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PubMed2005

Local excision for rectal cancer.

Local excision can be a definitive surgical procedure for some early cancers of the rectum, and it is an appealing technique in many ways. It reduces overall surgical trauma and can assure sphincter preservation. It is also associated with low morbidity. However, this technique has a number of limitations also. This article discusses the results of local excision for rectal carcinoma, including histologic features that impact survival and local recurrence-free rates, the importance of careful patient selection, and the potential role of adjuvant and salvage therapies. Technical considerations and alternative therapies are also discussed.

Chemotherapy, Adjuvant↗
PubMedDate not supplied

Interstitial high dose rate brachytherapy in locally progressive or recurrent head and neck cancer.

In a retrospective study, 19 patients with progressive or recurrent head and neck cancer which had been treated with interstitial high dose rate brachytherapy were analysed. All of them had been previously treated with external radiation. Initial therapy further included surgery in 9 cases and chemotherapy in 3 patients. Staging according to the TNM system revealed advanced stage tumors in the majority of patients. Interstitial brachytherapy was carried out with the isotope Iridium-192. The applied total dose at the reference isodose varied between 10 and 30 Gy. Application was fractionated once a week. A complete tumor remission was achieved in 5 patients and partial remission in 10 patients. In 4 patients the tumor continued to grow despite brachytherapy. The mean follow-up in our collective was 21 months. The calculated local control rate was 34% at 24 months. The survival rate was 49% at 12 months and 35% at 24 months. Interstitial brachytherapy is recommended as a palliative treatment in preirradiated squamous cell carcinoma with local recurrence or progression.

Brachytherapy↗
PubMed2005

[Kidney cancer local recurrence after 20 years].

The kidney cancer local recurrence after 20 years is a very rare process. Mostly its course is asymptomatic and it is recognized accidentally during ultrasonography examination. The imaging diagnostics is completed with computer tomography. The operative removal of the tumor, complemented with immunotherapy and radiotherapy, is the approved way of treatment. The presented in this article case of kidney cancer local recurrence after 20 years since nephrectomy caused by malignancy is the first such a distant case described in worldwide literature (according to our knowledge).

Carcinoma, Renal Cell↗
PubMed1987

[Thymoma--a retrospective study of 48 cases].

Of the 48 thymomas operated on between 1968 and 1985 50% were associated with myasthenia gravis, in 25% diagnosis was made due to accidental X-ray findings. In the staging according to Masaoka et al. [10] the following distribution was noted: I:22, II:5, III:18, IV:3. The 5-year survival rate of the 37 curatively resected patients was 78.5% (stage I: 88.6%, stage III: 55.6%). No stage III patient with residual tumor survived more than 2 years. Predominantly epithelial tumors had a significantly worse prognosis as compared to those with lymphocytic predominance. None of the 4 patients with category II thymoma survived more than 15 months. Association with myasthenia proved to have a negative prognostic influence in stage I and II patients. Frequency of local recurrences and metastases is documented. The value of irradiation and chemotherapy is discussed.

Adolescent↗
PubMed1983

Role of radiation therapy in the treatment of advanced vulvar carcinoma.

To evaluate different methods of radiation therapy for advanced vulvar malignancy, a retrospective study was done on 33 patients treated with radiation between 1950 and 1979. Group I consisted of 18 patients treated with surgery and radiation and group II of 15 patients treated with radiation alone. The patients received several kinds of radiation therapy. Group I received radiotherapy because of local recurrence or positive lymph nodes found in the groin and/or pelvis; the overall survival in that group ranged from 3 months to 11 years. Group II received radiation only because of locally advanced disease and/or associated medical problems; the overall survival in that group ranged from 2 to 40 months. We concluded that megavoltage radiation minimized the local reaction and that better local control was obtained with a combination of photons and electrons and an interstitial implant. Postoperative radiation for positive lymph nodes prevented local recurrence but did not seem to improve survival.

Adenocarcinoma↗
PubMed1994

Recurrence of breast carcinoma following immediate reconstruction: a 13-year review.

