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PubMed2003

Intraoperative radiotherapy in the multimodality approach to colorectal cancer.

The addition of intraoperative radiotherapy (IORT) to the multimodality approach for the treatment of locally advanced and locally recurrent colorectal cancer seems to result in improvements in local control and long-term survival. Local control and survival are most likely in patients in whom a gross total resection is accomplished. Peripheral nerve is the dose-limiting structure for patients treated with IORT. Further improvements in local control require the addition of dose modifiers during external beam radiotherapy or IORT. Distant relapse remains problematic, and effective systemic therapy is necessary to significantly improve long-term survival.

Colectomy↗

PubMed2001

Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ.

BACKGROUND: Breast conserving surgery (BCS) is common practice for unifocal ductal carcinoma in situ (DCIS) less than 4 cm in size, but the extent of tumor free margin width around DCIS necessary to minimize recurrence is unclear. METHODS: Clinical and pathologic details were recorded from all patients with pure DCIS < 4 cm in size, treated with BCS between 1978 and 1997. Histologic margins were measured by using an ocular micrometer. Patients with clear margins (> 1 mm) were divided up into 3 groups for analysis based on margin of normal tissue excised: 1.1-5 mm, 5.1-10 mm, and 10.1-40 mm. RESULTS: There were 66 patients with close margins (< or = 1 mm), of which 25 cases (37.9%) recurred. The recurrence rates for the 3 clear margin groups ranged from 4.5-7.1%. Median followup was 47 months (range 12-197 mos). Risk of recurrence in the group with close margins was greater than the subgroups with clear margins (P < 0.001); no differences in recurrence was seen between the individual subgroups with clear margins. Nuclear Grade 3 was predictive of recurrence (P = 0.03). Following excision alone, the recurrence rate was 18.6%, compared with 11.1% when radiotherapy was given as adjuvant therapy. Women with clear margins following excision had a recurrence rate of only 8.1%. CONCLUSION: After BCS for DCIS, close margins were associated with a high risk of local recurrence. Radiotherapy did not compensate for inadequate surgical clearance.

Adult↗

PubMed1995

Prevention of local recurrence by extended lymphadenectomy for rectal cancer.

This study was undertaken to determine if the degree of lymphadenectomy correlates with the prevention of local recurrence. The authors retrospectively reviewed the clinical data of 269 patients who underwent curative surgery for rectal cancer. The study was divided into three periods based on the method of lymphadenectomy as follows: period I (1963-1979) when extended lymphadenectomy was not performed; period II (1980-1985) when this was partially done with no attempt to dissect the obturator and proximal middle rectal lymph nodes; and period III (1986-1990) when this was completely performed for patients with appropriate indications. The local recurrence rates were 21%, 10%, and 8% for Periods I, II, and III, respectively (P < 0.05). The incidence of local recurrence tended to be greater in period I versus periods II and III according to type of operation, location, and stage of the primary tumors. The local recurrence rates arising from lateral node metastases were 11%, 4%, and 2% for periods I, II, and III, respectively (P < 0.05), while the incidence related to an insufficient surgical margin was approximately 5% throughout the three periods. We thus conclude that the degree of lymphadenectomy is a major determinant of local recurrence following a curative operation for rectal cancer.

Adult↗

PubMed1997

Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis.

PURPOSE: This study was designed to evaluate the frequency of microscopic distal intramural spread in rectal adenocarcinoma and its correlation to other histopathologic prognostic factors. METHODS: We examined 55 patients with adenocarcinomas of the lower one-third of the rectum and measured the extent of distal intramural spread in the submucosa and/or muscular layer in comparison with Dukes Stage, diameter of tumor, distance of distal margin of resection from tumor, depth of infiltration into perirectal adipose tissue, nodal status, neoplastic infiltration of lymphatic vessels, blood vessels, and nervous branches. RESULTS: Distal intramural spread was found in 40 percent of patients, 77 percent of whom had advanced tumors with nodal metastases. Distal intramural spread appeared to be strictly related to tumor size (superior to 40 mm), infiltration of the perirectal adipose tissue, multiple positive lymph nodes, presence of neoplastic emboli in the intramural lymphatic vessels, and neoplastic invasion of the nervous branches. Local recurrence occurred in one Dukes Stage B patient with a positive distal margin of resection and in four patients with a negative distal margin of resection: three Dukes Stage C and one Dukes Stage B patients with neoplastic involvement of the circumferential margin of resection of the mesorectum. CONCLUSION: These preliminary data suggest that distal intramural spread may carry little importance in determining local recurrence of rectal adenocarcinoma.

