Association between [18F]fluorodeoxyglucose uptake and prognostic parameters in breast cancer.

BACKGROUND: This study analysed the correlation between [(18)F]fluorodeoxyglucose (FDG) uptake assessed by positron emission tomography (PET) in breast tumours, and histopathological and inmunohistochemical prognostic factors. METHODS: FDG-PET was performed before surgery in 275 women with primary breast cancer. The standarized uptake value (SUV) was compared with histopathological findings after surgery. RESULTS: A positive relationship was found between the SUV and tumour size (r = 0.46, P < 0.001), axillary lymph node status (P < 0.001), histological type (P < 0.001), histological grade (P < 0.001), oestrogen receptor status (P < 0.001), p53 (P < 0.001) and Ki-67 (P < 0.001) expression. Multivariable linear regression showed that tumour size, histological grade, Ki-67 expression, oestrogen receptor status and histological type were significantly related to the SUV. CONCLUSION: The SUV is a preoperative and non-invasive metabolic factor that relates to some prognostic factors in breast cancer.

[New developments in the surgical treatment of breast cancer]. / Novedades en el tratamiento quirúrgico del cáncer de mama.

Adecuate surgical treatment is mandatory in order to achieve cure in patients with breast cancer. Breast surgeons have to choice the best surgical technique over the breast and over the axillary nodes. Two new surgical aproaches have been implemented in the last decade: oncoplastic conservative surgery and sentinel lymph node biopsy. Oncoplastic surgery provides oncologic safety results and good cosmetic outcome. In this paper the technical steps and indications of different oncoplastic techniques in conservative breast surgery are review. Concerning to axillary surgery sentinel lymph node biopsy is the gold standard. However there are several controversial points in sentinel node biopsy referring to indications, identification and histological findings.

Intraoperative and external beam radiotherapy in advanced resectable gastric cancer: technical description and preliminary results.

Twenty-two patients with resectable gastric cancer treated with intraoperative radiotherapy and external beam irradiation, in a Phase I-II oriented study, were analyzed. Tumor Stages were III & IV in 18 cases (82%). Tumor histology was described as diffuse undifferentiated type in 14 cases (63%). Following surgical resection of the primary tumor, IORT 15 Gy was delivered in the celiac axis area, using high energy electron beams ranging from 9 to 20 MeV. External beam irradiation fields covered the draining nodal areas of the upper abdomen and the gastric bed. There were no postoperative deaths. Reversible postoperative complications were recorded in 14 patients (63%). Long term complications observed were vertebral collapse and liver hemangiomas. First sites of recurrence have been: hepatic hilum (three cases), peritoneum combined with central axis nodes (two cases), liver metastasis (one case), and lung metastasis (one case). Survival data shows a follow-up period ranging from 1+ to 33+ months, with a median survival time for the entire group of 13+ months. At the time of this report, 16 patients (72%) are still alive and six have died (four from progressive malignant disease and two from intercurrent disease). From this preliminary data, it can be concluded that a combined approach with surgical resection, intraoperative radiotherapy, and external beam irradiation is feasible in advanced gastric carcinoma, and is not limited by toxicity or any complications observed. Despite this intense loco-regional therapeutic approach, the upper abdominal failure rate has been demonstrated in 22% of the cases.

Intraoperative radiotherapy for recurrent and/or residual colorectal cancer.

Intraoperative radiotherapy (IORT) is an attractive boosting modality in the combined treatment of recurrent and/or residual colorectal cancer. Twenty seven patients treated with IORT are analysed. Residual disease following resection of the primary tumor was treated in 11 cases (group I). Localized recurrent disease without previous radiotherapy was treated in 11 cases (group II). IORT was used in five additional patients with local recurrences in previously irradiated areas (group III). The treatment program consisted of maximal tumor resection, IORT (10-30 Gy) to the area of residual disease and external beam radiotherapy (46-50 Gy). The median follow-up time for the entire series of patients is 11 months. Local tumor control rates are 90% in group I, 63% in group II and 60% in group III. Toxicity and complications related to IORT observed in this initial experience have been pelvic pain (29%) and lower extremity neuropathy (3%). These early clinical results suggest that the IORT combined with surgery and external beam radiotherapy is feasible in primary and recurrent disease. Local control rates obtained in patients not suitable for curative surgery are encouraging.

18F-FDG PET complemented with sentinel lymph node biopsy in the detection of axillary involvement in breast cancer.

