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PubMed2003

Salvage radiotherapy for biochemical recurrence after radical prostatectomy: a study of 62 patients.

OBJECTIVES: To determine the predictive factors of prostate-specific antigen (PSA) recurrence after salvage radiotherapy (RT) for biochemical recurrence following radical prostatectomy (RP) to identify patients who may benefit from this treatment. METHODS: From June 1992 to January 2002, 62 patients experiencing PSA recurrence after RP were treated with RT at a dose of 65 Gy. No patient received hormonal therapy. PSA recurrence after RT was defined as three consecutive increased PSA measurements. The risk of experiencing PSA recurrence after RT was analyzed according to 10 factors: patient age, pre-RP PSA level, pathologic stage, Gleason score, surgical margin status, PSA nadir after RP, time to PSA recurrence after RP, pre-RT PSA level, PSA nadir after RT, and length of follow-up after RT. RESULTS: With a mean follow-up of 44 months (range 3 to 110), 23 patients (37.1%) experienced PSA recurrence after RT. Using univariate analysis, six factors were found to be predictive of PSA recurrence after RT: the length of follow-up after RT (P <0.0001), PSA nadir after RP (P = 0.0004), time to PSA recurrence after RP (P = 0.003), pre-RP PSA level (P = 0.008), Gleason score (P = 0.011), and pre-RT PSA level (P = 0.028). Using multivariate analysis, only the Gleason score (P = 0.015) and length of follow-up after RT (P = 0.02) were found to be predictive of PSA recurrence after RT. A Gleason score greater than 7 was a significant predictor of PSA recurrence after salvage RT (P = 0.04). CONCLUSIONS: In our experience, the Gleason score and length of follow-up were the sole independent predictors of PSA recurrence after salvage RT. Our findings suggest that patients with a Gleason score of 7 or less are more likely to benefit from salvage RT after RP and that the durability of the PSA response may be only transient.

Adenocarcinoma↗
PubMed2006

Effect of patient's sex on risk of recurrent venous thromboembolism: a meta-analysis.

BACKGROUND: Individual risk of recurrent venous thromboembolism affects patient management and might differ between men and women. We did a meta-analysis to assess from available evidence whether men and women have the same risk of recurrent venous thromboembolism after stopping anticoagulant treatment. METHODS: Eligible articles were identified by searches of MEDLINE (source PubMed, 1966 to February 2005), EMBase (1980 to February 2005), and the Cochrane database 2005, issue 1. Prospective cohort studies and randomised trials were eligible if they included patients with objectively diagnosed venous thromboembolism treated for a minimum of 1 month and followed up for recurrence after anticoagulant treatment was stopped. Data were extracted for study design, study quality, and the number, sex, and age of enrolled patients, risk factors for venous thromboembolism, treatment given, duration of follow-up, and the number of episodes of recurrent venous thrombosis. FINDINGS: 15 studies (nine randomised controlled trials and six prospective observational studies) enrolling a total of 5416 individuals (2729 men), of whom 816 (523 men) had recurrent venous thromboembolism after stopping treatment, were eligible for inclusion. The pooled estimate of the relative risk (RR) of recurrent venous thromboembolism for men compared with for women was 1.6 (95% CI 1.2-2.0). Significant heterogeneity was shown among individual study findings; however, the higher risk of recurrent venous thromboembolism in men than in women was consistent across predefined subgroups. The relative risk for recurrence in men from randomised trials (RR 1.3; 95% CI 1.0-1.8) was lower than that from observational studies (2.1; 1.5-2.9). The lower risk of recurrent venous thromboembolism in women did not seem to be accounted for by a reduced rate of recurrence after venous thromboembolism associated with oestrogen treatment or pregnancy. INTERPRETATION: Men seem to have a 50% higher risk than women of recurrent venous thromboembolism after stopping anticoagulant treatment. If confirmed by further prospective studies, this difference in risk of recurrence should be considered when duration of anticoagulant treatment is determined in individual patients.

Aged↗
PubMed2003

Predictors of reexcision findings and recurrence after breast conservation.

