The prognostic value of detecting symptomatic or asymptomatic recurrence in patients with gastric cancer after a curative gastrectomy.

BACKGROUND: Although studies have investigated whether a routine follow-up should be performed after a gastrectomy, no consensus has been reached on the significance of the follow-up or the optimal surveillance protocol. In the present study, we evaluated the significance of the presence or absence of symptoms in the detection of recurrences after curative gastrectomy for gastric cancer. METHODS: We retrospectively analyzed 173 patients with recurrent gastric cancer who underwent radical gastrectomy. We evaluated the prognostic significance of the presence of cancer-related symptoms at the diagnosis of recurrence, and the relationship between the presence of symptoms and other clinicopathological factors. RESULTS: We detected a symptomatic recurrence in 42.2% of patients. The presence of symptoms were significantly correlated with tumor size, pT stage, pN stage, pathologic stage, and short disease-free interval (<12 mo). The median disease-free survival (DFS), post-recurrence survival (PRS), and overall survival (OS) times for patients with asymptomatic recurrence were significantly longer than those of patients with symptomatic recurrence (disease-free survival was corrected as DFS, 11.1 versus 9.3 mo, P < 0.001; PRS, 4.9 versus 3.1 mo, P = 0.02; OS, 18.3 versus 12.3 mo, P = 0.001, respectively). Multivariate analysis showed that the presence of cancer-related symptoms (P = 0.033; hazard ratio [HR], 0.81) was an independent prognostic factor for PRS, as were short disease-free intervals (P < 0.001; HR, 2.42), age (P = 0.02; HR, 1.53), and the presence of chemotherapy in recurrence (P = 0.001; HR, 0.49). In addition, multivariate analysis indicated that the presence of symptoms, short disease-free interval, and age were also independent prognostic indicators for OS. CONCLUSIONS: Our results demonstrate that symptomatic recurrence is an important prognostic factor for PRS of patients with gastric cancer after a curative gastrectomy. The presence of symptomatic recurrence may be a new and beneficial prognostic marker to evaluate biologic aggressiveness, which is an important determinant of survival at the time of recurrence diagnosis during a follow-up for gastric cancer.

Does the metastatic lymph node ratio influence the disease-free survival of patients with breast cancer: single-center experiences.

BACKGROUND: Axillary lymph nodes (ALNs) are the most important prognostic factor for survival in breast cancer. Pathological evaluation can affect the number of involved lymph nodes. In the current study, we evaluated whether the metastatic lymph node ratio (n ratio) is important in predicting disease-free survival (DFS) for breast cancer patients. MATERIAL AND METHODS: From 802 breast cancer cases, 427 patients with ALN metastasis were analyzed retrospectively. The n ratio was categorized as n ratio 1 (1-10%), n ratio 2 (10.01-50%) and n ratio 3 (>50%). DFS was established according to the Kaplan-Meier method. Predicting risk factors for relapse were analyzed using the Cox proportional hazards model. RESULTS: The n ratio was significantly higher in breast cancer patients with advanced pathologic pT, pN and clinical stage, undifferentiated histology, lymphovascular and extracapsular invasion, more resected ALNs and positive progesterone receptor. In the univariate analysis, multicentricity, necrosis, grade, pN stage, estrogen receptor and progesterone receptor positivity, trastuzumab and neoadjuvant chemotherapy usage, the presence of inflammatory breast cancer and n ratio were found to be important factors in predicting DFS. Multivariate analysis indicated that multicentricity, neoadjuvant chemotherapy, trastuzumab usage and n ratio were significantly associated with prognosis. CONCLUSIONS: The n ratio is inexpensive, easily available and a simple prognostic factor for breast cancer patients with positive ALNs.

Induction chemotherapy and chemoradiation therapy for inoperable locally advanced non-small-cell lung cancer: a single-institution review of two different regimens.

