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Rectal cancer should no longer be thought of as only a surgically treated disease. Centers that treat large numbers of rectal cancer patients should provide state of the art radiotherapy and chemotherapy as well as offer anatomic tumor-specific operations for advanced-stage cancers and local treatment options for favorable, early lesions.
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OBJECTIVES: To evaluate positron emission tomography with C11-acetate as a method for detecting and localizing prostate cancer recurrence. No technique for localizing and detecting prostate cancer recurrence after biochemical relapse available today is sensitive enough to localize recurrence at a stage at which salvage radiotherapy is still curative. METHODS: Twenty patients (age 56 to 77 years) who had undergone radical prostatectomy and had an increasing prostate-specific antigen level measured on two consecutive occasions were included. In addition to the investigations usually performed when prostate cancer recurrence is suspected, they underwent positron emission tomography with C11-acetate as the marker. RESULTS: Pathologic uptake of acetate was seen in 15 (75%) of the 20 patients. In 8 of these patients, a solitary lesion was found (seven in the prostatic fossa and one at the regional lymph nodes). Multiple lesions were found in the remaining 7. False-positive uptake was seen in 3 men (15%). Additional investigations in these men revealed pathologic findings other than prostate cancer. CONCLUSIONS: Positron emission tomography with C11-acetate as marker is a promising method for early detection and localization of prostate cancer recurrence. False-positive uptake does occur.
BACKGROUND: The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone. METHODS: Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression. RESULTS: Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised. CONCLUSION: Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.
Thirty-eight patients with locally recurrent soft-tissue sarcomas of various histologic types and grades but with no evidence of distant metastases were studied. Twenty-five patients had more than one local recurrence. Most primary lesions had been initially treated by simple or "wide local" excision with removal of little or no surrounding normal tissue. The most common site for recurrence was the extremity. Sixteen patients received preoperative intra-arterial Adriamycin (30 mg/day X three days) and radiation therapy (3500 R over ten days) followed by wide resection of the recurrence and the previous operative field. Tumor-free margins were confirmed microscopically. There were no subsequent local recurrences in this group. In five patients, no preoperative therapy was used, and the resection was incomplete because of proximity to vital structures. In these patients, postoperative radiation therapy and chemotherapy could not prevent continued local tumor progression. Amputation for control of local recurrence was necessary in only three patients. the remaining patients underwent either resection alone or resection in combination with postoperative radiation and/or chemotherapy. Life-table analysis of these 38 patients shows an unexpectedly high predicted five-year survival of 76% (87% for patients whose local recurrence could be completely resected). This high salvage rate clearly justifies aggressive treatment of patients with local recurrences alone and warrants attempts to salvage functional extremities.
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.
OBJECTIVE: After radical retropubic prostatectomy a rise of the prostate-specific antigen (PSA) indicates a local recurrent or metastatic disease. If the bone scan shows no apparent bone metastasis, morphological imaging methods like x-ray computed tomography, magnetic resonance imaging or transrectal ultrasound often cannot distinguish between postoperative scar and local recurrence. Therefore we investigated the feasibility of fluorine-18-fluorodeoxyglucose positron emission tomography (F-18 FDG PET) for metabolic characterization of prostatic cancer, especially for differentiation of scar or recurrent prostate cancer after radical prostatectomy. METHODS: Dynamic PET with 370 MBq F-18 deoxyglucose (F-18 FDG) up to 60 min p.i. was performed in 2 patients with biopsy-proven benign prostatic hyperplasia, in 11 patients with a histologically proven prostate cancer prior to radical retropubic prostatectomy (RRP) and 7 patients with suspected local recurrence (with negative bone scan) after RRP prior to biopsy of anastomosis (3 local recurrence, 4 postoperative scar). RESULTS: Prostate cancer showed a very low F-18 FDG uptake. The placement of regions of interest was only possible by the use of other imaging methods. There was not difference between the F-18 FDG uptake of benign prostate hyperplasia, prostate carcinoma, postoperative scar or local recurrence after radical prostatectomy. CONCLUSION: F-18 FDG seems not to be useful to distinguish between postoperative scar and local recurrence after radical prostatectomy.
