 patients. Biopsy-proven diagnosis of recurrence was made a mean of 7.5 months (range: 0.5 to 44 months) after transplantation. Patients who had rapid progression to end-stage disease tended to experience more frequent recurrences. Of seven patients who received a second transplant, five patients lost the first graft to recurrent FGS, and four of those patients (80%) had a recurrence in the second allograft. Recurrent disease developed in 34% of patients concurrently treated with cyclosporine and in 28% of those treated with prednisone and azathioprine alone (NS). Patients with recurrent FGS who were treated with ACE inhibitors benefited from a significant reduction of proteinuria. Six patients underwent plasmapheresis after diagnosis of the recurrence. Three of five patients in whom the diagnosis was made early in the course of the disease and in whom plasmapheresis was initiated immediately had reversal of epithelial foot process effacement and remission of proteinuria. End-stage disease eventually developed in 14 allografts (56%) an average of 23.7 months (range: 1 to 65 months) after diagnosis of recurrent disease. The cause of failure was chronic rejection in four allografts and recurrent disease in the remaining 10 allografts. CONCLUSIONS: FGS recurs in approximately 30% of allografts and causes graft loss in half of these. Patients who have lost a first allograft to recurrent FGS are at high risk for developing recurrent disease in a second allograft. Prolonged allograft survival is possible in patients with recurrent FGS and may best be obtained with a combination of treatment modalities including cyclosporine (perhaps in higher dosages than are routinely used in clinical renal transplantation), ACE inhibitors, and early use of plasmapheresis. The efficacy of these modalities supports the notion that recurrent FGS is caused by a circulating humoral mediator.

Adolescent↗
PubMed1989

Analysis of independent variables affecting survival after recurrence of prostate cancer.

Two hundred and sixty-six patients developed recurrence after external beam radiation therapy for Stage B or C prostate cancer. The median survival from the time of recurrence was 30 months, the 5-year actuarial survival was 22% and the 8-year actuarial survival was 13%. The original stage influences survival after recurrence. Median survival is 35 months for Stage B and 27 months for Stage C. Five-year actuarial survivals are 31% for Stage B and 16% for Stage C. The site of recurrence (infield or metastatic) influences survival after recurrence. Median survival is 33 months for infield and 25 months for metastatic. Five-year actuarial survival is 30% for infield and 17% for metastatic. The time of recurrence influences survival after recurrence, comparing survival in patients recurring in the first year after treatment, to patients recurring in the second or later years after treatment. Median survival after recurrence is 14 months for those who recur in the first year, 32 months for those who recur later. Histologic grade influences survival after recurrence. Median survivals are 49 months for well differentiated, 31 months for moderately differentiated, and 23 months for poorly differentiated. Cox regression analysis indicates that original stage, site of recurrence (local vs. metastatic), time of recurrence after therapy, and histologic grade are all independent variables influencing survival after recurrence (p = less than .01). This study supports the aggressive treatment of prostate cancer to prevent recurrence and provides a means of estimating prognosis for patients who suffer a recurrence of their prostate cancer after treatment.

Humans↗
PubMed2006

The role of salvage surgery for recurrence of esophageal squamous cell cancer.

AIM: A consensus treatment strategy for recurrent esophageal squamous cell cancer (ESCC) has not been established. The purpose of the present study was to analyse the mode of recurrence, and evaluate the role of surgical salvage treatment in recurrence of ESCC. METHODS: Recurrence was detected in 131 of 367 consecutive patients with ESCC. We retrospectively analysed the mode of recurrence and treatment for recurrence. Recurrence was divided into four types; lymph node, hematogeneous, mixed and local. Treatments were classified into four groups; chemotherapy alone (C group), radiation therapy +/- chemotherapy (R group), surgery +/- other therapy (S group), and no therapy (N group). RESULTS: Of the 131 recurrences, the number of patients with lymph node, hematogeneous, mixed and local recurrence was 43, 44, 40 and 4, respectively. The number of patients in the C, R, S, N groups was 35, 35, 24 and 37, respectively. Of the 24 patients who received surgical treatment for recurrence, the number of patients with lymph node, hematogeneous, mixed and local recurrence was 11, 6, 6 and 1, respectively. The number of lesions in hematogeneous recurrence was 2 or less. The survival rate from recurrence to death in the C, R, S and N groups was 0, 3.9, 6.7 and 0%, respectively. A statistically significant difference was found in these groups (p < 0.0001). CONCLUSIONS: Salvage surgery is one of the useful treatment tools for resectable metastatic lesions. In such cases, the number of lesions, recurrent sites and effectiveness of chemotherapy and/or radiotherapy should be carefully evaluated.