AIM: The presence of axillary involvement is the most important prognostic factor in breast cancer. This study analysis the value of 18F-FDG PET in the detection of the lymph node status. METHODS: This study includes 200 breast cancer patients. The PET scans were obtained after the injection of 370 MBq of 18F-FDG; the breast areas, axillary, supraclavicular and internal mammary lymph node chains were evaluated. In a subgroup of 100 patients the PET-FDG scan was complemented with the study of the sentinel node (SN) in those cases which did not demonstrate pathological lymph node uptake. The standardized uptake value (SUV) was related to the tumour characteristics of size, histological type, axillary status and histological grading. RESULTS: The sensitivity and specificity of PET-FDG in the detection of axillary involvement was 84.1 and 97.8%, respectively. Seventeen false negative cases were obtained, and were associated with low SUV in the mammary tumour. In 15 cases the PET-FDG scans revealed pathological uptake foci that suggested involvement of the internal mammary chain. CONCLUSIONS: The PET-FDG avoids routine SN study in those cases presenting axillary uptake, but it must be complemented by sentinel node study in those cases without pathological uptake. The association of PET-FDG and SN improves the sensitivity in the detection of axillary involvement. Its sensitivity and specificity in the analysis of axillary status can be extended to the evaluation of the internal mammary chain.

[Determination of the lymphocytic and oncofetal antigen subpopulations in patients with adenocarcinomas of the stomach and of the colon and rectum (author's transl)]. / Determinación de las subpoblaciones linfocitarias y antígenos oncofetales en pacientes con adenocarcinoma gástrico y colorrectal.

The authors present a study of 50 patients with adenocarcinomas of the colon and rectum, patients with gastric adenocarcinomas, and 30 healthy individuals as a control group. In all subjects the following parameters were determined: total number of lymphocytes in the peripheral blood, T lymphocytes, T-active lymphocytes, and B lymphocytes. A study of the test for lymphoblastic transformation (TTL) with phytohemagglutinin (PHA) stimulation and the determination of alpha-fetoprotein (AFP) and carcino-embryonic antigen (CEA) were also carried out. In patients with gastric adenocarcinoma the results revealed a lymphopenia, especially at the expense of T and T-active lymphocytes, as well as a depression (in 73 per cent) of the lymphocytic response to the PHA stimulation. Patients with carcinoma of the colon showed significant results in the T-active lymphocyte population. In both neoplastic situations the determination for alpha-fetoprotein was negative, while the CEA presented a clear correlation with the evolutive stage of the tumor, being more demonstrative in the tumors located in the colon and rectum.

[Villous adenoma of the duodenum. Presentation of a case]. / Adenoma velloso de duodeno. Presentación de un caso.

A case of villous adenoma of the duodenum is presented; the wide implantation of the tumor imposed a cephalic duodenopancreatectomy. The endoscopic examination plays an important role in the diagnosis of these tumors, but it frequently; does not exclude the possibility of a malignant lesion, this fact renders difficult the choice of adequate treatment. We review the surgical approach of these tumors, which ranges from local resection to duodenopancreatectomy, depending on the pathological study and intraoperative findings.

[Cancer of the esophagus (I): its epidemiological, clinical and diagnostic assessment according to histological type]. / Cáncer de esófago (I): valoración epidemiológica, clínica y diagnóstica según el tipo histológico.

From 1975 to 1991, sixty-eight patients were treated with surgery for esophageal cancer at the Clínica Universitaria de Navarra. This study involves an analysis of epidemiologic and predisposing risk factors in relation with the histologic type of tumor: epidermoid carcinoma vs. adenocarcinoma. The difference in mean age of males (60.5 yrs.) as compared with that of females (48.7 yrs.) was statistically significant (p < 0.05). Likewise, the mean age of patients with epidermoid carcinoma (57.8 yrs.) was significant lower (p < 0.01) as compared with that of those with adenocarcinoma (66.3 yrs.). Smoking and alcoholism were common in the group of patients with epidermoid carcinoma, while Barrett's esophagus and hiatal hernia were frequently seen in patients with adenocarcinoma. Dysphagia was the most frequent symptom both at the start of disease (75%) and with the diagnosis established (96.7%). There was no significant difference in the symptomatology of patients with one type of tumor or the other. The efficacy of ancillary diagnostic procedures such as barium swallow, esophagoscopy, computerized tomography and biopsy were likewise assessed. The most frequent site of tumor was at the middle third, with majority of patients being at clinical stage 1-2 of disease at the time of diagnosis.