122 patients with prostatic carcinoma treated by radiation therapy were reviewed. An actuarial analysis was done on survival comparing patients treated by transurethral resection (TURP) prior to radiation to those diagnosed by needle biopsy. Survival rates were not significantly different between groups. TURP was also without effect on interval free of distant or local recurrence. Survival and time to distant or local recurrence were analyzed by tumor stage and grade. A multivariate analysis with the Cox model was made by which the effects of TURP and tumor grade and stage were examined simultaneously. TURP was without effect on survival rates and interval to distant or local recurrence after adjustments had been made for the effects of stage and grade.
BACKGROUND: We aimed to determine the outcome of resections for local recurrence of colorectal carcinoma in the presence of distant (M1) disease. METHODS: Patients who underwent resection of local recurrence in the presence of potentially resectable M1 disease were identified from the colorectal database. Outcome was determined by chart review. RESULTS: Forty-two patients (23 men) of mean age 60 years (range, 34-88 years) underwent complete gross resection of their local recurrence in the presence of M1 disease. Thirteen of the 42 underwent synchronous M1 resections to render them free of gross disease (R0). Nine of the 29 patients who left with residual disease (R1) subsequently underwent staged M1 resection, so that 22 of 42 were rendered R0 by surgery. The median survival of all patients was 14.5 months (interquartile range, 6-30 months), and that of patients rendered R0 was 23 months (interquartile range, 10-37 months), in comparison with 7 months (interquartile range, 3-25 months) for those of R1 status (P =.006; log-rank method). Ability to achieve R0 status by synchronous or staged resection was the only factor predictive of survival. CONCLUSIONS: The presence of M1 disease per se should not preclude resection of local recurrence, although case selection is problematic.
We reviewed 129 patients with subcutaneous sarcoma diagnosed from 1964 to the end of 1985 in a population-based series of sarcoma cases from southern Sweden. The annual incidence was 0.4 per 100,000, comprising 32% of all soft-tissue sarcomas of the extremities or the trunk wall. Compared to deep-seated sarcomas, subcutaneous tumours were half the size at diagnosis, more common in the lower leg and foot, more often malignant fibrous histiocytoma, and of a lower grade of malignancy. None of the low-grade and only 7% of the high-grade tumours recurred locally after wide local excision without radiotherapy. The cumulative five-year survival for all 129 patients was 80%. Multivariate analysis identified only high grade of malignancy and the size of the tumour (greater than 5 cm) as independent prognostic factors. We conclude that systemic or local adjuvant therapy is not generally indicated for subcutaneous sarcoma because of the good prognosis and low local recurrence rate after wide excision.
The incidence of local recurrence and cumulative survival rate were compared for two groups of patients with stage I malignant melanoma of the lower leg. Group 1 included 119 patients treated from 1964 to 1978 with a wide local excision extending to the ankle. Group 2 included 58 patients treated from 1978 to 1981 with a 5 cm incision margin in all directions. Lesions within both groups were comparable based on measurements of tumor thickness. However, level of invasion indicated significantly more advanced lesions in the first group. Risk of local recurrence was related to thickness and ulceration. There were no statistically significant differences in frequency of local recurrences or cumulative survival rates between the two groups.
Local recurrence of colorectal cancer after curative surgery is a major clinical problem. The aim of our study was to present our experience in this field. Between January 1990 and December 2000, 572 patients underwent resection for colorectal cancer in our department; 66 of them had local recurrence within the first 2 years. Most of those patients had Dukes' stage B (n = 24) or stage C (n = 37) tumors, which were located mainly in the rectum (n = 40) and sigmoid colon (n = 18). The incidence of local recurrence was 11% and 15.9% for tumors that were Dukes' stages B and C, respectively. Thirty-five of 66 patients received palliative treatment, and 28 of them died within 9 months. The remaining 31 patients underwent radical excision of the recurrent tumor: 11 of these patients died within 2 years, and 20 were still alive after 30 months. The only hope for long-term survival for patients presenting with local recurrence from colorectal cancer after primary radical treatment is to identify local recurrence at an early stage and treat it in a radical manner.
