Prognostic factors determining survival in patients with node positive differentiated thyroid cancer: a retrospective cross-sectional study.

OBJECTIVE: The prognostic factors for the disease-free status and overall survival among patients who had differentiated thyroid cancer with cervical lymph node metastasis were evaluated to develop a better understanding of the possible effects of lymph node metastasis on the disease process. DESIGN: The data from 101 patients who underwent modified radical neck dissection to determine the presence of cervical node positive differentiated thyroid cancer was evaluated and disease-free survival and overall survival rates were calculated. Prognostic factors predicting these survival rates were evaluated. SETTING: This research took place between July of 1994 and December of 2006 in the Department of General Surgery at Ankara Oncology Training and Research Hospital. PARTICIPANTS: One hundred and one patients underwent a modified radical neck dissection after the cervical nodes were assessed as positive for the presence of cancer. MAIN OUTCOME MEASURES: Ten-year disease-free survival and overall survival rates were measured. RESULTS: We calculated the 10-year disease-free survival rate at 67.3% and the overall survival rate at 86.1%. Age, thyroidal extracapsular invasion, vascular invasion, metastasis, age, completeness of resection, size score and TNM staging were found to be relevant to disease-free survival and overall survival in both the univariate and the multivariate analyses. While the age, metastasis, extent of disease score was relevant to disease-free survival and overall survival in the univariate analysis, this association is not found in the multivariate analysis. The histological type of the tumour was not predictive of disease-free survival, but the follicular type was closely related to the prognosis for overall survival. CONCLUSION: Cervical node metastasis in thyroid carcinoma slightly reduces overall survival. Prognostic factors can help identify high-risk patients and point towards an adequate therapeutic approach.

Application of sentinel node biopsy in breast cancer patients with clinically negative and positive axilla and role of axillary ultrasound examination to select patients for sentinel node biopsy.

PURPOSE: To evaluate the identification rate and the false-negative (FN) rate of sentinel lymph node biopsy (SLNB) using preoperative axillary ultrasound (AU) in patients with clinically negative and positive axilla and to prove that SLNB could also be performed in clinically axillary positive patients. METHODS: Three hundred and fifty seven consecutive T1-2 invasive breast cancer patients with clinically negative or positive axilla were enrolled in our Institution between 2006 and 2011. All patients had preoperative AU, and underwent SLNB followed by breast conserving surgery or mastectomy with level 1, 2 axillary dissection. SLNB was performed using 5 mL of 1% methylene blue. The identification (ID) rate and the FN rate of SLNB were calculated for patients with clinically negative and positive axilla, and for patients with negative AU. RESULTS: Two hundred thirty two patients (65%) were clinically axillary-negative and 125 (35%) were clinically axillary-positive. The ID rates of SLNB were 91 and 89% and the FN rates were 7 and 9%, respectively, in patients with clinically negative and positive axilla. The ID rate of SLNB increased to 94% and the FN rate decreased to 4% after the exclusion of 85 patients (24%) with metastatic lymph nodes on AU. CONCLUSION: SLNB can be safely applied to T1 tumors regardless of the clinical status of the axilla. Use of AU before SLNB significantly increases the ID rate and decreases the FN rate of SLNB in clinically axillary negative as well as in positive patients.

Prognostic factors for survival in breast cancer patients who developed distant metastasis subsequent to definitive surgery.

INTRODUCTION: The present study was undertaken to define the prognostic factors for overall survival subsequent to definitive surgery, and for survival after the development of distant metastasis in breast cancer patients who developed distant metastasis subsequent to definitive surgery. METHODS: The records of 470 breast cancer patients with T1-3 tumours and distant metastasis following surgery were reviewed. Prognostic factors were compared to the first metastatic sites as solitary skeletal, multiple skeletal, and visceral metastases, and were analysed for overall survival following surgery and survival after metastasis. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model. RESULTS: 79 patients (17 percent) had a solitary skeletal metastasis, 105 (22 percent) had multiple skeletal metastases, and 286 (61 percent) had a visceral metastasis. The five-year overall survival was significantly better for patients with a solitary bone metastasis (73 percent) compared to patients who had multiple bone metastases (46 percent), or a visceral metastasis (22 percent) (p-value is less than 0.0001). Pathological lymph node status 3, stage IIIC, grade 3, oestrogen receptor negativity, and visceral metastases were found to have independent detrimental influence on overall survival following surgery and survival after metastasis. A long-term metastasis-free interval affected post-metastatic outcome favourably. Radiotherapy improved overall survival. CONCLUSION: Pathological lymph node status, stage, grade, and oestrogen receptor status predicted survival after surgery as well as after the development of metastasis. Solitary bone metastasis has a more favourable prognosis than multiple bone metastases, and compared to visceral metastasis, skeletal metastasis has a more favourable prognosis.

