Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Prognostic Factors for Operated Gallbladder Cancer.

PURPOSE: The prognosis of gallbladder cancer is poor. Lymph node metastasis and the stage are known to be the strongest prognostic factors for survival. The aim of this study was to determine the importance of complementary surgery and other prognostic factors for survival of operated gallbladder cancer. MATERIAL AND METHOD: We retrospectively analyzed 62 localized gallbladder cancers. The prognostic factors for survival were evaluated by univariate and multivariate analysis. RESULTS: The 3-year overall survival (OS) and disease-free survival (DFS) rates were 52.8 and 43.5%, respectively. Totally, 37 patients (59.6%) were diagnosed incidentally during simple cholecystectomy which was performed for benign causes but only 56.4% of them underwent complementary surgery. 51.6% of the recurrence was detected during 18.4 months of follow-up time. R0 resection, T stage, and pathological stage were found to be related with both OS and DFS by univariate analysis. Grade, lymph node metastasis, and adjuvant chemotherapy were also related with DFS. Presence of recurrence, recurrence side, performance score (PS), and perineural invasion (PNI) were related with OS. Peritoneal metastasis, advanced stage disease, and lymph node metastasis were more common among patients who did not undergo complementary surgery. Adjuvant chemotherapy was given more frequently to patients who undergone complementary surgery group. The multivariate analysis indicated that grade, lymph node metastasis, stage, recurrence site, PS, and adjuvant chemotherapy stage were independent prognostic factors for DFS on the other and only stage was a prognostic factor for OS. CONCLUSION: Our results showed that incidental diagnosis or complementary surgery was not related with DFS or OS but stage was only an independent prognostic factor for both OS and DFS in resected gallbladder cancer.

Capecitabine-cisplatin versus 5-fluorouracil/leucovorin in combination with radiotherapy for adjuvant therapy of lymph node positive locally advanced gastric cancer.

AIM OF THE STUDY: Although surgery is considered to be curative treatment, recurrence rates are high in gastric cancer. Adjuvant 5-fluorouracil (5-FU) based chemoradiotherapy has been shown to improve the prognosis. We compared tolerability and efficacy of the two different chemotherapy regimens; 5-FU/leucovorin (LV) versus cisplatin with capecitabine (XP) combined with radiotherapy (RT) in the adjuvant therapy of the lymph node positive locally advanced gastric cancer. MATERIALS AND METHODS: Totally, 104 patients who underwent curative surgery with lymph node resection were evaluated, respectively. Patients were stratified two group based on the adjuvant chemoradiotherapy regimen. Group 1 (n = 46) received XP followed capecitabine with RT (XRT) then XP. Group 2 (n = 58) received 5-FU/LV combined with RT postoperatively. Two groups were compared based on clinicopathological parameters. Factors related with disease-free survival (DFS) and overall survival (OS) were analyzed. RESULTS: Totally, 32 patients had recurrent disease, and there was no difference between two groups. While peritoneal metastasis was more common in XP arm, distant metastasis was commonly seen in 5-FU/LV arm. There was no significant difference between two groups in regard of Grade 3/4 toxicitis; hematologic toxicities were more in 5-FU/LV group than XP arm. In addition, dose modification because of toxicities were more frequent in 5-FU/LV arm (P = 0.003). For all groups, lymph node dissection type was related with DFS, surgical margin and recurrence were important for OS. CONCLUSION: XP-XRT regimen is well tolerated with lower toxicity compared the standard 5-FU/LV-RT. Although there is no difference with respect to outcome, patients with XP arm without the necessity of intravenous catheter admitted hospital less frequent than bolus5-FU/LV arm.

Gastric Adenocarcinoma Biomarker Expression Profiles and their Prognostic Value.

Expression levels of several molecules implicated in carcinogenesis were examined by immunohistochemical staining, and the prognostic significance of their expression levels in gastric adenocarcinoma (GA) was evaluated. A total of 115 GA and 20 control gastric tissue samples were evaluated by immunohistochemistry using 33 antibodies targeting molecules known to play a part in the development of various tumors. Overexpression of carbonic anhydrase IX (CAIX) and loss of AT-rich interactive domain-containing protein 1A (ARID1A), aldehyde dehydrogenase 1 (ALDH1), and CD44 expression in GA patients were significantly correlated with lymph node (LN) metastasis, advanced tumor stage, and poor prognosis. The results demonstrated that ALDH1A and ARID1A may be strong independent prognostic factors associated with overall survival and recurrence-free survival (p < 0.01 and p < 0.05, respectively). Our results demonstrated that ALDH1, CD44, ARID1A, and CAIX in immunoreactive GA tumor cells exhibit different expression profiles compared with control cells and that these differences are associated with patient survival. The molecules with differential expression profiles were associated with some common functions, including hypoxia, epithelial-to-mesenchymal transition, and SW1/SNF-mediated chromatin remodeling. In addition, the loss of ALDH1, ARID1A, and CD44 and the overexpression of CAIX are important for tumor invasion and metastasis; therefore, they may serve as useful prognostic indicators of long-term survival in patients with GA. In conclusion, our study found that abnormal expression of some of the proteins evaluated in GA tumor cells might have an important role in carcinogenesis and tumor progression and thus may influence the prognosis of patients with GA.