The aim of this study was to evaluate both the risk factors of local recurrence and the prognostic significance of local recurrence in relation to surgical treatment and/or radiation therapy of breast cancer. A total of 1574 primary breast cancer patients, undergoing surgical treatment and/or radiation therapy between 1980 and 2001, were included in this study. Radical mastectomy was performed in 1144 patients, subcutaneous mastectomy in 141 and breast-conserving therapy in 289. The clinical stage was significantly earlier in the subcutaneous mastectomy and breast-conserving therapy groups than in the radical mastectomy group. A positive surgical margin was observed in 9 (6.4%) out of 141 patients in the subcutaneous mastectomy group and 51 (176%) out of 289 in the breast-conserving therapy group. Local recurrence occurred more frequently in the subcutaneous mastectomy and breast-conserving therapy groups than in the radical mastectomy group. Independent prognostic factors in local recurrence were lymph node metastasis in the radical mastectomy group, and surgical margin in the subcutaneous mastectomy group and the breast-conserving therapy group. Independent prognostic factors in overall survival were local recurrence, lymph node metastasis and estrogen receptor status in the radical mastectomy group, and lymph node metastasis and estrogen receptor status in the breast-conserving therapy group. In conclusion, the surgical margin status is an important factor in the risk of local recurrence in patients who have undergone a subcutaneous mastectomy or breast-conserving therapy. The significance of local recurrence for overall survival may be different among these three treatments.
Abdominoperineal resections for rectal cancer are being performed with decreasing frequency in favour of sphincter-saving resections. It remains to be demonstrated that sphincter preservation has not resulted in compromised local disease control, disease-free survival and survival. For this purpose 315 patients with rectal carcinoma have been studied. In 44 cases (13.9%) it was only possible to perform a colostomy; a curative resection has been carried out in 206 (65.3%). Sphincter-saving procedure was performed whenever possible: the length of margin of resection was at least 2 cm. The operation were: 61 abdominoperineal excisions (AP), 135 anterior resections (AR), 10 transanal excisions (excluded from this analysis). The distribution of tumors in the various Duke's stages was: Dukes A--28 patients, Dukes B--143, Dukes C--35. The thirty-days mortality was 6 patients (9.8%) for AP and 6 (4.4%) for AR. Local recurrence was: AP 9 cases (16.1%), AR 16 cases (12.4%); for tumors 4-8 cm from anal verge recurrence was 18.7% for AP, 17.1% for AR. Concerning staging, local recurrence was more common in the Dukes C stage (36%) than in the Dukes B (11.2%) or in the Dukes A (3.7%). 5 years survival after AP was 54.6 percent and after AR 57.9 percent. Concluding, in our experience, there was no significant relationship between local recurrence or survival and type of curative surgery (AP or AR). Local recurrence and survival were only related to tumor stage (p less than 0.01): lateral tumor extension in these advanced and aggressive lesions appears to be the major determinant of local recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)
The sensitivity of immunoscintigraphy (ISC) with monoclonal antibodies (Mab) depends on the Mab type, the radiophysical properties of the isotope, the labeling method and the tumor localization. We investigated 38 studies with three different Anti-CEA Mab (In111/I131 BW 431, n = 12; I131 IMACIS-1, n = 11; Tc99m BW 431/26, n = 15) in 35 postoperative tumor patients (31 colorectal, 1 gastric, 2 breast and 1 pancreas cancer) with a total of 62 tumor manifestations. Planar ISC was used in all studies. A dual isotope technique with Tc99m-colloid was applied for imaging of liver metastases in the In111/I131 BW 431/31 and I131 IMACIS-1 studies. Whereas the global sensitivity, ranging from 64-73%, was comparable, the different physiological properties of the Mab preparations caused marked differences in the imaging capabilities of certain tumor localizations, especially in the liver. All Mab underestimated the extent of liver involvement, however, the highest regional sensitivity (75%) was found with the I131 IMACIS-1. In contrast, Mab with the highest physiological liver uptake (In111 BW 431/31, Tc99m BW 431/26) imaged liver metastases in most cases unspecifically as cold spot, yielding a sensitivity of 0-9%. No differences between the Mab were seen in the regional sensitivity with respect to lung metastases, which ranged between 33-40%. All tested Mab showed a high sensitivity in imaging local recurrences ranging between 50% for the I131 IMACIS-1 and 100% for the Tc99m BW 431/26. We conclude, that in postoperative tumor patients anti-CEA ISC with Tc99m BW 431/26 is the method of choice for the detection of local recurrences.(ABSTRACT TRUNCATED AT 250 WORDS)
The efficacy of radiotherapy of renal cell carcinomas is limited by its side effects. To avoid gastrointestinal problems the dose must not exceed 45 Gy, but with corresponding protocols no effect has been seen in curative and adjuvant trials. A new three-step protocol combining surgery with intraoperative radiotherapy focussed on the tumor bed fading out the intestine (IORT) and external boost radiotherapy (40 Gy) was used in six patients with local recurrences after tumor nephrectomy. No increase in morbidity was induced by IORT. One year after radiotherapy no recurrences have been seen in the radiation field. We recommend this protocol for patients with solitary local recurrences and for tumors of clinical stage T3 and T4.