[Cancer of the esophagus (II): the results of surgery, anatomicopathological study and patient survival]. / Cáncer de esófago (II): resultados de la cirugía, estudio anatomopatológico, y supervivencia de los pacientes.

We present a retrospective study of 68 esophageal cancer patients treated with surgery between 1975 and 1991. Results showed a resectability of 73.5% with the most frequent surgical approach being a Lewis esophagectomy. The mean hospitalization time was 24.7 days with a postoperative mortality of 7.3%. Other complications included anastomotic leakage, wound infection, sepsis and pulmonary disorders. Over-all survival at 3 years was 17.3%, reaching 24% in resected patients. Survival according to lymph node involvement was 13.4% for lymph node positive patients and 34.5% for node negative patients. According to histopathologic stage, survival rates were 34.6% and 8.59% for early and advanced tumor respectively, the difference being statistically significant using the Mantel-Haenszel test.

[Biopsy techniques for the diagnosis of non-palpable mammary lesions]. / Técnicas de biopsia para el diagnóstico de lesiones mamarias no palpables.

Facing a non-palpable mammary lesion requiring a diagnostic biopsy, consideration must be given to the most suitable guiding method for obtaining the latter. Three methods are employed at present: stereotaxy (basically in cases of microcalcifications), echography (above all in the nodules), and magnetic resonance (for lesions not made visible through the previous systems). The next step is to select the most suitable biopsy technique. The most classical and reliable technique is the surgical biopsy with prior marking using a metallic harpoon, but, besides its high cost, it has the drawback of being an aggressive technique for the diagnosis of a benign pathology. Numerous systems of puncture have been developed as alternatives. Puncture with a fine needle is technically simple to carry out and can provide good results in the mammary nodules, but the existence of positive and negative false results has progressively limited its use. As an alternative, the systems of biopsy with a broad needle have made it possible to obtain multiple cylinders with a high diagnostic reliability, above all in the case of mammary nodules. However, their use in microcalcifications continues to show negative false results. The arrival of systems of vacuum-assisted biopsy has made it possible to obtain cylinders of greater quality, above all in cases of microcalcifications. Finally, the systems of percutaneous resection biopsy by means of cannulas with a diameter of 22 mm make it possible to completely extract lesions of a size below that of the cannula, with a reliability similar to that of the surgical biopsy.

[Imaging techniques for axillary lymph node staging in breast cancer]. / Técnicas de imagen para la valoración del estado ganglionar axilar en el cáncer de mama.

The axillary lymph node status is the most important prognostic factor in breast cancer, and the axillary dissection as the gold standar for staging. It requires radical surgery, which is accompanied by importants postoperaive problems. Axillary lymph nodes can be imaged with a wide variety of available diagnostic radiological test (ultrasonography, mammography, computed tomography and magnetic resonance imaging). In these anatomic imaging, the limph nodes whit metastatic disease appear dense, enlarged or spiculated. Difficulties arise, not in visualization of the axillary lymph nodes, but in reliably separating normal from those involved with metastatic disease. Radionucleide studies and positron emisión tomography provide biochemical information, but are limited by resolution constrains.

[Primary hepatic actinomycosis]. / Actinomicosis primaria hepática.

We present a patient complaining of abdominal pain during eighteen months, localized in left subcostal region, weight loss, asthenia and anorexia for the previous 5 months and fever one month before his admission. He presented painful hepatomegaly, leukocytosis, with an increased percentage of mature and inmature neutrophils, anemia, elevated erythrocyte sedimentation, thrombocytosis, hypergammaglobublinemia and dissociated cholestasis. Complementary exams demonstrated the presence of a poorly vascularized occupying process, localized in the left hepatic lobe. Following laparotomy and biopsy-resection of the process in hepatic left lobe, staining revealed isolated, Gram + filaments and histopathological study showed multiple micro-abcesses displaying actinomyces-like characteristics. There was no evidence of any other pathological process except for previous history of dental abscesses and extractions, which could represent the primary focus for hematogenous dissemination. There was satisfactory response to erythromycin.

[Esophagectomy for esophageal cancer excluding cardial involvement. Analysis of 40 cases]. / Esofaguectomía por cáncer esofágico con exclusión de la localización cardial. Análisis de 40 casos.