To evaluate the effect of immediate reconstruction on the incidence, location, detection, and treatment of recurrent breast cancer, a review of 306 patients operated on according to a standard protocol during the 10-year period 1979 through 1988 was performed. Reconstruction techniques included submuscular implants (207), tissue expanders (84), and musculocutaneous flaps (15). During a minimum follow-up period of 3 years with a mean of 6.4 years, 60 patients (19.6 percent) developed recurrent disease, at a mean interval to recurrence of 31 months. The first locations of recurrences were local (16), regional (11), and systemic (33). Recurrence rates by stage included stage I, 7 patients (5.2 percent); stage II, 45 patients (32.1 percent); and stage III, 8 patients (40 percent). It was not possible to include comparisons with internal control groups of patients in our institution who were not reconstructed or who had delayed reconstructions, thereby preventing conclusions based on such comparisons. Our recurrence data are similar to literature reports of recurrence rates in patients who were not reconstructed after mastectomy. Detection and treatment of recurrences were not inhibited by the reconstructions. When radiation therapy was used in the treatment of local recurrences, the development of symptomatic capsular contracture was recorded in 58 percent of the patients.

Adenocarcinoma↗
PubMed1996

Local recurrence rate in a randomised multicentre trial of preoperative radiotherapy compared with operation alone in resectable rectal carcinoma. Swedish Rectal Cancer Trial.

OBJECTIVE: To find out whether short-term high-dose preoperative radiotherapy can reduce local recurrence rate without increasing postoperative mortality in patients with resectable rectal cancer. DESIGN: Randomised trial. SETTING: Nationwide Swedish multicentre trial. SUBJECTS: From March 1987 to February 1990, 1168 patients were randomised. In each group, 454 patients had curative surgery. INTERVENTIONS: Patients were allocated to preoperative irradiation (25 Gy in five fractions in one week) followed by operation within a week, or to surgery alone. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality, and local recurrence rate. RESULTS: After a minimum follow-up of two years, 9% (51/553) of the patients in the irradiated group who had had the tumour resected had developed a local recurrence, compared with 24% (131/557) in the surgery alone group (p < 0.001). In patients who underwent curative operations, the local recurrence rates were 7% (33/454) and 20% (93/454), respectively (p < 0.001). The corresponding figures for all patients with Dukes' stage tumours were: A 3% (6/181) and 9% (14/154) (p = 0.04); Dukes' stage B 7% (14/195) and 18% (31/173), (p < 0.01) and Dukes' stage C 18% (31/177) and 37% (86/ 230), (p < 0.001), respectively. CONCLUSION: Preoperative irradiation with a short-term high-dose regimen reduces the local recurrence rate by roughly 65% after a minimum follow-up of two years. The influence on survival will be analysed after a minimum of five years followup.

Combined Modality Therapy↗
PubMed1998

Local recurrence following rectal resection for cancer.

Recurrent rectal carcinoma following surgery carries an extremely poor prognosis and subsequent intervention is usually palliative. The incidence of local recurrence (LR) following curative surgery for rectal cancer has been reported to range from 3.7 to 50%. Current treatment strategy for rectal cancer aims at minimizing LR by either pre-operative radiotherapy or adjuvant chemoradiotherapy. Three hundred and fifty-four patients underwent surgical resection for rectal cancer in our department between April 1989 and March 1994, of which 47 (13%) were Dukes A, 88 (25%) Dukes B, 143 (40%) Dukes C and 76 (22%) Dukes D. Two hundred and seventy-eight (79%) patients were defined as having had curative resection (Dukes A, B and C). Overall, total LR occurred in 43 (12.2%) of 354 patients, while LR following curative resection occurred in 16 (9.4%) of the 278 patients. The incidence of LR became higher with increasing depth of invasion and lymph nodal involvement as shown by its direct relationship to stage of disease: Dukes A (0%), B (5.7%), C (14.6%) and D (22.3%). Local recurrence following resection for rectal cancer in our series is low. Pre-operative radiotherapy or adjuvant chemoradiotherapy may not further reduce this low incidence of LR significantly and its role needs to be re-evaluated for institutions with low local recurrence rates.

Adult↗
PubMed1992

Anorectal melanoma: clinical characteristics and the role of abdominoperineal resection.

Twenty-four patients with primary anorectal melanoma diagnosed since 1974 have been retrospectively studied. The most common presenting symptom was rectal bleeding, typically misdiagnosed as hemorrhoids. Progressive disease most commonly presented as a large pelvic mass, diffuse bilateral pulmonary nodules, or diffuse liver metastases. Twenty-one patients (88%) died of their disease; none survived more than 6 years. Among the patients who have died of their disease, mean survival was 2.2 years. Among assessable stage I patients initially managed with abdominoperineal resection (APR), 50% developed recurrent local regional disease (mean disease-free interval = 23 months), compared with 100% of those managed with more limited surgery (mean disease-free interval = 16 months). Even after APR, however, distant metastases were common, and there was no prolongation of survival for patients treated with APR. Primary melanoma of the anorectum has a high metastatic potential and carries a grave prognosis. APR appears to have some effect in controlling local and regional disease, but prolongation of survival will depend both on earlier diagnosis and on development of more successful therapeutic approaches.