Adult↗
PubMed2003

Predictors and patterns of recurrence after resection of hepatocellular carcinoma.

BACKGROUND: The majority of patients with hepatocellular carcinoma (HCC) who undergo complete tumor resection subsequently develop tumor recurrence. The objectives of this study were to determine the risk factors for recurrence of HCC after hepatectomy and to examine the outcomes once tumor recurrence occurs. STUDY DESIGN: From February 1990 to May 2001 a total of 164 patients underwent liver resection for HCC at our institution and were prospectively followed. Time to recurrence and survival after recurrence were determined by Kaplan-Meier analysis. Patient, tumor, and treatment characteristics were tested for their prognostic significance by univariate and multivariate analysis using the logrank test and the Cox proportional hazards model, respectively. RESULTS: The median patient age was 64 years (range 21 to 87 years) and 106 patients (65%) were male. After a median followup of 26 months, 90 patients (55%) have developed recurrent cancer. Among them, 75 patients (83%) had tumor detectable in the liver, which was the only site of disease in 67 (74%). In all, 15 patients (20%) had extrahepatic disease (7 lung, 4 peritoneum, 2 pancreas, 1 bone, and 1 brain). The median time to recurrence was 24 months (range 1 to 274 months). Predictors of recurrence on univariate analysis were tumor size greater than 5 cm, more than one tumor, cirrhosis, vascular invasion (microscopic or macroscopic), and tumor satellites. On multivariate analysis only tumor size greater than 5 cm (p = 0.04) and vascular invasion (p = 0.01) predicted recurrence. The median survival after recurrence was 11 months (range 0 to 60 months). Of the 90 patients who developed tumor recurrence 49 (67%) were able to undergo additional ablative or surgical therapy (33 embolization, 9 ethanol injection, and 14 re-resection). On multivariate analysis vascular invasion in the original tumor predicted poor survival after recurrence (p = 0.009). CONCLUSIONS: The liver is the predominant site of first recurrence after resection of hepatocellular carcinoma, and once recurrence occurs survival is limited. The current study underscores the need for effective adjuvant therapy for patients with HCC treated with partial hepatectomy.

Actuarial Analysis↗
PubMed2004

Recurrence and survival after first-ever stroke in the area of Bajo Aragon, Spain. A prospective cohort study.

OBJECTIVE: There have been no prospective studies in Spain focused on stroke recurrence. The purpose of this work is to estimate the risk of stroke recurrence and mortality in the community of Bajo Aragón, Spain and to compare it with previous studies conducted in other countries. METHODS: A cohort of 425 patients with first ever stroke was followed-up for a mean period of 4 years (range: 20-78 months). The mean age was 75.4 years. The survival function for recurrence and mortality was analysed by means of the actuarial method. Survival comparisons were made for the different vascular risk factors with the Kaplan-Meier method. The risk of recurrence and death was adjusted for relevant variables with the Cox proportional hazards model. We also made a separate analysis by stroke subtypes. RESULTS: At the end of the follow-up we found an overall mortality of 38% (163/425) with 69 patients dying in hospital, and an overall recurrence rate of 17.6% (63/356). The cumulative risk of recurrence was 2.1% at 30 days, 9.5% at 1 year and 26% at 5 years. The cumulative risk of mortality was 16% at 30 days, 30% at 1 year and 48% at 5 years. Only age (Hazard Ratio: 1.05, 95% CI: 1.02-1.08) and the addition of risk factors (Hazard Ratio: 1.32, 95% CI: 1.12-1.57) were significant predictors of recurrence. In general, none of the risk factors individually predicted stroke recurrence. The highest risk of recurrence was observed in large-vessel atherothrombotic infarction followed by cardioembolic infarction. In cardioembolic stroke, the association of atrial fibrillation plus either valvular disease or congestive heart failure significantly predicted recurrence of the same type (Relative Risk: 3.1; 95% CI: 2.2-4.4). CONCLUSION: The risk of early stroke recurrence in our area was lower than those observed in most studies, so was the risk of long-term mortality. However, the risk of long-term recurrence was similar. Age was the main predictor of death and recurrence. The patients with atrial fibrillation plus another heart disease are at increased risk of recurrent cardioembolic stroke.