A comparison of the outcomes of non-randomised chemotherapy regimens in node positive breast cancer.

Adjuvant chemotherapy increases disease-free survival (DFS) and overall survival (OS) following surgery for breast cancer. However, debates concerning the type of adjuvant chemotherapy continue. The effect of adjuvant chemotherapy on loco-regional recurrence-free survival (LFS) was also reported. The present study was undertaken to compare the results of adjuvant FAC (5-fluorouracil, Doxorubicin, Cyclophosphamide) and CMF (Cyclophosphamide, Methotrexate, 5-fluorouracil) chemotherapy on DFS, OS and LFS for node positive breast carcinoma treated with mastectomy in a non-randomised setting. Data from 688 consecutive lymph node positive breast cancer patients who underwent radical or modified radical mastectomy and received adjuvant FAC (600/60/600 mgr/m2 for 6 cycles every three weeks) or CMF (600/40/600 mgr/m2 for 6 cycles on days land 8 every four weeks) chemotherapy were reviewed. The effect of FAC on DFS, OS and LFS as compared with CMF was analysed. Survival curves were generated by the Kaplan-Meier method, and a multivariate analysis was performed by the Cox proportional hazard model. Adjuvant FAC was found to improve DFS, OS and LFS. 5-year DFS, OS and LFS were longer for patients treated with FAC as compared to CMF (67% versus 53%, p < 0.001; 77% versus 66%, p < 0.001, and 97% versus 91%). Adjusted hazard ratio (HR) for potential risk factors and tamoxifen treatment showed that FAC treated patients much benefitted in terms of survival as compared to CMF treated patients (HR 0.53, CI 0.40-0.69 for DFS; HR 0.48, CI 0.35-0.65 for OS, and HR 0.33, CI 0.16-0.65 for LFS). In conclusion, adjuvant FAC improves DFS, OS and LFS as compared to CMF in node positive breast carcinoma patients treated with mastectomy.

The effects of locally injected granulocyte macrophage-colony stimulating factor on the healing of intraoperatively irradiated intestinal anastomoses in rats.

Intraoperative irradiation is used to reduce the number of local recurrences and to increase disease free survival in the treatment of intestinal malignancies. Irradiation for the local control of tumours diminishes the wound healing in the intestine as in any other tissues. For many surgeons, it seems too risky to make resection and anastomosis in an irradiated intestine. Granulocyte Macrophage-Colony Stimulating Factor (Gm-csf) had been successfully used in chronic and incisional dermal wounds. In this study, we evaluated the effect of locally applied Gm-csf on intraoperatively irradiated rat small intestinal anastomosis. 160 male Sprague-Dawley rats were randomized into 4 groups. In group 1 (control), ileal resection was made (1 cm. in length) and anastomosis was performed. In group 2, ileal resection and anastomosis were performed and 50 microgr. rHu Gm-csf was injected subserosally in the perianastomotic area. In group 3, intraoperatively 2000 cGy irradiation was applied to the intestine following ileal resection and anastomosis. In group 4, ileal resection and anastomosis were performed, and 50 microgr. rHu Gm-csf was injected subserosally in the perianastomotic area, then intraoperatively 2000 cGy irradiation was applied to the intestine. On the 3rd and 7th days, relaparotomies were made in order to measure the bursting pressures of the anastomotic segments. The measurement of hydroxyproline levels were evaluated to determine the amount of anastomotic collagen. Histopathological evaluations were also performed. The bursting pressure values in gm-csf given groups were significantly higher than their control groups. The hydroxyproline content of group 4 was significantly higher than group 3 on the 3rd day. In conclusion, these data indicate that local injection of Gm-csf improves the wound healing of intraoperatively irradiated bowel anastomosis.

Effects of locally applied recombinant human granulocyte-macrophage colony-stimulating factor on ischemic bowel anastomoses in rat.