Prognostic markers for metastatic colon cancer patients undergoing multiple metastasectomies.

BACKGROUND/AIMS: Following metastasis resection, 5-year survival rate has been reported as approximately 40%. There is no consensus regarding prognostic factors related to progression-free survival after repeated metastasectomies. MATERIALS AND METHODS: A total of 21 patients with metastatic colorectal cancer who underwent repeated metastasectomies were retrospectively analyzed. The periods between the first and second metastasectomies and that between the second metastasectomy and progression were defined as metastasis-free survival 1 (MFS1) and metastasis-free survival 2 (MFS2), respectively. Univariate analysis was used to analyze factors related to MFS1 and MFS2. RESULTS: Approximately two-thirds of the patients had synchronous metastasis, which were localized mostly in the liver (90%). During a 49-months follow-up, MFS1 was 15.7 (8.4-23) months and MFS2 was 26.3 (12.3-40.4) months. Systemic chemotherapy followed the first metastasectomy (p=0.01), and the recurrence site (p=0.03) was found to be related to MFS1. Furthermore, the number of metastases during the first metastasectomy (p=0.02), the type of the chemotherapy regimen administered following the first metastasectomy (p=0.04), and the number of metastases before the second metastasectomy (p=0.03) were significantly related to MFS2. CONCLUSION: Surgical resection is currently the most effective and curative form of therapy for colorectal metastasis, whenever possible. Repeated metastasectomies can be achieved safely in experienced centers; thus, the operability of the patients should be evaluated by a multidisciplinary approach during treatment.

Clinical importance of discordance of hormone receptors and Her2/neu status after neoadjuvant chemotherapy in breast cancer.

PURPOSE: The aim of this study was to compare the hormone receptors' (HR) and HER2/neu status between core needle biopsy (CNB) and residual tumor after surgery of breast cancer treated with neoadjuvant chemotherapy (NAC), and also to evaluate the impact of discordance and other clinicopathological factors on survival. METHODS: Oestrogen receptor (ER), progesterone receptor (PR) and HER2/neu status were evaluated by immunohistochemistry (IHC) on 90 CNBs of primary tumors and surgical specimens after NAC (study group); 53 patients without NAC served as control group, and discordance was compared between the two groups. The association between discordance of HR status after NAC and various other clinicopathological factors was tested with Spearman's test. RESULTS: Pathological complete response (PCR) was achieved in 10 (11.1%) patients after NAC. ER and PR changed significantly more in the study than in the control group. ER and PR discordance was detected in 10 (12.5%) and 17 (21.2%) patients in the NAC group and in 1 (1.8%) and 2 (3.7%) patients in the control group (p=0.04 and p=0.005, respectively). ER discordance was related with HER2/neu change. Furthermore, PR discordance correlated with CNB, ER and treatment response, while HER2/ neu discordance was associated with treatment response (p=0.05). ER discordance was found to be an independent prognostic factor for progression-free survival (PFS) (p=0.02). CONCLUSION: NAC might cause alterations in ER, PR or HER2//neu status in breast cancer, and they should be re-tested in the residual tumor after NAC to optimize adjuvant therapy.

Factors that Affect Patients' Decision-Making about Mastectomy or Breast Conserving Surgery, and the Psychological Effect of this Choice on Breast Cancer Patients.

BACKGROUND: Breast cancer is the most common cancer in women. Primary treatment is surgery, with breast conserving surgery (BCS) being widely used for early-stage disease. Due to changes in body image, depressive symptoms can occur after surgery. Here, we evaluate factors that affect patients' decision on surgery, and investigate differences in the level of depression after mastectomy or BCS in a population of Turkish patients. PATIENTS AND METHODS: One hundred breast cancer patients who had undergone mastectomy or BCS and were followed up at our institution between 2007 and 2008 were included. Patients were questioned about their involvement in surgical decision-making. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria via a Structural Clinical Interview for DSM (SCID). Severity of depression was evaluated by using the Beck Depression Inventory (BDI). RESULTS: Patients who were older than 50 years, had more than 1 child, a history of lactation, and a positive family history of breast cancer mostly preferred mastectomy. However, patients who sought a second opinion and further information on BCS preferred BCS (p < 0.005). There was no statistical correlation between marital status, first childbearing age, and educational status and the decision on surgery type (p > 0.005). Mastectomy patients were prone to depression, but this was not statistically significant (p = 0.099). CONCLUSION: Age, parenthood, lactation, and positive familial history, as well as thorough information about the type of surgery were important factors for the patients' decision. After breast cancer surgery, patients might experience depression affecting treatment and quality of life. Therefore, adequate information and communication are essential.