Academic Medical Centers↗
PubMed2003

Uncontrolled local disease after salvage treatment for ipsilateral breast tumour recurrence.

AIM: Uncontrolled local disease (ULD) following breast conservation constitutes a clinical problem with a major impact on quality of life. The current study analysed the outcome following treatment of ipsilateral breast tumour recurrence (IBTR) and the risk for ULD with the aim to identify risk factors for ULD. METHODS: In a cohort of 5502 patients treated for invasive breast cancer Stage I-II with breast-conserving surgery 1976-1998 in Stockholm, 307 patients with subsequent IBTR were identified. The majority (n = 219) had received postoperative radiotherapy. Twenty-six per cent of the patients received adjuvant tamoxifen, for 2 or 5 years, and 9% received adjuvant polychemotherapy. Median follow-up time was 11(2-23) years. 50/307 patients developed ULD, defined as the appearance of clinically manifest invasive adenocarcinoma in the remaining breast or on the ipsilateral chest wall which could not be eradicated within 3 months of detection. Multivariate linear logistic regression was used in the statistical analysis to identify prognostic factors for ULD. RESULTS: Five years following the diagnosis of IBTR the cumulative incidence of ULD was 13%. Five independent risk factors for ULD were identified; non-surgical treatment of IBTR, disseminated disease concurrent with IBTR, axillary lymph node metastases (at primary breast conservation), time < 3 years between breast conservation and IBTR, no adjuvant endocrine therapy. Eighty-eight per cent of the patients were treated with salvage mastectomy (n = 207) or re-excision (n = 62). The cumulative incidence at 5 years of ULD following salvage mastectomy and salvage re-excision were 10% and 16% respectively compared to 32% among patients treated non-surgically. Following IBTR, the 5-year overall survival among patients with local control was 78% in contrast to 21% among patients with ULD. CONCLUSION: Uncontrolled local disease is an infrequent but important outcome following breast-conserving surgery. Primary postoperative radiotherapy reduces the risk for IBTR and is therefore recommended as part of the primary treatment to avoid both IBTR and ULD. In addition to radiotherapy, adjuvant therapy reduces the risk for IBTR and thereby the risk for subsequent ULD. Patients with IBTR, independent of concurrent distant metastases, should when feasible be recommended for salvage surgery as it provides superior local control compared to salvage systemic therapy alone.

Adenocarcinoma↗
PubMed1986

[Significance of distant metastases and secondary cancers as a cause of death in patients with ENT cancers].

Hospital charts and autopsy reports of 148 patients with head and neck carcinoma were reviewed in order to assess the mortality from distant metastases and other primaries. 49% of the patients with uncontrolled local or regional disease died with distant metastases. Only 4% of these patients had a second primary. In patients with controlled local and regional disease the opposite was found. Distant metastases were uncommon (9%). Yet, 44% of the patients died of a second primary located in the upper aerodigestive tract or lungs. If life expectancy in patients with controlled head and neck carcinoma is to be improved, early detection of second primaries is important. As only 9% of patients with locally controlled disease die from distant metastases adjuvant chemotherapy is not indicated.

Carcinoma, Squamous Cell↗
PubMed1998

[Strategy for multimodal therapy of soft tissue sarcomas of the trunk and extremities].

The aim of surgical therapy for soft tissue sarcoma is local tumor control with the best possible functional result. Only small, superficial, well-differentiated or strictly intracompartmental lesions should be treated by surgery alone. In all other cases, especially for recurrent lesions, multimodality treatment strategies should be applied. For locally advanced lesions, neoadjuvant therapy can achieve tumor response. Aside from systemic chemotherapy and preoperative radiation therapy, isolated limb perfusion with tumor necrosis factor and melphalan can aid local control, and thus enable limb-sparing resection. The application of adjuvant systemc chemotherapy must be further investigated in prospective trials before a general recommendation can be given. If the patient has distant metastases, decisions regarding treatment of the local lesion must take into account quality-of-life aspects. Should complete resection not be possible, multimodality strategies may be able to control the tumor for a longer period.