Adult↗
PubMed2003

The natural history of recurrence after bronchoplastic procedures for non-small cell lung cancer.

BACKGROUND: The natural course of recurrence after bronchoplastic procedures for non-small cell lung cancer (NSCLC) has not been described. METHODS: Sex, age, tnm-stage, histology, neoadjuvant chemotherapy, disease-free interval (months), exact localisation of tumour recurrence, time between first and second recurrence (months), survival after first and second recurrence (months), causes of death were retrospectively recorded in 83 patients operated between December 1993 and July 2001. RESULTS: One patient was lost to follow-up, five resections were nonradical. Survivors' follow-up lasted 5 to 100.7 months (mean 43.3). Fourteen patients (14.4%) died tumor free. Eleven (13.2%) distant recurrences were diagnosed 1 to 42 months (mean 10.6) postoperatively, eight (9.6%) died 0 to 17 months (mean 7.55) after diagnosis. Nine local recurrences (10.8%)-5 unifocal, 4 multifocal-occurred 2 to 35 months (mean 17.3) postoperatively, eight died 0 to 8 months (mean 2.13) after diagnosis. Nine mixed recurrences (10.8%)-1 synchronous, 8 metachronous-were found (14.8%) 2 to 21 months postoperatively (mean 8.3). All died 4 to 41 months (mean 17.83) after diagnosis. Fourteen mediastinal lymph node recurrences occurred, ten as a primary recurrence and four as secondary. Lymph nodes were involved in all multifocal recurrences. Intrabronchial recurrence was observed in five patients and was always a result of progressive regional lymph node recurrence. CONCLUSIONS: The pattern and natural history of recurrence cannot be sufficiently explained by stage and surgical radicality and suggest different genetic characteristics of the primary tumor. In case of reoperation due to intrabronchial recurrence adjuvant mediastinal irradiation should be considered.

Adult↗
PubMed2005

Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials.