Adenocarcinoma↗

PubMed2005

Detection of residual tumor after radiofrequency ablation of liver metastasis with dual-modality PET/CT: initial results.

The aim of this study was to determine the accuracy of dual-modality positron emission tomography(PET)/computed tomography (CT) in the detection of residual tumor after radiofrequency ablation (RFA) of liver metastasis of colorectal cancer. Eleven patients with 16 hepatic metastases (mean size 2.9 cm) from colorectal cancer were enrolled in this study, and 19 RFA procedures and 32 PET/CT examinations were performed. The patients had PET/CT before and after RFA using [18F]-2-fluoro-2-deoxy-D: -glucose. CT images alone were read by two radiologists, PET images alone were evaluated by two nuclear physicians. Fused images were read by one physician of each speciality in consensus. The accuracy for detection of residual tumor by the different imaging modalities following RFA was assessed. Eleven patients with a mean age of 63 (range 55-71) years were evaluated. The mean follow-up period was 393 days. The overall procedure-based sensitivity for detection of residual tumor was 65% for PET and PET/CT and 44% for CT alone. The accuracies were 68% and 47%, respectively. Four patients had residual tumor after RFA, six patients total developed local recurrence. PET/CT therefore possibly proved superior to CT alone when assessing the liver for residual tumor after RFA.

Aged↗

PubMed2004

Surgical treatment of locally recurrent rectal cancer.

BACKGROUND: The aim of our study was to analyse data of patients treated by salvage surgery for locally recurrent rectal cancer, with emphasis on the question whether salvage surgery is still worthwhile when adjuvant radiotherapy is no longer a treatment option. METHODS: Forty patients (19 males/21 females) treated by surgery with curative intent for locally recurrent rectal carcinoma were analysed. Local recurrence was defined as cancer recurrence within the lower pelvis. Salvage surgery included abdominoperineal resection, abdominosacral resection, exenteration (posterior or total) and local resection. Clinical and pathological factors were analysed to identify prognostic factors for survival. RESULTS: The median overall survival was 25 months (95% CI: 13-37 months) and 5-year survival was 28% (95% CI: 12-45%). The absence of symptoms at the time of recurrence, central localisation and the absence of microscopic involvement of surgical margins, but not additional radiotherapy, were found to be significant independent prognostic factors for better survival after salvage surgery. CONCLUSION: Salvage surgery, alone or in combination with radiotherapy, can achieve radical resection of locally recurrent rectal cancer and can result in long-term survival.

Adenocarcinoma↗

PubMed2000

Local and distant failures after limited surgery with positive margins and radiotherapy for node-negative breast cancer.

PURPOSE: To determine the outcome of patients with positive margins after lumpectomy for breast cancer and to address the issue of the relationship between local recurrences and distant metastasis in the absence of chemotherapy. METHODS AND MATERIALS: Among 3697 patients with primary breast cancer, we retrospectively analyzed 152 patients who had undergone conservative surgery with axillary dissection, had infiltrating carcinomas with positive margins, were node-negative, and received radiotherapy without chemotherapy. One-third received hormonal therapy. Endpoints were local failure and distant metastasis. Median follow-up was 72 months. RESULTS: Five- and 10-year recurrence-free survival were 0.80 and 0.71 respectively for local recurrences, and 0.85 and 0.73 respectively for metastasis. Infiltrating carcinoma on the margins was associated with early local relapse as opposed to intraductal carcinoma. Local and distant recurrences had similar patterns of yearly-event probabilities. Hazard of relapsing from metastasis was 2.5 times higher after a local recurrence. In the multivariate analysis, negative estrogen receptors (ER-)(p = 0.0012), histologic multifocality (p = 0.0028), and no hormonal therapy (p = 0.017) predicted local relapses, while ER- (p = 0.004) and pathologic grade (p = 0.009) predicted metastasis. Hormonal therapy did not prevent early local recurrences. CONCLUSION: In this population, reexcision is advisable for local purposes and because the data support the hypothesis that local and distant recurrences are tightly connected.

Adult↗

PubMed1986

Effects of postoperative mediastinal radiation on completely resected stage II and stage III epidermoid cancer of the lung.