PURPOSE: We compared 2 different chemotherapeutic agents in combination with cisplatin as induction chemotherapy (ICT) followed by chemoradiation therapy (CHRT) in patients with inoperable locally advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: A total of 90 patients with inoperable locally advanced NSCLC received 3 courses of ICT consisting of gemcitabine 1200 mg/m2 on day 1 and day 8 every 3 weeks and cisplatin 75 mg/m2 on day 1 every 3 weeks (group 1; n = 39) or docetaxel 75 mg/m2 on day 1 every 3 weeks and cisplatin 75 mg/m2 on day 1 every 3 weeks (group 2; n = 51) followed by CHRT (docetaxel 30 mg/m2 every week and cisplatin 20 mg/m2 every week with 6600 cGy radiation therapy). RESULTS: After the ICT, the response rate for group 2 (88.2%) was significantly higher than that of the gemcitabine-cisplatin arm (64.1%; P = .017). The response assessment performed on first month after CHRT revealed statistical difference for objective response rate in group 2 when compared with group 1 (P = .04). At the median follow-up of 15.7 months (range, 5-36 months), median overall survival (OS) was 12 months in group 1 (95% CI, 9.1-14.8) and 29.9 months in group 2 (95% CI, 16-43). Median progression-free survival (PFS) was 8 months in group 1 and 15 months in group 2. There was statistically significant difference between the 2 groups regarding OS and PFS (P = .043). CONCLUSION: Our results suggest that OS, PFS, and local control rate are significantly improved with ICT consisting of docetaxel and cisplatin when compared with gemcitabine-cisplatin in inoperable locally advanced NSCLC.

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.

Prognostic factors of patients who received chemotherapy after cranial irradiation for non-small cell lung cancer with brain metastases: A retrospective analysis of multicenter study (Anatolian Society of Medical Oncology).

PURPOSE: Almost half of all patients diagnosed with non-small cell lung cancer (NSCLC) have distant metastases at presentation. One-third of patients with NSCLC will have brain metastases. Without effective treatment, the median survival is only 1 month. However, it is difficult to treat brain metastases with systemic chemotherapy since the agents have difficulty crossing the blood-brain barrier. Therefore, it is important to estimate the patient's survival prognosis. The aim of this study was to analyze prognostic factors for survival in Turkish patients who received chemotherapy after cranial irradiation for NSCLC with brain metastases. METHODS: We retrospectively reviewed 698 patients with brain metastases resulting from NSCLC. Ten potential prognostic variables were chosen for analysis. Univariate and multivariate analyses were conducted to identify prognostic factors associated with overall survival (OS). RESULTS: Among the 10 variables for univariate analysis, six were identified to have prognostic significance; these included sex, smoking history, histology, number of brain metastases, extracranial metastases, and neurosurgical resection. Multivariate analysis by the Cox proportional hazard model showed that a smoking history, extracranial metastases, and neurosurgical resection were independent negative prognostic factors for OS. CONCLUSION: Smoking history, extracranial metastases, and neurosurgical resection were considered independent negative prognostic factors for OS. These findings may facilitate pretreatment prediction of survival and can be used for selecting patients for more appropriate treatment options.

Adrenal mass of unusual etiology: Ewing sarcoma in a young man.

Ewing sarcoma and peripheral primitive neuroectodermal tumor belong to the Ewing sarcoma (ES) family of tumors originating from a primitive neural tube. We report a 31-year-old man who was admitted to the urology clinic with complaints of fever, nausea, and dysuria. A right-sided adrenal mass was detected during ultrasonography. The lesion was then evaluated with magnetic resonance imaging, which showed areas of necrosis amid heterogeneous solid areas. Whole body scan with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography and bone scan studies showed pulmonary and osseous metastatic foci. The mass and right kidney were removed by an open approach. An immunohistochemical and molecular workup enabled the diagnosis of ES. The patient also underwent radiotherapy and chemotherapy. The patient remained in fairly good health during the 18-month follow-up period, but showed progression of all metastatic foci and died 26 months after treatment. In conclusion, adrenal ES should be included in the differential diagnosis of nonfunctional adrenal lesions despite its rare occurrence.