PURPOSE: To identify predictors of reexcision findings and local recurrence in the setting of breast-conserving therapy with radiation. METHODS: The records of 535 patients who underwent breast-conserving surgery followed by radiation for Stage I or II cancer between 1972 and 1996 were reviewed. The mean follow-up period for surviving patients without evidence of recurrence is 6 years. Various clinical and pathologic prognostic factors were examined for significance with regard to reexcision findings and recurrence rates. Pathologic margin status was classified as negative, close (<or=2 mm), positive, or indeterminate. RESULTS: The pathologic margin status was the most important predictor of local recurrence. The freedom from local relapse (FFLR) at 6 years was 97% for patients with negative pathologic margins and 86% for all others (p < 0.0001). There was no significant difference in recurrence rates among patients with close, positive, or indeterminate margins. However, the use and sequencing of systemic therapy affected recurrence rates among these patients. For patients with close, positive, or indeterminate margins, the crude risk of local recurrence was 4% among patients who received tamoxifen or received chemotherapy integrated with or after radiation. The risk of local recurrence was 16-29% among the patients with close, positive, or indeterminate margins who did not receive systemic therapy or who received radiation after completion of chemotherapy. Local recurrence rates were low in patients with negative margins (2-8%) regardless of the use of systemic therapy or its timing. The presence or absence of residual disease at reexcision did not predict recurrence as long as the final margins were negative. Among patients who underwent reexcision before radiation, extensive intraductal component (EIC) (p = 0.0001) and young patient age (p = 0.03) were predictive of residual disease in the specimen. Patients with initially close margins and no EIC had a low risk of residual disease at the time of reexcision, as did patients older than age 65 without EIC. CONCLUSION: Pathologic margin status is the most important predictor of local recurrence after breast conservation with radiation. Patient age and EIC were significant predictors of residual disease at reexcision. The use and timing of systemic therapy appear to influence the risk of local recurrence in patients who do not have negative lumpectomy margins.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1998

Results and prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma.

PURPOSE: To review the results and evaluate the prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma. METHODS AND MATERIALS: We reviewed the records of 74 patients with locally recurrent nasopharyngeal carcinoma treated at the University of California, San Francisco between 1957 and 1995. The histologic types included squamous cell carcinoma in 6 (8.1%), nonkeratinizing carcinoma in 48 (64.9%), and undifferentiated carcinoma in 20 (27%) cases. The site of recurrence was in the primary in 46 (62.2%), in the neck nodes in 20 (27%), and in both sites in 8 (10.8%) patients. The recurrent disease was Stage I in 10 (13.5%), Stage II in 16 (21.6%), Stage III in 20 (27%), and Stage IV in 28 (37.9%) patients. Thirty-seven (50%) patients developed recurrence within 2 years and 58 (78.4%) within 5 years after initial treatment. Radiotherapeutic techniques used in the retreatment of primary recurrence consisted of external beam radiotherapy (EBRT), intracavitary brachytherapy, heavy-charged particle beam, and gamma knife, alone or in combination. Reirradiation doses ranged from 18 to 108 Gy, with a median dose of 60 Gy. Treatment of recurrent neck nodes consisted of radical neck dissection (RND) +/- intraoperative radiotherapy (IORT), or EBRT +/- hyperthermia, or chemotherapy +/- hyperthermia. Chemotherapy was used in 22 (30%) patients. Median follow-up was 20 months (range: 2 to 308 months). RESULTS: The 3-, 5-, and 10-year actuarial overall survival following retreatment were 49, 37, 18%, respectively. Thirty-six patients (49%) were free of further local-regional recurrence after retreatment. The 3-, 5-, and 10-year local-regional progression-free rates were 52, 40, and 38%, respectively. On univariate analysis, histologic type (p < 0.0001), interval to recurrence (p = 0.034), and treatment modality for early-stage disease (p = 0.01) were significant prognostic factors for overall survival, with age being marginally significant (p = 0.053). For local-regional progression-free rate, only histology was significant (p = 0.035). On multivariate analysis, age (p = 0.026), histology (p = 0.015), and interval to recurrence (p = 0.030) were significant for overall survival, and only histology (p = 0.002) and presence of complications (p = 0.016) were significant for local-regional progression-free rate. Of the 64 reirradiated patients, late complications were documented in 29 (45%) patients. The late complications were permanent in 21 (33%) and severe in 15 (23%) patients. CONCLUSION: Retreatment using radiotherapy alone or in combination with other treatment modalities can achieve long-term local-regional control and survival in a substantial proportion of patients with locally recurrent nasopharyngeal carcinoma. Age, histology, and interval to recurrence were independent prognostic factors for overall survival, but only histology and presence of complications were significant for local-regional progression-free rate.