Chemotherapy, Adjuvant↗
PubMed1986

Ovarian epithelial tumors of borderline malignancy. A clinical and pathologic study of 109 cases.

One hundred nine cases of ovarian tumors of low malignant potential (borderline tumors) diagnosed at Stanford University Medical Center from 1958 to 1982 were reviewed. The patients ranged in age from 10 to 79 years (mean, 40.5 years). The histologic types and corresponding stages of these neoplasms were 73 serous (Stage IA: 35 patients; Stage IB+C: 16 patients; stage II: 8 patients; Stage III: 14 patients), 30 mucinous (Stage IA: 27 patients; Stage IB+C: 3 patients), and 6 mixed seromucinous (all Stage IA). Borderline endometrioid, clear cell, and Brenner tumors were excluded. Follow-up information from 3 to 27 years from the time of initial diagnosis (mean, 7.6 years; median, 7.1 years) revealed that 89 patients are alive without further evidence of neoplasm, and three patients died of unrelated disease without recurrent tumor. Seventeen patients have developed persistent or recurrent neoplasms in the contralateral ovary (six patients) and/or elsewhere within the peritoneal cavity (15 patients) at 5 to 226 months (mean, 61 months) after the initial excision. All of the second neoplasms were borderline serous or seromucinous tumors histologically identical to the original tumor; none of the borderline mucinous tumors recurred. Patients who initially had Stage III borderline serous tumors developed persistent or recurrent neoplasms more commonly (64%) than did patients with lower stage tumors (12%). No correlation was found between the development of a subsequent serous neoplasm and patient age, the primary tumor size, or any single histologic feature. Following treatment of the subsequent neoplasms, 13 patients are free of neoplasm, one patient is alive with tumor, one patient has died of intercurrent disease with tumor, and two patients have died with widespread abdominal tumor 53 and 232 months after their initial diagnosis. These findings confirm the excellent prognosis for patients with borderline serous tumors, despite involvement of the peritoneal cavity and the development of recrudescent tumor, although long-term follow-up is indicated. Mucinous borderline tumors, as defined by published criteria, almost invariably present as localized (low-stage) tumors and, in our experience, do not recur when confined to the ovary.

Adolescent↗
PubMed2001

[Lymphatic metastases in the parotid region from malignant skin neoplasm of the head: considerations for surgical treatment based on personal clinical experience].

The present paper considers some of the problems linked to the surgical treatment of parotid metastases. The authors base these considerations on their limited personal cases and on the most accredited literature. In the presence of cutaneous malignancies of the upper portion of the face, accurate clinical-radiological evaluation must be made of the parotid and neck region. Elective parotidectomy is performed when the cutaneous carcinoma is quite extensive or located in proximity of the gland or when the case involves a melanoma. Depending on the oncological margins, a sub-total parotidectomy may be enough; however, the facial nerve must be sacrificed if there is a clinical deficit or if it is directly affected by the tumor. As the dimensions of the neoplasm increase, the feasibility of saving the nerve decreases. Prophylactic treatment of the neck is advisable in parotid metastases from cutaneous malignancies, particularly melanoma. Nevertheless, it is possible to perform a selective dissection, avoiding the V level of the neck as the incidence of its involvement is quite low. Prognosis for these tumors is extremely poor. Of the eleven patients surgically treated, only 4 (36%) survived: 2 passed away from other causes not involved in the base pathology; 2 for distant metastases but with no signs of local recurrence and 1 other for recurrence of the primary pathology in the maxillary sinus mucosa. There is no difference in the survival of the two main histological groups: 2 out of 3 of the patients with melanoma (67%) died as did 3 out of 5 (60%) of those with epidermal carcinoma. This does not, obviously, include the two patients who died from other causes.

Aged↗
PubMed1998

Progression in and survival of patients with locally advanced prostate cancer (T3) treated with radical prostatectomy as monotherapy.