The imaging techniques used to follow-up patients submitted to surgery for colorectal cancers are presented as are their advantages and disadvantages. The sensitivity of ultrasonography (US) for postoperative surveillance of the liver varies considerably according to whether the absence or presence of metastases is sought (83%) or their exact number (53-82%). US is recommended by French clinicians as the standard follow-up examination whereas, American clinicians tend to discuss CT-Scan or MRI for the same purpose. Some authors advocate Doppler ultrasonography for the detection of liver metastases. Spiral CT-Scan offers better results than conventional CT and is now considered second in rank to US for follow-up studies. Its sensitivity exceeds 90% for metastases greater than 1 cm. IRM and arterial CT-scan are not applicable for follow-up but are sometimes indicated for difficult cases before hepatectomy. US is also an appropriate technique for postoperative exploration of the abdominal cavity. When the CEA level and the US examination are normal, this technique is sufficient. However, in dubious clinical or biological cases, US should be associated with a spiral CT-Scan. Most clinicians recommend a reference CT-Scan, two to four months after the resection and every 6 months for 2 years and then annually. The same follow-up strategy is advocated after abdominoperineal resection and for surveillance of the pelvis. The sensitivity of CT-Scan is between 69 and 88% but it is unable to differentiate recurrence from fibrosis. IRM, with a sensitivity of 90%, is the best method for overcoming with problems related to the differential diagnosis and particularly novel fast acquisition imaging and contrast agents. Ultrasonoendoscopy, repeated every 4 to 6 months after anterior resection, is also a useful examination for surveillance of the pelvis. PET-Scan has produced encouraging results for the detection of metastases and for the differential diagnosis between local recurrence and fibrosis. When available, this technique could become the "gold standard" for the surveillance of patients following surgery for colorectal cancers.
BACKGROUND: Local excision for T1 rectal cancers with Transanal Endoscopic Microsurgery (TEM) is an accepted standard of care. However for T2/T3 rectal cancers, the high local failure indicates that this is not a valid option. MATERIALS AND METHODS: Between 1990 and 2000, 83 patients with rectal adenocarcinoma underwent complete full thickness local excision. The mean diameter of the tumor was 3.4+/-1.7 cm, 60% were located more than 5 cm from the anal verge; 43% of patients received radiation therapy (26 pre- and 10 postoperatively). RESULTS: Postoperative complications occurred in 15 patients (18%); there were no postoperative deaths. Mean follow-up was 37 months (range 18-118). The pathological stage was: Tis 9, T1 39, T2 23, T3 12. The overall local recurrence rate was 0% for Tis, 13% for T1, 17% for T2 and 50% for T3. Recurrence was managed surgically in 65% and nonsurgically in 35% because of advanced disease or poor general condition. Overall 5-year survival rates were 100%, 92%, 75% and 69% for Tis, T1, T2 and T3, respectively. CONCLUSION: Local excision with TEM is effective for early (Tis, T1) rectal cancers. Patients with T2 tumors can be treated with preoperative chemoradiation and subsequently local resection. Patients with T3 should not be treated with local excision unless they are unable to tolerate more extensive surgery.