Adult↗
PubMed1999

Local-regional control of recurrent breast carcinoma after mastectomy: does hyperfractionated accelerated radiotherapy improve local control?

PURPOSE: Hyperfractionated, accelerated radiotherapy (HART) has been advocated for patients with local-regionally recurrent breast cancer because it is believed to enhance treatment effects in rapidly proliferating or chemoresistant tumors. This report examines the value of HART in patients with local-regionally recurrent breast cancer treated with multimodality therapy. METHODS AND MATERIALS: The study included 148 patients with local-regionally recurrent breast cancer after mastectomy, who were treated with definitive local irradiation and systemic therapy consisting of either tamoxifen, cytotoxic chemotherapy, or both, along with excision of the recurrent tumor when possible. Patients with distant metastases were excluded, except for two patients with ipsilateral supraclavicular nodal metastases. Patients received comprehensive irradiation to the chest wall and regional lymphatics to a median dose of 45 Gy, with a boost to 60 Gy to areas of recurrence. Sixty-eight patients (46%) were treated once daily at 2 Gy/fraction (fx), and 80 (54%) were treated twice daily at 1.5 Gy/fx. Forty-eight patients (32%), who had palpable gross disease that was unresponsive to systemic therapy and/or unresectable, were irradiated. The median follow-up time of surviving patients was 78 months. RESULTS: Overall actuarial local-regional control (LRC) rates at 5 and 10 years were 68% and 55%, respectively. Five- and ten-year actuarial overall survival (OS) and disease-free survival (DFS) rates were 50% and 35%, 39% and 29%, respectively. Univariate analysis revealed that LRC was adversely affected by 1. advanced initial American Joint Committee on Cancer (AJCC) stage (p = 0.001), 2. clinically evident residual disease at time of treatment (p < 0.0001), 3. more than three positive nodes at initial mastectomy (p = 0.014), 4. short interval from mastectomy to recurrence (< 24 months, p = 0.0007), 5. nuclear grade (III vs. I or II, p = 0.045), and 6. number of recurrent nodules (1 vs. > 1, p = 0.02). Patient age at time of recurrence (< 40 vs. > or = 40 years), recurrence location on the chest wall, estrogen receptor status, progesterone receptor status or menopausal status did not adversely affect LRC. On multivariate analysis, only clinically evident residual disease at the time of treatment and short interval from mastectomy to recurrence remained significant. When once-a-day irradiation was compared to the twice-a-day schedule, no significant differences were seen in LRC (67% vs. 68%), OS (47% vs. 52%), or DFS (42% vs. 36%) for the entire group of patients at 5 years. Pairwise comparison of the two fractionation schedules in each of the adverse outcome subgroups identified above showed no clinically significant differences in LRC at 5 years. For the 48 patients who began radiotherapy with measurable gross local recurrence, the complete response rate to radiotherapy was 73%, with no difference seen between the two fractionation schedules. The incidence of acute and chronic radiation-related complications was similar in both treatment groups. CONCLUSIONS: Hyperfractionated accelerated radiotherapy, although well tolerated by patients with local-regionally recurrent breast cancer, did not result in superior local-regional control rates when compared to daily fractionated regimens. Alternative strategies, such as dose escalation or chemoradiation, may be required to improve control.

Adolescent↗
PubMed1998

Reoperation for recurrent chronic visceral ischemia.