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.

Modified docetaxel and cisplatin in combination with capecitabine (DCX) as a first-line treatment in HER2-negative advanced gastric cancer.

BACKGROUND: Docetaxel and cisplatin in combination with fluorouracil (DCF) regimen is accepted to be one of the standard regimens in the treatment of advanced gastric cancer. However, substantial toxicity has limited its use in daily clinical practice. Therefore, modification of DCF regimens, including introduction of capecitabine has been investigated to improve the safety profiles. In the present study, the efficacy and toxicity of a regimen with a modified dose of docetaxel and cisplatin in combination with oral capecitabine (DCX) was evaluated in untreated patients with HER2-negative advanced gastric cancer. MATERIALS AND METHODS: Fifty-four patients with HER2-negative locally advanced or metastatic gastric cancer were included in this cohort. Patients received docetaxel 60 mg/m2 plus cisplatin 60 mg/m2 (day 1) combined with capecitabine 1650 mg/m2 (days 1-14) every 3 weeks. Treatment response, survival, and toxicity were retrospectively analyzed. RESULTS: The median age was 54 years (range: 24-76). The majority of patients (70%) had metastatic disease, while 11 patients (21%) had recurrent disease and underwent curative gastrectomy, and 5 patients (9%) had locally advanced disease (LAD). The median number of DCX cycles was 4. There were 28 partial responses and 11 complete responses, with an overall response rate of 72%. Curative surgery could be performed in four patients among five with LAD. At the median follow-up of 10 months, the median progression-free survival (PFS) and overall survival (OS) of the entire cohort of patients were 7.4 and 12.1 months, respectively. Dose modification was done in 12 patients due to toxicity in 8 and noncompliance in 4 patients. The most common hematological toxicity was neutropenia, which occurred at grade 3-4 intensity in 10 of 54 patients (27.7%). Febrile neutropenia was diagnosed only in two cases. CONCLUSIONS: DCX regimen offers prominent anti-tumor activity and considered to be effective first- line treatment with manageable toxicity for patients with HER2-negative advanced gastric cancer.

XELIRI plus bevacizumab compared with FOLFIRI plus bevacizumab as first-line setting in patients with metastatic colorectal cancer: experiences at two-institutions.

BACKGROUND: Efficacy of chemotherapy plus bevacizumab has been shown in patients with metastatic colorectal cancer (mCRC) compared with chemotherapy alone. The aim of the present study was to evaluate the efficacy and safety of FOLFIRI or XELIRI regimens in combination with bevacizumab for mCRC patients in a first-line setting. MATERIALS AND METHODS: A total of 132 patients with previously untreated and histologically confirmed mCRC were included. They were treated with either FOLFIRI-Bevacizumab (Bev) or XELIRI-Bev according to physician preference. The efficacy and safety of the two regimens were compared. RESULTS: Between 2006 and 2010, 68 patients were treated with the XELIRI-Bev regimen, while the remaining 64 patients received the FOLFIRI-Bev regimen. The median age was 58.5 years (53.6 years in the FOLFIRI-Bev and 59.7 years in the XELIRI-Bev arm, p=0.01). Objective response rate was 51.6% for FOLFIRI-Bev versus 41.2% for XELIRI-Bev (p=0.38). At the median follow-up of 24.5 months, the median progression-free survival (PFS) was not different between two groups (14.2 months in FOLFIRI-Bev vs. not reached in the XELIRI-Bev, p=0.30). However, median overall survival time for the FOLFIRI-Bev arm was better than that for patients treated with XELIRI- Bev, but these differences was not statistically significant (37.8 months vs. 28.7 months, respectively, p=0.58). Most commonly reported grade 3-4 toxicities (FOLFIRI-Bev vs XELIRI-Bev) were nausea/vomiting (7.8% vs. 14.7%, p=0.27), diarrhea (10.9% vs 22.1%, p=0.10), hand-foot syndrome (0% vs 8.8%, p=0.02) and neutropenia (18.7% vs 27.9%, p=0.22). CONCLUSION: Our results showed that FOLFIRI-Bev and XELIRI-Bev regimens were similarly effective treatments in a first-line setting for patients with untreated mCRC, with manageable adverse event profiles.