BACKGROUND: In early breast cancer, variations in local treatment that substantially affect the risk of locoregional recurrence could also affect long-term breast cancer mortality. To examine this relationship, collaborative meta-analyses were undertaken, based on individual patient data, of the relevant randomised trials that began by 1995. METHODS: Information was available on 42,000 women in 78 randomised treatment comparisons (radiotherapy vs no radiotherapy, 23,500; more vs less surgery, 9300; more surgery vs radiotherapy, 9300). 24 types of local treatment comparison were identified. To help relate the effect on local (ie, locoregional) recurrence to that on breast cancer mortality, these were grouped according to whether or not the 5-year local recurrence risk exceeded 10% (<10%, 17,000 women; >10%, 25,000 women). FINDINGS: About three-quarters of the eventual local recurrence risk occurred during the first 5 years. In the comparisons that involved little (<10%) difference in 5-year local recurrence risk there was little difference in 15-year breast cancer mortality. Among the 25,000 women in the comparisons that involved substantial (>10%) differences, however, 5-year local recurrence risks were 7% active versus 26% control (absolute reduction 19%), and 15-year breast cancer mortality risks were 44.6% versus 49.5% (absolute reduction 5.0%, SE 0.8, 2p<0.00001). These 25,000 women included 7300 with breast-conserving surgery (BCS) in trials of radiotherapy (generally just to the conserved breast), with 5-year local recurrence risks (mainly in the conserved breast, as most had axillary clearance and node-negative disease) 7% versus 26% (reduction 19%), and 15-year breast cancer mortality risks 30.5% versus 35.9% (reduction 5.4%, SE 1.7, 2p=0.0002; overall mortality reduction 5.3%, SE 1.8, 2p=0.005). They also included 8500 with mastectomy, axillary clearance, and node-positive disease in trials of radiotherapy (generally to the chest wall and regional lymph nodes), with similar absolute gains from radiotherapy; 5-year local recurrence risks (mainly at these sites) 6% versus 23% (reduction 17%), and 15-year breast cancer mortality risks 54.7% versus 60.1% (reduction 5.4%, SE 1.3, 2p=0.0002; overall mortality reduction 4.4%, SE 1.2, 2p=0.0009). Radiotherapy produced similar proportional reductions in local recurrence in all women (irrespective of age or tumour characteristics) and in all major trials of radiotherapy versus not (recent or older; with or without systemic therapy), so large absolute reductions in local recurrence were seen only if the control risk was large. To help assess the life-threatening side-effects of radiotherapy, the trials of radiotherapy versus not were combined with those of radiotherapy versus more surgery. There was, at least with some of the older radiotherapy regimens, a significant excess incidence of contralateral breast cancer (rate ratio 1.18, SE 0.06, 2p=0.002) and a significant excess of non-breast-cancer mortality in irradiated women (rate ratio 1.12, SE 0.04, 2p=0.001). Both were slight during the first 5 years, but continued after year 15. The excess mortality was mainly from heart disease (rate ratio 1.27, SE 0.07, 2p=0.0001) and lung cancer (rate ratio 1.78, SE 0.22, 2p=0.0004). INTERPRETATION: In these trials, avoidance of a local recurrence in the conserved breast after BCS and avoidance of a local recurrence elsewhere (eg, the chest wall or regional nodes) after mastectomy were of comparable relevance to 15-year breast cancer mortality. Differences in local treatment that substantially affect local recurrence rates would, in the hypothetical absence of any other causes of death, avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.

Aged↗
PubMed1999

Recurrence of maltreatment: an application of the National Child Abuse and Neglect Data System (NCANDS).

OBJECTIVE: The research describes and compares patterns of maltreatment recurrence across multiple states using large samples, confirms the patterns of recurrence found in the literature, and explores unreported patterns of recurrence. METHOD: A recurrence data set for calendar years 1994 and 1995 was constructed from the multi-state case level data from the National Child Abuse and Neglect Data System. These data were available for 10 states and included a range from 2,419 to 99,288 substantiated or indicated report-child pairs per state. A common set of data constructs lent consistency to data construction and analysis, while preserving differences in policy. Event History Analysis (survival) techniques were used. RESULTS: Single site studies were confirmed across the 10 states. These include the pattern where neglect is most likely to recur, followed by physical abuse and then sexual abuse. Similarly, younger children are more likely to recur. A finding of the analysis is that the likelihood of recurrence increases in a systematic and consistent fashion based upon the sequential ordering of recurrent maltreatment events. Also, the likelihood of recurrence is associated with the provision of postinvestigative services. CONCLUSION: Highly consistent patterns of recurrence were observed across states. Children experiencing multiple recurrences compared to no recurrence or one recurrence may represent a special at risk population requiring additional research. Adequate baselines and an understanding of recurrence is needed when considering recurrence as an outcome indicator or in developing risk assessment tools. Important recurrence patterns may be difficult to detect reliably with relatively small samples.

Adolescent↗
PubMed1997

Metastatic risk for distinct patterns of postirradiation local recurrence of posterior uveal melanoma.