PURPOSE: Recurrent visceral ischemia after a failed visceral revascularization occurs in up to one third of patients, yet no comprehensive report has described the management of this problem. The purpose of this study was to examine the presentation, surgical management, and outcome of patients with recurrent visceral ischemia. METHODS: Between 1959 and 1997, 109 patients underwent primary visceral revascularization at the University of California, San Francisco. Nineteen patients (17.4%) had recurrent visceral ischemia (12 chronic visceral ischemia, seven acute visceral ischemia). Fourteen additional patients with recurrent chronic visceral ischemia were referred after failed primary revascularization (two patients underwent multiple operations before referral). Thirty visceral reoperations were performed for recurrent visceral ischemia in 24 patients (10 patients with recurrence at University of California, San Francisco, 14 referred patients). Symptom-free and overall survival rates were determined by life table analysis. RESULTS: Of seven patients (6.4%) who had recurrent acute visceral ischemia, six (85.7%) died of bowel infarction. Twelve patients (11%) had recurrent chronic visceral ischemia. Patients with recurrent chronic visceral ischemia received their diagnoses earlier and lost less weight than at their initial presentation (p = 0.004 and 0.001, respectively). Recurrent ischemia was associated with younger age, greater weight loss, and modification of surgical technique at the time of initial operation (p = 0.5, 0.009, and 0.02, respectively). For 20 (90.9%) of the 22 first reoperations, antegrade aortovisceral bypass (n = 10) or transaortic visceral endarterectomy (n = 10) was used. Multiple techniques (four antegrade bypass, two retrograde bypass, one endarterectomy, one anastomotic revision) were used in the eight second or third reoperations. Postoperative mortality and complication rates were 6.7% and 33.3%, respectively. Symptoms recurred in six of 22 patients (27.3%) after the first reoperation, three of whom were cured or improved after additional reoperations. The life table symptom-free survival rate after reoperation was 77.3% and 62.8% at 1 and 5 years, respectively. The life table overall survival rate after reoperation was 74.6% at 5 years. CONCLUSIONS: Recurrent visceral ischemia is not uncommon after primary visceral revascularization. These results show that reoperation for recurrent chronic visceral ischemia can be accomplished safely and effectively with established revascularization techniques. Furthermore, after repeat visceral revascularization patients achieve durable relief of symptoms and have life expectancy rates comparable with those of patients who undergo primary visceral revascularization.

Chronic Disease↗
PubMed2000

Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation.

BACKGROUND: Even though the introduction of endoscopic surgical techniques to inguinal hernia therapy dates back 10 years, only a few data exist concerning the problem of development of a recurrence after endoscopic repair. Similarly there are only anecdotal reports on the feasibility of an endoscopic reintervention for this situation. For the first time we are able to present data of a prospective study on both issues. STUDY DESIGN: We analyzed the data of a prospectively documented series of 46 transperitoneal hernia repair reinterventions after endoscopic hernia repair. In 33 patients from our own clinic we evaluated the cause of recurrence after transperitoneal hernia repair. Together with these and 13 more patients sent to us from external clinics we examined the efficiency of an endoscopic reoperation. RESULTS: When implanting a 13 x 8-cm mesh with an incision (phase I) we found the main cause of recurrence to be that the mesh was too small (47.4%) and the region of the mesh incision was insufficient (42.1%). After a change to a 15 x 10-cm implant without incision (phase II) the main cause of recurrence was found to be a mesh dislocation (38.9%) and the rate of recurrence dropped from 2.8% (phase I) to 0.36% (phase II). The transperitoneal reoperation lasted for a median of 75 minutes (range 45 to 170 minutes) for the medial recurrence and a median of 110 minutes (range 65 to 190 minutes) for the lateral recurrence (p = 0.009). The total rate of complications was 10.9%, and the rate of re-recurrence was 0% after a median followup of 26 months (range 2 to 72 months). CONCLUSIONS: To avoid hernia recurrence after transperitoneal hernia repair operations a sufficiently large mesh (at least 15 x 10 cm) has to be implanted, preferably without an incision, after an extensive parietalization. The endoscopic reoperation for recurrence can be done only in a transperitoneal way and is effective with comparably low complication rates. The procedure is significantly easier for a medial recurrence compared with a lateral recurrence. This method of reoperation should be reserved for endoscopically experienced surgeons.

Adult↗
PubMed2006

Stroke recurrence and its prevention in patients with patent foramen ovale.

BACKGROUND: It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence. METHODS: Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed. RESULTS: Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01). CONCLUSIONS: The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.

Cardiac Surgical Procedures↗
PubMed1999

Quality of life in women with recurrent breast cancer.