This is a study of esophageal resection for cancer of the esophagus in 40 patients, 34 of which were diagnosed as squamous carcinoma and 6 as adenocarcinoma excluding the cardias, tumor localization includes cervical esophagus in one case and all the rest in the thoracic esophagus, 2 in the proximal third, 25 in the middle third and 12 in the distal third. With regard to surgical approach, 11 were treated with total esophagectomy (7 Akiyama, 4 transhiatal resection) and of the 29 treated, of subtotal esophagectomy, 24 were according to the Lewis technique and 5 through a left-sided thoracotomy. Reconstruction was done with stomach in 33 cases six with colon and one with jejunum. Complications were detected in 52.5% the patients with pleuro-pulmonary being the most frequent, anastomotic dehiscence occurred in 5 cases (4 of which were chose manually). The operative mortality rate was 5% and the actuarial survival at 5 years was at 28.4%.

[Treatment of cancer of the esophagus. New strategy with the multidisciplinary treatment]. / Revisión del tratamiento del cáncer de esófago. Nueva estrategia con el tratamiento multidisciplinar.

This study is an update of the clinico-anatomical characteristics of esophageal cancer, as well as the different current therapeutic modalities, their indications and results. The therapeutic protocol for the study and treatment of epidermoid cancer of the esophages followed in the University Clinic of Navarra is likewise espounded.

[Internal derivation in the treatment of hepatic hydatidosis]. / Derivación interna en el tratamiento de las hidatidosis hepáticas.

The results of the surgical treatment of human hydatic cyst by cystojejunostomy are presented. This technique was performed in 17,3% of all cysts treated by the authors. The conditions for using technique, as well as it morbidity and mortality are reviewed. The authors' conclusion is that cystojejunostomy is a valid surgical technique for hydatic cyst in some cases in which it is indicated.

[Submucosal lipomas of the colon]. / Lipomas submucosos de colon.

Three cases of symptomatic colonic lipoma are presented. All were submucous. Clinical findings were abdominal pain, changes in intestinal rythm and rectorragia. All patients had an important loss of weight, a previously undescribed finding. Two patients had a colonic diverticulosis too. The diagnosis was made by means of radiology (barium enema) and surgery was performed in all cases with excellent results.

[Multidisciplinary protocol for the treatment of epidermoid carcinoma of the esophagus: experience from 1985 to 1989]. / Protocolo multidisciplinar de tratamiento del carcinoma epidermoide de esófago: experiencia 1985-1989.

A phase II study activated in 1985 for the multidisciplinary treatment of squamous cell carcinoma of the esophagus is described. The treatment program included simultaneous neoadjuvant continuous infusion chemotherapy with cisplatinum and 5-fluorouracil, preoperative radiotherapy (46 Gy in 5 weeks) and delayed programmed surgery (or radical irradiation in selected cases). Twenty-one patients with tumor stages I (6), II (10), III (5) entered in the study and 20 patients completed the treatment program. Severe toxicity observed was: esophagitis 100%, bone marrow aplasia 30%, severe weight loss 52%. One patient developed a tracheo-esophageal fistula at the end of radiotherapy. Clinical objective tumor response rate was 85%. Pathologic complete tumor response rate was 47%. Median follow-up of the entire group is 11 months (range 2 + to 49 + months). Ten patients have been alive for more than 12 months; six are still alive without any evidence of disease (from 12 + to 49 + months). It is concluded that the protocol described is feasible, with treatment related severe but reversible toxicities, and able to induce a high rate of tumor response and long term survivors in patients with initial locally advanced tumor stages.

[Complementary chemotherapy of breast cancer; experience at the University Clinic of Navarra]. / Quimioterapia complementaria del cáncer de mama; experiencia de la Clínica Universitaria de Navarra.

From 1982 to 1989, 68 patients were treated with the diagnosis of breast cancer. 57 were premenopausal and 11 postmenopausal. The most frequent stage was T2N1 (44.1%) followed by T1N1 (20.6%). The mean dosage of chemotherapy given were 91.2% for cyclophosphamide, 88% for methotrexate and 94% for 5-fluorouracil. The treatment was well tolerated and the most frequent toxicity encountered was leukopenia. The disease free survival were 89.4% at 96 month for premenopausal and 63.3% at 68 month for postmenopausal. We have not seen any differences in the disease free survival in relation to the size of the tumor or the status of the hormonal receptors of the tumor. The most important prognostic factor were the number of positive axilar nodes affected and the dosage of chemotherapy.