OBJECTIVE: The purpose of the study is to compare the prognostic significance of horizontal/marginal versus vertical/diffuse patterns of postirradiation local recurrence of posterior uveal melanoma. DESIGN: The study design was a nonrandomized, retrospective clinical study. Semiparametric and nonparametric statistical techniques were used. PARTICIPANTS: Seven hundred sixty-six posterior uveal melanoma patients were studied. INTERVENTION: Either iodine-125 plaque or helium ion radiation therapy was performed. MAIN OUTCOME MEASURES: Local tumor recurrence and systemic metastasis were measured. RESULTS: Local tumor recurrence was detected in 66 (8.6%) of 766 irradiated tumors. The 5-year actuarial rate of local recurrence was 10%. The recurrence pattem was horizontal/marginal in 27 patients (41%) and vertical/diffuse in 39 patients (59%). Systemic metastasis was detected in 5 patients (19%) with horizontal/marginal recurrence and in 19 patients (49%) with vertical/diffuse recurrence. After known metastatic risk factors were controlled, the relative risk for metastasis was 2.2 for horizontal/marginal recurrence and 5.1 for vertical/diffuse recurrence (P = 0.05). The actuarial rate of systemic metastasis was 2.9% per year for all patients, 6.3% per year for patients with horizontal/marginal recurrence, and 15.5% per year for patients with vertical/diffuse recurrence. CONCLUSIONS: Postirradiation local recurrence of posterior uveal melanoma is a risk factor for systemic metastasis. Vertical/diffuse recurrences may be associated more strongly with metastatic disease than horizontal/marginal recurrences.

Adult↗
PubMed2000

Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation.

BACKGROUND/AIMS: Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation is not without drawbacks due to a higher tendency to variceal recurrence. We conducted a randomized cohort study to delineate the long-term history of variceal recurrence following ligation and sclerotherapy, and to clarify the impact of recurrence on rebleeding and on the consumption of endoscopic treatment resources. METHODS: Two hundred cirrhotic patients with esophageal variceal bleeding were randomized to undergo maintenance endoscopic variceal sclerotherapy or ligation. RESULTS: One hundred and forty-one patients achieved variceal eradication and were regularly followed up for 2.2 to 6.7 (mean: 5.1 +/- 1.2) years. The demographic data, hepatic reserve, bleeding severity, and endoscopic features of both sclerotherapy (n=70) and ligation (n=71) showed no difference. Forty (57.1%) patients who underwent sclerotherapy experienced 58 recurrences of esophageal varices, in contrast to the 46 (64.8%) patients who underwent ligation and experienced 81 episodes of recurrence. Kaplan-Meier analysis showed that within 2 years variceal recurrence was more frequent for ligation than sclerotherapy, and the difference decreased thereafter. Multiple recurrence appeared more common with ligation (1/2/3/4/5 episodes of recurrence: 46/23/8/3/1 vs. 40/14/3/1/0, p=0.08). On multifactorial analysis, the endoscopic treatment method and red wale markings were the two factors determining variceal recurrence. Rebleeding from recurrent esophageal varices was unusual and showed no difference between the two groups (7/58 vs. 6/81, p>0.05). Rebleeding from gastric varices was more common after eradication by sclerotherapy (7/19 vs. 1/16, p=0.085) than by ligation. The number of sessions required for eradication of recurrent varices was no different between the two groups. CONCLUSIONS: Early recurrence and multiple recurrence of esophageal varices are more likely in patients undergoing endoscopic ligation, compared to sclerotherapy; however, the recurrence did not lead to a higher risk of rebleeding or require more endoscopic treatment.

Aged↗
PubMed2003

Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy.

BACKGROUND/AIMS: We conducted a retrospective cohort study to investigate factors to early and late phase recurrence of hepatocellular carcinoma (HCC). METHODS: The study population consisted of 249 patients including 157 with cirrhosis who underwent hepatectomy for HCC. The endpoint was time-to-recurrence. Using a Cox regression model, factors to early and late phase recurrences were investigated censoring recurrence-free patients at the 2-year time point and in patients without recurrence at 2 years. RESULTS: Actuarial probability of overall recurrence at 1, 3, and 5 years were 0.301, 0.623, and 0.790, respectively, with a median follow-up of 624 days. Early recurrence was observed in 123 out of 249 patients; while late recurrence was found in 61 out of 113 patients. Factors to early recurrence were as follows: non-anatomical resection, presence of microscopic vascular invasion, and serum alpha-fetoprotein level >or=32 ng/ml. Those contributing to late phase recurrence were higher grade of hepatitis activity, multiple tumors, and gross tumor classification. CONCLUSIONS: Variables associated with metastatic recurrence were factors to early phase recurrence; whereas those related with elevated carcinogenesis contributed to late phase recurrence, thus providing an epidemiological evidence that different mechanisms, i.e. metastasis and de novo, are involved in intrahepatic recurrence after hepatectomy for HCC.