Although the psychosocial concomitants of early-stage breast cancer have been well-documented, the relationship between cancer recurrence and quality of life remains less clear. We conducted a prospective, longitudinal study in order to clarify the relationship between recurrent cancer and quality of life, and to determine predictors of quality of life following recurrence. Sixty-nine women with recurrent breast cancer completed questionnaires assessing multiple components of quality of life at three time points: prior to recurrence, immediately after the diagnosis of recurrence, and at follow-up 6 months later. Perceptions of overall quality of life, general health status, emotional, social, and physical functioning were poorer immediately following the diagnosis of recurrence than they had been prior to recurrence. These women also evidenced significant improvement in several domains of quality of life between initial recurrence and follow-up; nonetheless, most areas of quality of life were impaired compared to pre-recurrence. Self-reported physical symptoms were a strong predictor of post-recurrence ratings of overall quality of life. These data suggest that the recurrence of breast cancer is associated with significant changes in quality of life. Quality of life did not progressively deteriorate, however, attesting to the resilience of women coping with this major stressor. These data shed light on issues of potential importance to patients managing this serious illness and may have implications for health-care professionals working with this population.

Aged↗
PubMed1997

Risk factors for local recurrences after limb-salvage surgery for high-grade osteosarcoma of the extremities.

BACKGROUND: Improvements in preoperative staging as well as in chemotherapeutic regimens have made limb-salvage surgery a reliable modality of treatment for high-grade osteosarcomas of the extremities, with local recurrences in most series of less than 10% after this type of surgery. The quality of surgical margins and local response to preoperative chemotherapy are known to be the most significant factors in recurrence [1, 8-10, 12], and complications related to the biopsy procedure may also be a significant factor. The study reported here comprised a histopathological analysis of our recurrent cases as part of an effort to identify the impact of each of the factors cited above. MATERIALS AND METHODS: Five hundred fourteen cases of high-grade, non-multicentric osteosarcoma of the extremities were treated at the Istituto Ortopedico Rizzoli between March 1983 and August 1991. In this study we analyzed 23 cases of local recurrence in patients with classic osteosarcoma who underwent limb-salvage procedures. RESULTS: In 15 cases we found correlation between the site of local recurrence and the site where the margins were less than wide. In five cases the recurrence was secondary to complications of the biopsy procedure (hematoma, delayed healing). In one case we suspect a previously undetected skip lesion. In the remaining two cases no clear explanation was found for the recurrence. There was also a statistically significant difference in the time of appearance of recurrences related to the tumor response to chemotherapy. CONCLUSIONS: For only two cases of recurrence was there no clear explanation. In one we suspect an undetected skip metastasis, and in the other there were certain factors which may have increased its risk of recurrence (non diagnostic trochar biopsy followed by an incisional biopsy, fair tumor necrosis, recurrence in a 'problem' anatomical site, i.e., the popliteal space). In the remaining cases the following factors were found to be directly related to the development of a local recurrence: a) the quality of the surgical margins, b) site of the biopsy as well as complications related to the biopsy procedure, c) local response to preoperative chemotherapy.

Adolescent↗
PubMed2003

Sites of recurrence in oral and oropharyngeal cancers according to the treatment approach.

OBJECTIVE: The purpose of this study is to evaluate the rates and the sites of tumour recurrence in patients with oral and oropharyngeal carcinomas. DESIGN: This is a retrospective study of a series of cases treated in a single institution. PATIENTS AND METHODS: A series of 2067 patients with oral and oropharyngeal squamous carcinoma, treated from 1954 to 1998 were analysed. The treatment approach was: surgery, 624 cases (30.2%); radiotherapy alone, 729 cases (35.3%); radiotherapy and surgery, 552 cases (26.7%) and radiotherapy and chemotherapy, 162 cases (7.8%). MAIN OUTCOME MEASURES: Tumour recurrence was observed in 1079 patients (52.2%): 561 cases of local recurrences (27.1%); 168 neck recurrences (8.1%); 252 locoregional recurrences (12.2%); 59, distant metastasis (2.9%) and 39 (1.9%), combination of distant metastasis with local, neck or locoregional recurrence. RESULTS: The rates of recurrence varied significantly according to the treatment performed. Oral cavity cancer patients undergoing radiotherapy alone or in combination with chemotherapy presented the highest rates of neck recurrences (22.5 and 40.0%, respectively) for clinical stage (CS) I/II and of local (41.2 and 30.1%) and locoregional (21.7 and 31.1%) recurrences for CS III/IV; yet, for CS III/IV, surgery without neck dissection was associated with the highest rates of neck recurrences (20.7%), but no differences were observed in the rates of local or locoregional recurrences for CS I/II patients. For oropharynx cancer patients with CS I/II there was no difference in the rate of locoregional failures according to the treatment. However, patients with CS III/IV undergoing radiotherapy present a highest rate of local (42.3%) and locoregional (28.8%) failures. CONCLUSION: The results suggest that surgery should be the first option for initial clinical stage oral and oropharyngeal cancers. For advanced cases independently of the site of the tumour, surgery and postoperative radiotherapy should be the standard of care because it is associated with the lowest rates of locoregional recurrence.