BACKGROUND: Ischemia is one of the most common causes of anastomosis disruption. In the present study we investigated the effect of locally injected recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on ischemic bowel anastomosis in rats. METHODS: 144 male Sprague-Dawley rats were randomized into four groups: in group 1, colon anastomoses were performed; in group 2, anastomoses were performed then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area; in group 3, anastomoses were performed on ischemic colon segments, and in group 4, colon anastomoses were performed on ischemic segments and then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area. On the 3rd and 7th post-operative days, the rats were sacrificed and anastomotic bursting pressures were measured. Hydroxyproline contents were studied on the tissues from the anastomotic line. Three anastomotic segments were saved from each group for histopathological studies before bursting pressure measurement. RESULTS: The bursting pressure in group 3 was significantly weaker than in the other groups. There were no significant differences between the bursting pressures in groups 1 and 4. The levels of hydroxyproline content in group 4 were significantly greater than in group 3. CONCLUSIONS: These data suggest that the local injection of rhGM-CSF improves the healing of ischemic and even normal colon anastomoses.

Comparison of completion thyroidectomy and primary surgery for differentiated thyroid carcinoma.

AIM: The objective of this study is to analyze the complication rates after the completion thyroidectomy and compare them with primary total thyroidectomy. METHODS: The outcomes of patients with differentiated thyroid carcinoma who were operated over a period of eight years were evaluated. One hundred and forty-one patients underwent completion thyroidectomy and 92 patients had primary surgery. RESULTS: The two groups were comparable in respect of clinical variables. Residual tumor was found in 66 of 141 patients (46.8%) in completion thyroidectomy group. The rate of the two most important complications, permanent recurrent laryngeal nerve palsy and permanent hypoparathyroidism were 3.5 and 4.2%, in completion thyroidectomy group, and 3.3 and 4.3%, in primary total thyroidectomy group. The complication rates were not significantly different between groups. CONCLUSION: In conclusion, completion thyroidectomy can be done safely in a specialized center with acceptable morbidity.

Prognostic significance of axillary node and infraclavicular lymph node status after mastectomy.

AIMS: The American Joint Committee on Cancer staging system for breast carcinomas has been revised. According to this revised staging system, metastasis to infraclavicular lymph nodes and number of positive axillary nodes have prognostic significance and a new stage, stage IIIC, has been introduced. The aim of this study is to investigate the association of positive axillary nodes by level and number with survival and stage migration between the old and the new stages in a large series of mastectomy patients. METHODS: Data from 1277 consecutive breast cancer patients treated by mastectomy were studied, retrospectively. Prognostic value of number of positive axillary nodes and entirely invasion of apex axillary nodes were analysed. Survival curves were generated by Kaplan-Meier method, and multivariate analysis was performed by Cox proportional hazard model. RESULTS: Five-year survival rates for metastasis to axillary level III and for stage IIIC breast cancer were 35.4 and 38.2%, respectively. Metastases to apex axillary nodes, 4-9 and 10 or more positive lymph nodes were found to be adverse and independent prognostic factors for survival in lymph node positive patients. CONCLUSION: Invasion of infraclavicular nodes and 4-9 and > or =10 positive axillary lymph nodes were independent predictors for survival in node positive breast carcinomas in this series. Patients with the new stage IIIC had the worst survival among breast cancer patients.

Prognostic factors affecting local recurrence and survival for operable rectal cancers.

The aim of this study was to define the local recurrence, survival rates and independent prognostic factors for survival, and local recurrence in patients with rectal carcinoma treated throughout 7 years. Between January 1990 and January 1998, 197 consecutive patients with rectal carcinoma, who underwent resection by conventional technique in Ankara Oncology Hospital, were retrospectively reviewed. Several clinical and pathological characteristics of patients were categorized. Kaplan-Meier method was used to obtain survival curves, and independent prognostic factors affecting survival and local recurrence were obtained by Cox regression analysis. 5-year survival, and local recurrence rates were 59%, and 33%, respectively. Stage, location of the tumour in distal one third, anterior resection, and poor differentiation were found to be independent detrimental influence on local recurrence. The independent prognostic factors for survival were invasion of tumour into serosa and adjacent organs, lymph node metastases and the total number of resected lymph nodes. Adjuvant therapy affected favourably local recurrence in stage II and III patients, and survival in stage III patients. In conclusion our local recurrence is high in stage I patients as well as in stage II and III patients although most of the patients received adjuvant therapy. Conventional technique might be responsible for high local recurrence rates; therefore, total mesorectal excision technique may be the proper choice to achieve a local recurrence rate under 10% and to have a better survival.

Treatment of iatrogenic ureteral injuries during various operations for malignant conditions.