Adult↗
PubMed1992

Recurrent malignant melanoma: the identification of prognostic factors to predict survival.

The prognostic factors for stage 1, 2 melanoma have been elucidated. Tumor thickness, ulceration of the primary melanoma, and perhaps, primary site may be used to predict the percentage of patients with regional nodal disease or systemic metastases and the prognosis of patients who have only cutaneous disease at diagnosis. Very little is known about prognosis once there is a recurrence. A retrospective, computer-aided chart review identified 4,185 patients registered at the Duke University Melanoma Database who had stage 1, 2 disease at diagnosis. During a mean follow-up period of 7 years, 35.9% experienced a recurrence. Local regional recurrences explained 62.5% to 85.5% of the recurrences. Even after elective node dissections, local regional recurrences explained most relapses (58.1%). Sixty-five percent of the recurrences occurred within the first 3 years of of follow-up. There was a pronounced difference in 5-year survival in those patients who suffered a recurrence sometime during their clinical course compared with those who never relapsed (p = 0.00001, for trunk primary melanoma). Patients with local or regional recurrence have a better prognosis than patients who relapse systemically, with 5-year survivals from the time of recurrence of 55% for a patient with a local recurrence, 51% for a patient with a regional nodal recurrence, and 20% for a patient with a systemic recurrence. A multivariate regression analysis identified thickness, ulceration of the primary melanoma, and age and location of the primary melanoma on the extremity as variables that predicted prognosis. The only factors concerning the recurrent state that added prognostic information was the disease-free interval and the presence of systemic metastases as the initial recurrence.

Adolescent↗
PubMed1998

Treating recurrence of parotid benign pleomorphic adenomas.

Treatment for recurrence after surgical removal of parotid benign pleomorphic adenoma (PBPA) has not been well defined and is often followed by further recurrence. Surgery is overwhelmingly the most common approach. The risk of facial nerve injury is greater at reoperation since the nerve is less well defined. The value of radiation therapy (RT) has not been determined and incurs with it the risk of possible late occurrence of malignancy or nerve damage. The charts of patients with recurrent PBPA treated consecutively by a single surgeon from 1965 to 1993 were reviewed. All patients had a histopathologically verified diagnosis of PBPA both at the time of primary and subsequent surgeries. Follow-up was obtained from clinical charts and correspondence communication. Recurrence curves were generated using the Kaplan-Meier method. Thirty-nine patients with recurrent PBPA (36 referred and 3 treated primarily at Mayo) were evaluated. The patients were classified according to the type of surgery: 14 patients had previously undergone some form of parotidectomy or had only resection of the tumor for recurrence, and 25 patients underwent parotidectomy since this had not been performed primarily. The mean age in the two groups was 49 and 50 years respectively. The mean follow-up was 10 years after the recurrence treatment. The mean time between initial resection and recurrence in the two groups was 14 and 15 years. The mean time between the recurrence treatment and a second recurrence was 7.5 years. Nine patients had RT in addition to the local resection. Of this group 3 patients (33%) developed another recurrence. Five patients had local resection only, and of this group 1 patient (20%) developed another recurrence. Of the group that had superficial parotidectomy, 3 patients had additional RT and one of these patients (33%) developed another recurrence. Twenty-two patients had superficial parotidectomy only, and of this group 3 patients (14%) developed another recurrence. Only 2 of the 39 patients had complications. One patient developed Frey's syndrome after superficial parotidectomy and 1 patient developed facial paralysis after RT. As in other series, the number of patients is inadequate to allow for firm conclusions. However, it appears that when previous parotidectomy has been performed, simple excision with a margin of surrounding tissue would seem appropriate. Parotidectomy should be carried out if not performed previously. In simple excision after previous parotidectomy, there is a greater risk to the facial nerve because of difficulty in distinguishing the facial nerve from surrounding scar tissue. Our preference is to use general anesthesia so that branches of the nerve are not paralyzed and stimulation of the nerve aids in safe dissection. The value of RT is still indeterminate.