Adolescent↗
PubMed2001

Primary soft tissue sarcoma and its local recurrence: genetic changes studied by comparative genomic hybridization.

The aims of this study were to compare genetic aberrations in primary soft-tissue sarcomas and their local recurrences and to evaluate the genetic changes occurring during tumor progression. A primary soft-tissue sarcoma and its subsequent local recurrence were analyzed in 20 tumor pairs by comparative genomic hybridization. The samples were obtained before application of radio- or chemotherapy. Copy number aberrations were detected in 50% of the primary tumors and in 70% of the local recurrences. In primary tumors, the mean number of changes was 2.45 (range, 0 to 11) whereas in local recurrences, it was 5.05 (range, 0 to 17). The mean increase of changes from primary tumor to local recurrence was 2.6 per tumor pair (P =.02). Gains predominated over losses in both primary tumors and their local recurrences. The number of high-level amplifications was twofold in local recurrences. The most frequent gain affected 5p14-p15.1 (10% of primary tumors, 25% of local recurrences) and the most frequent loss, 9p (9p21-pter in 5% of primary tumors; 9p22-pter in 30% of local recurrences). In conclusion, our results show an increase in the number of genetic changes in local recurrences, due to tumor progression. Loss at 9p and gains at 5p and 20q were more frequent in local recurrences, and high-level amplification of 18p11.3 was not detected in any of the primary tumors. Although all these alterations were not specific to local recurrences, they may represent changes important during tumor progression.

Adult↗
PubMed2002

Consequences of axillary recurrence after conservative breast surgery.

BACKGROUND: The aim was to study the incidence, time course and prognosis of patients who developed axillary recurrence after breast-conserving surgery, and to evaluate possible risk factors for axillary recurrence and prognostic factors after axillary recurrence. METHODS: In a population-based cohort of 6613 women with invasive breast cancer who had breast-conserving surgery between 1981 and 1990, 92 recurrences in the ipsilateral axilla were identified. Risk factors for axillary recurrence were studied in a case-control study nested in the cohort, and late survival was documented in the women with axillary recurrence. RESULTS: The overall risk of axillary recurrence was 1.0 per cent at 5 years and 1.7 per cent at 10 years. The risk of axillary recurrence increased with tumour size (P = 0.033) and was highest in younger women (odds ratio (OR) 3.9 for women aged less than 40 years compared with those aged 50-59 years). Radiotherapy to the breast reduced the risk of axillary recurrence (OR 0.1 (95 per cent confidence interval 0.1 to 0.4)). The breast cancer-specific survival rate after axillary recurrence, as measured from primary treatment, was 78.0 per cent at 5 years and 52.3 per cent at 10 years. Tumour size and node status had a statistically significant effect on death from breast cancer. CONCLUSION: Axillary recurrence is rare, although more common in younger women with large tumours. Radiotherapy to the breast was protective. Tumour size and node status were the most important prognostic factors in women with axillary recurrence.

Adult↗
PubMed2002

Recurrences of hepatocellular carcinoma following initial remission by transcatheter arterial chemoembolization.