We randomly assigned 230 patients with resected Stage II or III epidermoid (squamous-cell) lung cancer to receive postoperative adjuvant radiotherapy or no adjuvant treatment. Careful intraoperative staging had been performed in all patients. Before randomization, patients were stratified according to stage, weight loss, age, and institution. Prognostic variables, such as stage, weight loss, age, nodal-disease status, and tumor status, were equally distributed between the two groups. The mean time from randomization to analysis was 3.5 years among the 210 eligible patients. There was no evidence that radiotherapy improved survival, and although recurrence rates appeared to be somewhat reduced among patients assigned to radiotherapy, these decreases were not statistically significant. However, radiotherapy did produce a striking and significant reduction in recurrences to the ipsilateral lung and mediastinum. Moreover, overall recurrence rates were reduced by radiotherapy in patients with N2 disease (P less than 0.05), although even this subgroup had no evidence of improved survival. We conclude that radiotherapy can reduce local recurrences after resection of epidermoid carcinoma of the lung, but that it does not increase survival rates.

Carcinoma, Squamous Cell↗

PubMed2001

Intraarterial infusion chemotherapy and radiotherapy with or without surgery for patients with locally advanced or recurrent breast cancer.

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

Adult↗

PubMed1991

The role of multimodality therapy in soft-tissue sarcoma.

Soft-tissue sarcomas are uncommon malignancies. The development during a period of 8 years, in one institution, of a prospective data base incorporating more than 1600 patients with these tumors is described. The most common sites for occurrence are the extremities, but they can occur in any of the soft tissues of the body. Liposarcoma and leiomyosarcoma are the most common histopathologic conditions identified. Prognostic factors for both recurrence and survival include site, histopathology, size, grade, and adequacy of resection. A prospective randomized trial of the use of adjuvant radiation by the brachytherapy technique in extremity lesions has shown a decrease in local recurrence, but no impact on survival. Eligible patients not randomized to the trial show no difference in local recurrence or survival, regardless of whether they received adjuvant radiation.

Adolescent↗

PubMed1984

The relevance of internal mammary lymphoscintigraphy in the management of breast carcinoma.

The incidence, implications, and significance of an abnormal internal mammary lymphoscintigram (IML) in 981 breast carcinoma patients without histologic or clinical evidence of axillary metastases is reported. A 13%-16% incidence of parasternal abnormality in patients with early, operable disease correlates well with clinical data. The statistically significant increase, with P consistently less than or equal to 0.005, in incidence of local or distant relapse associated with an abnormal IML when compared to the normal IML emphasizes the value of the procedure as a marker. These results indicate that patients with negative axillae but an abnormal IML should be considered to have stage II disease and should be offered adjuvant therapy. The significance of the IML in determining the true extent of disease in patients with apparent local relapse as well as the prognostic implications of an abnormal IML in 311 patients seen initially with recurrent breast carcinoma is also reported.

Actuarial Analysis↗

PubMed1992

Refinement of clinicopathologic staging for localized soft tissue sarcoma of the extremity: a study of 423 adults.

PURPOSE: The prognostic value of factors used in clinicopathologic staging of localized soft tissue sarcoma (STS) of the extremity were analyzed comprehensively. PATIENTS AND METHODS: Four hundred twenty-three patients with STS that was confined to the extremity were admitted to Memorial Sloan-Kettering Cancer Center from 1968 to 1978. Cox models for the hazards rates of tumor mortality, development of a distant metastasis, strictly local recurrence, and postmetastasis survival were developed. Tests of changes in the prognostic value of the important variables over time were performed, as well as an analysis of the effect of a local recurrence on the hazard rate of distant metastasis. RESULTS: Three unfavorable characteristics contained independent prognostic value for the rates of distant metastasis and tumor mortality: high grade (P less than .00001), deep location (P less than .0002), and size greater than or equal to 5 cm (P less than .007). Their Cox model coefficients did not differ significantly (P greater than or equal to .65); thus, a staging scheme based on the risk of ever developing a distant metastasis would assign equal prognostic weights to grade, depth, and size. The tumor grade effect during the initial 18 months was much larger in magnitude than those for depth and size, and its effect disappeared beyond that time (P = .0003). Thus, a staging scheme based on the risk of early metastatic spread would assign a distinctly larger prognostic weight to grade and lesser but equal weights to depth and size. There was no local recurrence effect on the rate of distant metastasis in the high-risk group (high grade, deep, and greater than or equal to 5 cm; P = .75), but there was a significant association among the remaining groups combined (P = .0039). The magnitude of this association actually increased according to the number of favorable characteristics presented (P = .0024). CONCLUSIONS: The refinement of clinicopathologic staging may depend on the choice of outcome variable: ultimate prognosis versus early metastatic spread. Additionally, the observed local recurrence effect may be explained by a tendency for some patients to acquire one or more unfavorable risk factors at the time of local recurrence.