Adenoma, Pleomorphic↗
PubMed1998

Tumor recurrence in stage I ovarian serous neoplasms of low malignant potential.

Eleven patients treated at the University of Texas M. D. Anderson Cancer Center for recurrent disease after resection of a stage I ovarian serous neoplasm of low malignant potential (SNLMP) are reported. At the time of diagnosis, the age of the patients ranged from 26 to 43 years (mean 33). Seven patients had stage IB tumors and 4 had stage IA tumors. All patients were treated with a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The size of the ovarian tumors ranged from 4 to 15 cm in maximum dimension. Stromal microinvasion was seen in 2 cases, and foci of endosalpingiosis were seen in the peritoneum in 8 cases. Nine patients were treated with radiotherapy and 2 with chemotherapy. The time to recurrent disease ranged from 7 to 39 years (mean 16). Eight tumors recurred in the pelvis or abdomen, 2 in the neck with subsequent abdominal involvement, and 1 in the pleura without abdominal or pelvic involvement. In 10 cases, the recurrent tumors were serous carcinoma, and in 1 case it was a SNLMP. Recurrences were treated with chemotherapy in 10 cases and with hormones in 1 case. Seven patients died of progressive serous carcinoma 2 to 5 years after the recurrence. One patient died of leukemia with recurrent ovarian tumor 10 years after the recurrence was detected. Two patients are alive with progressive disease 1 and 7 years after the recurrence, and 1 patient whose disease recurred as a SNLMP is alive with no evidence of disease 9 years after the recurrence. These 11 patients were compared with 16 patients who had stage I ovarian SNLMPs that did not recur after a minimum follow-up of 15 years. There was no difference in the age of the patients, gravidity, size of the tumors, or several microscopic parameters, including degree of epithelial proliferation, number of mitoses, and nuclear atypia. Microinvasion was found in one case. The only significant difference between the two groups was the low frequency of endosalpingiosis in the cases that had no disease recurrences (12.5% versus 72.7%). In summary, we found no clinical or pathologic features that can unequivocally predict the recurrence of stage I ovarian SNLMPs. Because of the long interval to recurrence, the fact that the recurrent tumors in 10 of 11 patients were serous carcinomas, and the result of the X-chromosome inactivation in one case, the recurrent tumors could represent independent primaries or a slow progression of one clone present in the SNLMPs.

Adult↗
PubMed1997

Recurrence of type I membranoproliferative glomerulonephritis after renal transplantation: analysis of the incidence, risk factors, and impact on graft survival.

BACKGROUND: The information in the medical literature on the incidence of recurrence of type I membranoproliferative glomerulonephritis (MPGN) after renal transplantation and its impact on graft survival is limited because most data are derived from case reports or from studies involving a small number of patients. METHODS: We analyzed the data from our transplant center. Among 1097 adult patients receiving their first allograft between 1977 and 1994, we identified 32 patients with type I MPGN. RESULTS: A recurrence was detected in 9 of the 27 recipients of a first cadaveric graft (33%). The cumulative incidence reached 48% at 4 years after transplantation when patients with graft failure from other causes were censored. All patients with recurrent MPGN had clinically significant proteinuria (>1 g/24 hr) that was first observed at a median time of 20 months (range, 1.5-42 months) after transplantation. Graft survival was significantly worse in patients with recurrence as compared with patients without recurrence. Mean duration of graft survival after the diagnosis of recurrence was 40 months. We could not detect any clinical characteristics of patients or donors that were associated with recurrent disease. However, an increased risk of recurrence was observed in patients with the HLA haplotype B8DR3. Four patients received an HLA-identical graft from a living related donor. Recurrence occurred in three patients (75%), with ensuing graft loss in two. The only patient with a haploidentical living related graft did not have a recurrence. Five patients with a recurrence in the first graft received a second transplant. Recurrence was observed in four of these patients (80%). CONCLUSIONS: Type I MPGN recurred after renal transplantation in half of the patients. The incidence may be even higher in recipients of an identical living related donor graft and in patients receiving a second transplant after having experienced a recurrence in their first graft. Recurrence of type I MPGN has a detrimental effect on graft survival.