In the present study we report twenty-nine patients with iatrogenic injuries and management during various operations for malignant conditions. The patients were reviewed in order to identify and study the incidence, type of treatment administered and outcome. The study group was composed of 29 patients with 31 iatrogenic injuries between 1992 and 1999. General surgical, gynecological and urological procedures accounted for 24 (83%), 4 (14%), and 1 (3%) injuries respectively. Twenty-eight injuries were diagnosed at operation and three after an interval of 5, 17 and 45 days. Of the injuries, 51% occurred in the lower third of the ureter, 30% in the upper third and 19% in the middle third. Complete transsection, excision, ligation and partial transection accounted for 19 (61%), 9 (29%), 2 (7%), and 1 (3%) respectively. Treatment consisted of end-to-end ureteroureteral anastomosis in 18 cases; ileal interposition in 4 cases; transureteroureterostomy and ureteroneocystostomy in 2 cases; surgical repair, nephrectomy, ureterocutaneostomy and ileal loop in each of the remaining cases. Primary healing was obtained in all patients. General surgical procedures are the most common cause of iatrogenic injuries during malignant conditions. The proper identification and, when necessary, identification of the ureter at the pelvic brim, should decrease the incidence of iatrogenic ureteral injury. When identified at injury and treated immediately such injuries seldom lead to loss of renal function. We do not advocate to perform nephrectomy for any type of ureteric injury since the preservation of the kidney should be the aim of a surgeon.

Nitric oxide biosynthesis and malondialdehyde levels in advanced breast cancer.

BACKGROUND: Nitric oxide (NO) is a free oxygen radical studied in many tissues. Its tumour killing structure is shown especially by macrophages. The end products of NO are nitrite and nitrate. Their plasma levels are used biochemically to determine nitric oxide synthase (NOS) activity. The proliferative capacity of cancer cells accompanies the alteration in oxidant-anti-oxidant status. The risk of breast cancer is decreased in association with an increased level of polyunsaturated fatty acids in the erythrocyte membranes. The more the anti-oxidant capacity increases, the more the transformed cells grow. Malondialdehyde (MDA) is a lipid peroxidation marker, and low plasma levels of MDA are associated with advanced stages of breast cancer. METHODS: In the present study, the alteration of serum plasma levels of nitrate, nitrite and MDA were determined in patients with stage IIIB breast cancer and controls. RESULTS: It was found that products of NO biosynthesis were higher and plasma MDA levels were lower in patients with breast cancer. CONCLUSIONS: It can be stated that in advanced breast cancer, the NO radical production is increased while the lipid metabolism is altered, and these changes can be related to an alteration in oxidant-anti-oxidant status.

Germinal cell tumors of the testis in cryptorchids.

The medical records of 876 patients with germinal cell tumor of the testis seen at our hospital between 1984 and 1996 were analyzed; 25 (2.85%) were reported to have tumors in undescended testis. Twenty-one patients had unilateral involvement and four had bilateral. Cryptorchidism was corrected ipsilaterally in 7 patients with intrascrotal testicular cancer between 6 and 13 years of age. The primary tumor was in the abdominal testis in 11 patients and in the inguinal canal in 7 (28%) patients. Three patients had persistent Müllerian duct syndrome. One of the three patients with persistent Müllerian duct syndrome also had transverse testicular ectopia. Clinical staging showed 10 stage I, 8 stage IIC, 3 stage III and 4 stage IV. Tumor histologic types on orchidectomy showed seminoma in 20, non-seminoma in 3 and mixed tumors in 2 patients. According to stage and histologic findings all patients were treated with radiotherapy or chemotherapy. Overall, 3 and 5 years survival in seminoma patients was 100% while in non-seminoma and mixed tumor patients was 80% and 60%, respectively. Since orchidopexy offers only limited protection against future malignancy if performed after 2 years of age, the treatment of choice should be orchidectomy. Cryptorchid testes that descended spontaneously or by hormonal therapy should be followed lifelong by testicular ultrasound at least once a year for early detection of cancer. For bilaterally orchidectomised cases administration of androgens is mandatory to prevent sexual dysfunction and hot flushes.

Reconstruction of a chest-wall defect with dehydrated human dura mater graft.

A case of soft-tissue sarcoma of the posterior thoracic wall is presented with full-thickness resection and reconstruction of the defect with dehydrated human dura mater graft. The superiority and advantages of the graft are emphasised.