Adult↗

PubMed2000

Local recurrence after mastectomy or breast-conserving surgery and radiation.

Approximately 10% to 15% of patients with stage I/II invasive breast cancer will develop a clinically isolated local recurrence. The standard management of an ipsilateral breast tumor recurrence following breast-conserving surgery and radiation is salvage mastectomy, while local excision and radiation are optimal treatment of a chest wall recurrence following initial mastectomy. Although there are few data regarding the efficacy of systemic therapy after isolated local relapse, chemotherapy and/or hormonal therapy should be considered for most patients because of the high risk of subsequent distant relapse. However, local relapse does not always herald distant metastases. A prolonged interval between initial treatment and local recurrence is the most important prognostic factor for subsequent outcome, and when combined with other favorable characteristics, can predict 5-year survival rates of 70% or higher.

Breast Neoplasms↗

PubMed2004

Breast conservation therapy for invasive lobular carcinoma: the impact of lobular carcinoma in situ in the surgical specimen on local recurrence and axillary node status.

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

Adult↗

PubMedDate not supplied

[Breast-conserving surgery in breast cancer].

Breast-conserving surgery is the treatment of choice for the breast cancer T < 3 cm. The local recurrence is a problem of diagnosis and consequent treatment. We enrolled, from 1987 to 2004, 1504 breast cancer. In 803 (53.4%) tumor with T < 3 cm we performed conserving surgery. The sentinel lymph node (SN) technique induce to limit the axillary dissection in patients T1a-b to the SN only if non metastatic and located to the first level, the dissection of the 1st level of the axilla in patients T1c-T2 < 3 cm and SN negative, complete axillary dissection in patients with metastatic SN or located to the 2nd level. Our percentage of local recurrence in the follow-up was 3.5% at 5 years and 6% at 10 years.

Axilla↗

PubMed1989

[Deep rectal cancer: selection of surgical methods in relation to site and extension].

The procedure of choice for most pT1 and a few pT2 tumors in the lower-third of the rectum is excision or local endoscopic polypectomy. In 602 radically resected low rectal carcinomas, the local recurrence rate for LAR was 18% and for APE 17%. There was no difference in local recurrence for UICC stage I and II tumors with a small (less than or equal to 2 cm) versus a large (greater than or equal to 3 cm) distal margin. However, in UICC stage III B and III C there was a statistically significant difference between a small (56%) and a large (22%) distal margin for LAR, while the local recurrence was 29% for APE. LAR in stage III B + C should be performed only when a distal margin of 3 cm is guaranteed.

Follow-Up Studies↗

PubMed1989

Local recurrence after breast-conserving surgery and radiotherapy.

The time course and prognosis of local recurrence was studied for 1593 stage I-II patients treated by macroscopically complete excision of the primary tumor with or without axillary dissection, followed by megavoltage radiotherapy (mean tumor bed dose 78 Gy). The actuarial cumulative breast failure rate was 7% at 5, 14% at 10, 18% at 15 and 20% at 20 years. The proportion of recurrences occurring at a distance from the original tumor bed increased with time, most recurrences after 10 years being "new tumors". Of 178 breast recurrences observed, 159 (89%) were operable. Overall survival following operable relapse was 69% at 5 and 57% at 10 years. Prognosis after local failure depended both upon the disease-free interval and the extent of the recurrence. Late recurrences diagnosed after 5 years had an excellent outlook (5-year survival 84%). Small recurrences confined to the breast had a favorable prognosis, even if occurring before 5 years. Local control after salvage mastectomy (88% at 5 years) was better than after conservative salvage surgery. This extensive experience illustrates that recurrence in the breast after conservation therapy is characterized by a protracted course, and is not associated with the poor prognosis attributed to local relapse after mastectomy. The diagnosis and surgical treatment of mammary recurrence is an important component of the breast-conserving strategy.

Breast Neoplasms↗

PubMed1997

[Surgical and multimodal therapy of recurrent rectum carcinoma].

The following guidelines can be recommended for the treatment of recurrent rectal cancer: The therapeutical procedure depends on aetiology and shape of the recurrence. A surgical approach is worth striving for, if a R0-resection can be achieved. Multimodality therapy improves resectability and especially also the local recurrence free and overall survival time. Radiochemotherapy, possibly combined with hyperthermia or IORT are the most effective treatment strategies in combination with surgery.

Chemotherapy, Adjuvant↗