Adult↗
PubMed2006

Breast cancer local recurrence after mastectomy and TRAM flap reconstruction: incidence and treatment options.

BACKGROUND: The transverse rectus abdominis musculocutaneous (TRAM) flap is the standard in autologous breast reconstruction. The management of local recurrence of breast cancer after TRAM flap breast reconstruction has not been well described. The purpose of this study was to examine the incidence of local recurrence of breast cancer after TRAM flap breast reconstruction, evaluate treatment modalities, and determine outcomes in such cases. METHODS: A retrospective review was conducted of all patients who underwent immediate breast reconstruction with a free or pedicled TRAM flap over a 15-year period. Those patients who experienced local breast cancer recurrence were identified. A subset of complete skin-sparing mastectomy patients was also identified for review. RESULTS: From 1987 to 2002, 419 TRAM flap breast reconstructions were performed in 395 patients. Thirty-four (9 percent) were complete skin-sparing mastectomy using a periareolar mastectomy incision only. The mean follow-up time in this study was 4.9 years (range, 1 to 14.7 years). Local recurrence occurred in 16 of 419 patients (3.8 percent), with a mean time to local recurrence of 1.6 years (range, 0.2 to 7.0 years). There were no local recurrences seen in patients following complete skin-sparing mastectomy. Treatment of local recurrence included excision, chemotherapy, radiotherapy, and bone marrow transplant. Only three of the 16 patients (19 percent) required removal of the entire TRAM flap to manage local breast cancer recurrence. Nine of 16 patients (56 percent) with local recurrence died of disease at a mean of 1.2 years after the development of recurrence. CONCLUSION: Long-term follow-up demonstrated a local recurrence rate after TRAM flap breast reconstruction similar to that reported in the literature. Local recurrence was effectively managed with surgical excision of the involved tissues, chemotherapy, and/or radiation therapy. Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or involvement of the flap pedicle with disease. The risk of local recurrence was not increased following complete skin-sparing mastectomy.

Adult↗
PubMed2006

Early and late recurrence after liver resection for hepatocellular carcinoma: prognostic and therapeutic implications.

OBJECTIVE: To evaluate the predictive factors, the therapy, and the prognosis of intrahepatic recurrence (IR) after surgery for hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: The predictive factors of IR are debated. To class the recurrence according to the modality of presentation may help to find a correlation and to select the right therapy for the recurrence. METHODS: A total of 213 patients were evaluated. Risk factors for recurrence were related to time (<2 years and >2 years) and type of presentation (marginal, nodular, and diffuse). Prognosis and therapy for the recurrence were studied in each group of patients. RESULTS: IR was observed in 143 patients; 109 were early (group 1) and 34 late recurrences (group 2). Cirrhosis, chronic active hepatitis (CAH) and HCV positivity were independently related to the risk of recurrence with a cumulative effect (92.5% of recurrences in patients with 3 prognostic factors). For group 1, the neoplastic vascular infiltration together with cirrhosis, HCV positivity, CAH, and transaminases were significant; all the 11 patients with 5 negative prognostic factors showed an early recurrence. On the contrary, only cirrhosis was related to a late recurrence. Survival rate was significantly better in late than in early recurrence (61.9%, 27.1% and 25.7%, 4.5% at 3-5 years); a curative procedure was performed in 67.6% in group 1 and 29.3% in group 2. After a radical treatment of IR, the survival was comparable with the group of patients without recurrence. CONCLUSIONS: Early and late recurrences are linked to different predictive factors. The modality of presentation of the recurrence together with the feasibility of a radical treatment are the best determinants for the prognosis.

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