PURPOSE: We determine the progression and survival rates in patients with locally advanced prostate cancer treated with radical prostatectomy without adjuvant treatment, and investigate subgroups of patients who may not benefit from this treatment. MATERIALS AND METHODS: Radical prostatectomy was performed in 83 patients with T3 prostate cancer. The patients were divided in subgroups with T3G1 to 2 and T3G3 tumors, which were evaluated for clinical progression, local recurrence, distant metastases, biochemical progression, and overall and cancer specific survival at 5 and 10 years by Kaplan-Meier curves. The results were compared to those of 190 patients with locally confined tumors. RESULTS: At 5 and 10 years overall survival was 75 and 60%, and cancer specific survival was 85 and 72%, respectively. At 5 and 10 years clinical progression was 41 and 69%, local recurrence 18 and 44%, and distant metastases 31 and 50%, respectively. Biochemical progression at 5 years was 71%. Patients with poorly differentiated tumors showed significantly lower survival and higher progression rates compared to those with well or moderately differentiated tumors. Progression and survival in patients with T3G1-2 tumor were not significantly different from those for patients with locally confined tumors. CONCLUSIONS: Radical prostatectomy as monotherapy in patients with locally advanced nonmetastatic prostate cancer (T3) produces acceptable results in those with well or moderately differentiated tumors. The results of progression and survival are not significantly different from those in patients with locally confined prostate cancer. However, patients with poorly differentiated tumors (T3G3) have early progression and need adjuvant treatment following surgery.

Actuarial Analysis↗
PubMed1997

The impact of residual disease on local recurrence in patients treated by initial unplanned resection for soft tissue sarcoma of the extremity.

BACKGROUND AND OBJECTIVES: "Unplanned excision" in soft tissue sarcoma (STS) is defined as the gross removal of tumor without preoperative staging or consideration of the need for removal of normal tissue around the tumor. This study evaluated whether unplanned excision in patients with extremity STS would have an impact on local relapse (LR), even if reexcision of the tumor bed was undertaken. METHOD: Two hundred thirty-nine (239) patients with primary, extremity STS treated with limb salvage surgery were included in this study. Of the 239, 78% were treated with surgery and irradiation. Forty-seven tumors were low-grade and 192 high grade. Mean tumor diameter was 7.5 cm. Twenty had local recurrences and 64 relapsed systemically. RESULTS: Only margin and prior surgery were significant in univariate analysis (P < 0.05, log-rank test). The Cox multivariate analysis revealed that both margin of resection (P < 0.001) and the status of the local tumor site (P < 0.05) at definitive surgery were significant predictors of local relapse. CONCLUSIONS: These results suggest that the presence of microscopic disease in the reexcised specimen following unplanned resection is a risk factor for local disease recurrence.

Adolescent↗
PubMedDate not supplied

Salvage surgery after radiotherapy failure in T1-T2 squamous cell carcinoma of the glottic larynx.

BACKGROUND: This study was undertaken to analyze the clinical course of patients who developed local (primary) recurrence after high-dose irradiation of T1 -T2 squamous cell carcinoma of the glottic larynx. METHODS: Between May 1977 and December 1989, 247 patients with previously untreated T1 and T2 invasive squamous cell carcinoma of the glottic larynx were treated for curative intent with radiotherapy. Local recurrence occurred in 26 of 247 patients (11%). Successful surgical salvage was defined as no evidence of recurrent cancer for at least 2 years after salvage surgery and continuously thereafter. RESULTS: Two patients refused to undergo salvage surgery and one patient had unresectable disease. Of 23 patients who underwent salvage surgery, 19 had a total laryngectomy and 4 had a voice-sparing procedure. One patient who was continuously free of disease, died less than 24 months after salvage surgery; this patient was excluded from all local control and survival analyses, leaving 22 patients available for analysis. Successful salvage was achieved initially in 13 (59%) of the 22 patients. Two patients with local failure after voice-sparing salvage surgery underwent completion laryngectomy; one was salvaged, so that 14 of 22 (64%) were ultimately salvaged. The rate of successful salvage did not correlate with preirradiation T stage, time to failure after irradiation, or time from clinical suspicion of recurrence to histologic proof. In a subgroup of patients (those with positive margins, tumor extension into the soft tissues of the neck, or two or more adverse histologic features), the risk of local-regional recurrence after salvage laryngectomy was 80%. CONCLUSION: There are few data in the literature regarding the clinical outcome of patients whose tumors are not controlled by initial radiotherapy. This series and previous publications from other institutions indicate that most patients who develop primary failure undergo salvage surgery, which is successful in approximately 50-80% of the patients. The rate of surgical complications is acceptable and is related to radiotherapy dose. At our institution, most patients who had recurrence after radiotherapy underwent total laryngectomy. More than 50% of the patients who experienced recurrence after irradiation originally had tumors of such extent that they would have required total laryngectomy if surgery had been recommended instead of radiotherapy for the initial treatment. It is reasonable to consider reirradiation in patients with a very high risk of local-regional recurrence after salvage laryngectomy.

Biopsy↗