BACKGROUND AND AIMS: The aim of this study was: (i) to define the characteristics of hepatocellular carcinoma (HCC) associated with recurrences following initial remission by transcatheter arterial chemoembolization (TACE); (ii) to evaluate the patterns of recurrences; and (iii) find a better surveillance method of detecting recurrent HCC. METHODS: Out of 230 consecutive HCC patients who underwent TACE, 77 with initial remission were followed prospectively for at least 12 months. We compared the recurrence rates according to the characteristics of the tumors and analyzed the locations of the recurrent HCC. The diagnostic efficacies of CT scans with serum AFP, angiography and Lipiodol CT scan in detecting recurrent HCC were also evaluated. RESULTS: Recurrent HCC was detected in 40 patients during a median period of 27 months. The recurrence rate of multinodular HCC was higher than the single nodular type. All six patients with portal vein thrombosis recurred. Even though 45% of recurrences were adjacent to original tumors, 63% were separated from them (8% at both). Hepatocellular carcinoma with heterogeneous Lipiodol uptake tended to recur at the site adjacent to the original tumors more frequently than HCC with homogeneous Lipiodol uptake. Only 18 of 40 recurrent HCC were initially detected by serum alpha-fetoprotein (AFP) and CT scans: 19 by angiography and three only by Lipiodol CT scan. CONCLUSION: Our data indicated that HCC of the multinodular type and with portal vein thrombosis recur more frequently following initial remission by TACE. It is also suggested that regular angiography in addition to serum AFP and CT scan may be valuable in detecting recurrent HCC. Other treatment modalities may need to be combined to ablate tumors completely and to therefore reduce recurrences, especially in HCC with heterogeneous Lipiodol uptake.

Adult↗
PubMed1996

Intravesical instillation of epirubicin: effect on tumour recurrence in patients with dysplastic epithelium after transurethral resection of superficial bladder tumour.

OBJECTIVE: To evaluate whether the intravesical instillation of epirubicin is effective in preventing the recurrence of tumour in the bladder where dysplastic mucosa remains after transurethral resection of tumour. PATIENTS AND METHODS: Biopsy specimens were taken from apparently normal areas of the bladder mucosa in patients undergoing transurethral resection of the primary tumours. Of the 75 evaluable patients, 18 (24%) had abnormalities in at least one or more specimens. The patients were divided into two groups, 57 with normal and 18 with abnormal biopsy results. Intravesical chemotherapy with epirubicin (20 mg/40 mL saline) was randomized to patients in each group. Tumour recurrence rates were estimated and compared amongst the groups. Factors related to tumour recurrence were evaluated using univariate and multivariate analyses. RESULTS: The risks of tumour recurrence and progression were evaluated in 18 patients with concomitant mucosal abnormalities. All 10 patients with abnormal biopsy results who were treated with epirubicin had recurrence of tumour within a mean interval of 9 months, whereas six of eight controls had recurrence within a mean of 10.9 months. While there was progression in grade in four of 10 patients with abnormal biopsy results and treated with epirubicin, none of the recurrent tumours in six control patients with mucosal abnormalities progressed in grade. The overall recurrence-free rate of the patients with mucosal abnormalities was higher in controls than in those receiving epirubicin, but the difference was not statistically significant. There were no significant differences in recurrence rate for those treated with epirubicin and controls in the 57 patients with normal biopsy results. Univariate analysis showed that the recurrence-free rates were significantly influenced by tumour multiplicity and the mucosal biopsy results (P < 0.001 and P = 0.02, respectively). In a Cox proportional-hazards model, tumour multiplicity alone had prognostic significance for tumour recurrence (P = 0.002). CONCLUSIONS: The prophylactic intravesical instillation of epirubicin had no effect in preventing tumour recurrence and, conversely, it may promote tumour progression in bladders with dysplastic mucosal changes.

Administration, Intravesical↗
PubMed1999

Location of pelvic recurrence after 'curative' low anterior resection for rectal cancer.

AIMS: It has been emphasized that the mesorectum is the key to local recurrence after resection for rectal cancer. In view of this we studied the location of recurrences, relative to the bed of the primary tumour, the neorectum and the level of anastomoses, in patients referred for recurrences after low anterior resection (LAR) in the < >. METHODS: The relative level above the anal verge of the primary cancer, the anastomosis and the recurrence was registered by proctoscopy in 46 patients operated on for recurrent cancer after low anterior resection. The origin of the recurrence was determined from the operative specimen. RESULTS: The median level of the primary cancers was 10 cm above the anal verge, with the anastomoses 2 cm lower, the majority being within 2 cm. Most recurrences were within 1 cm of the anastomosis. No rectal cancer occurred more than 3 cm distal to the anastomosis. Seventy to 80% of recurrences started peri-rectally, most invading the anastomosis. CONCLUSIONS: The tumour bed is most often the origin of the recurrence. Recurrences were mostly due to inadequate radial, and in a few cases longitudinal, dissection of the mesorectum. Virtually all recurrences were within reach of the examining finger. At follow-up of rectal cancers most local recurrences can therefore be identified earlier by digital examination than by proctoscopy.