Prognostic factors for lymph node negative stage I and IIA non-small cell lung cancer: multicenter experiences.

BACKGROUND: Surgery is the only curative treatment for operable non-small lung cancer (NSCLC) and the importance of adjuvant chemotherapy for stage IB patients is unclear. Herein, we evaluated prognostic factors for survival and factors related with adjuvant treatment decisions for stage I and IIA NSCLC patients without lymph node metastasis. MATERIALS AND METHODS: We retrospectively analyzed 302 patients who had undergone curative surgery for prognostic factors regarding survival and clinicopathological factors related to adjuvant chemotherapy. RESULTS: Nearly 90% of the patients underwent lobectomy or pneumonectomy with mediastinal lymph node resection. For the others, wedge resection were performed. The patients were diagnosed as stage IA in 35%, IB in 49% and IIA in 17%. Histopathological type (p=0.02), tumor diameter (p=0.01) and stage (p<0.001) were found to be related to adjuvant chemotherapy decisions, while operation type, lypmhovascular invasion (LVI), grade and the presence of recurrence were important factors in predicting overall survival (OS), and operation type, tumor size greater than 4 cm, T stage, LVI, and visceral pleural invasion were related with disease free survival (DFS). Multivariate analysis showed operation type (p<0.001, hazard ratio (HR):1.91) and the presence of recurrence (p<0.001, HR:0.007) were independent prognostic factors for OS, as well visceral pleural invasion (p=0.01, HR:0.57) and LVI (p=0.004, HR:0.57) for DFS. CONCLUSIONS: Although adjuvant chemotherapy is standard for early stage lymph node positive NSCLC, it has less clear importance in stage I and IIA patients without lymph node metastasis.

Gallbladder metastasis secondary to gastric cancer as a first site of recurrence presented with acute cholecystitis: case report and literature review.

Metastasis to the gallbladder from other malignancies is extremely rare and is related with a very poor prognosis. Malignant melanoma has been reported to be the most common origin of gallbladder metastasis. Although only eight cases of gallbladder metastasis originating from gastric cancer have been documented in the literature based on small series, of these cases, only one case with signet ring cell carcinoma histology has been reported previously. We report the case of a 58-year-old male with early-stage signet ring cell carcinoma of the stomach who presented with acute cholecystitis previously treated with curative gastrectomy. After laparoscopic cholecystectomy, the diagnosis of gallbladder metastasis with signet ring cell histology secondary to gastric cancer was made. To our knowledge, this is only the second case of signet ring cell carcinoma of the stomach metastasized to the gallbladder as a first site of recurrence. We suggest that for patients with gastric cancer who complain of the findings of acute cholecystitis or cholecystolithiasis, gallbladder metastasis from gastric cancer should be considered in the differential diagnosis.

Myasthenia gravis and autoimmune Addison disease in a patient with thymoma.

The association of thymoma with myasthenia gravis has been well documented. However, the relationship between these two syndromes and Addison disease are very rarely encountered in clinical practice. We report on a 32-year-old man who underwent a resection for thymoma 48 months ago. The diagnosis of Addison disease was made followed by a diagnosis of myasthenia gravis on the basis of a high titer of acetylcholine receptor levels. The treatment of oral prednisolone 7.5 mg/day and oral prostigmine 180 mg/day was initiated. His symptoms and physical signs were improved after this treatment. To our knowledge, this is the fourth reported case of thymoma synchronously associated with myasthenia gravis and Addison disease.