Adult↗
PubMed2001

Pathological serosa and node-based classification accurately predicts gastric cancer recurrence risk and outcome, and determines potential and limitation of a Japanese-style extensive surgery for Western patients: a prospective with quality control 10-year follow-up study.

UICC classification accurately predicts overall survival but not recurrence-risk. We report here data of overall and first site-specific recurrence following curative surgery useful for the development of recurrence-oriented preventive target therapies. Patients who underwent resection for gastric cancer were stratified according to curability of surgery [curative (R0) vs non-curative resection], extent of surgery [limited (D1) vs extended (D2) node dissection] and pathological nodal/serosal status. The intent-to-treat principle, log-rank test and Cox regression analysis were used for statistical analysis of time-to-event (recurrence, death) endpoints. Curative resection only produced a chance of cure whereas survival was very poor following non-curative resection (P < 0.0001). For D2 R0 subgroup of patients, a pathological serosa and a node state-based classification into three groups, proved to be of clinical implication. Risk of recurrence after a median follow-up of 92 months was low among patients with both serosa and node-negative cancer (first group; 11%), moderate among those with either serosa or node-positive cancer (second group; 53%) and very high among those with both serosa and node-positive cancer (third group; 83%). In multivariate analysis, the relative risks of recurrence and death from gastric cancer among patients in the second and third groups, as compared to those in the first, were 7.07 (95% CI, 2.36-21.17; P = 0.0002) and 16.19 (95% CI, 5.76-45.54; P < 0.0001) respectively. First site-specific recurrence analysis revealed: low rate of loco-regional recurrence alone (12%), serosa state determinant factor of the site-recurrence (peritoneal for serosa-positive and haematogenous for serosa-negative cancers) and dramatic increase of all types of recurrence by the presence of nodal metastases. Our findings demonstrate that a pathological serosa- and node-based classification is very simple and predicts accurately site-specific recurrence-risks. Furthermore they reveal that risk of recurrence following curative D2 surgery alone is low for serosa- and node-negative cancers, but very high in serosa- and node-positive cancers suggesting the need for new therapeutic strategies in this subgroup of patients.

Adult↗
PubMed2000

Recurrent primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis after transplantation.

Viral hepatitis and malignancy frequently recur after transplantation, but recurrence of primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis is controversial. Differences in study design, number of patients, immunosuppressive treatment, length of follow-up, and criteria for recurrence account for discrepant results. Most patients with suspected recurrent disease are asymptomatic after transplantation. In patients transplanted for PBC, antimitochondrial antibodies frequently persist and do not correlate with disease recurrence; liver biopsy remains the gold standard for diagnosis. Exclusion of other disorders that can mimic PBC is paramount prior to making a diagnosis of recurrent disease. The effects of immunosuppression may modify or delay disease expression within the graft. If PBC recurs, intermediate-term patient and graft survival is excellent, but long-term studies will be necessary to address the impact of disease recurrence on the allograft. Due to lack of a diagnostic gold standard, a diagnosis of recurrent PSC after transplantation is difficult to make. An accurate diagnosis of PSC recurrence requires well-defined cholangiographic and histologic criteria. Other disorders that can produce biliary strictures after transplantation should be excluded. As with PBC, the effects of immunosuppression may modify or delay disease expression within the graft; medium-term patient and graft survival is excellent. Recurrence of autoimmune hepatitis is based on clinical, biochemical, serologic, and histologic criteria. As in patients transplanted for PBC and PSC, other conditions that can mimic autoimmune hepatitis require exclusion prior to making a diagnosis of recurrence. Most adult recipients respond to an increase in immunosuppression, whereas pediatric recipients do not respond as well. A cautious approach to withdrawal of immunosuppression is warranted in all patients transplanted for autoimmune hepatitis and the consequences of recurrent disease within the graft will require prolonged follow-up. Future studies should focus on preventive and therapeutic strategies for recurrent autoimmune diseases after transplantation.

Adult↗