Is preoperative ultrasound of the axilla necessary in screen-detected breast cancer?

BACKGROUND: Axillary ultrasound (US) with fine needle aspiration biopsy (FNAB) of suspicious lymph nodes helps identify patients with axillary metastases preoperatively avoiding a 2-step axillary procedure. However, it does not accurately differentiate between low and high axillary tumour burden. Our aim was to determine the rationale of preoperative axillary US in screen-detected breast cancer. METHODS: We retrospectively analysed patients, aged between 50 and 69 years, which had an invasive breast cancer diagnosed in the Slovenian National Breast Cancer Screening program between January 2012 and June 2017. Proportion of patients that proceeded directly to ALND and the proportion of patients with unnecessary ALND as a result of positive US-FNAB were calculated. RESULTS: Altogether 892 patients were eligible for analysis. Preoperative US of the axilla was performed in 856/892 (96%) patients, while 36/892 patients (4%) did not undergo US of the axilla. We have found out that upfront ALND due to positive US-FNAB was performed in 91/856 (10.6%) patients. 116/856 patients (13.6%) had tumours in inner quadrants and maximal mammographic tumour size ≤ 2 cm. Among them only 1/116 (0.9%) proceeded directly to ALND due to positive US-FNAB.The final pathology of those who underwent upfront ALND due to positive US-FNAB showed low axillary tumour burden not meeting the indications for ALND in 13/91 (14.3%) patients.Among patients without preoperative axillary US, only 1/36 (2.8%) met the indications for ALND. CONCLUSION: Our results showed that performing US of the axilla is not justified in screen detected breast cancer patients.

Locoregional disease control after external beam radiotherapy in 91 patients with differentiated thyroid carcinoma and pT4 tumor stage - a single institution experience.

Background Locoregional recurrence is common in patients with locally advanced differentiated thyroid carcinoma (DTC). Our aim was to find out the rate of locoregional control of the disease after external beam radiotherapy (EBRT) of the neck and mediastinum in patients with DTC and pT4 tumor. Patients and methods Altogether 91 patients (47 males, 44 females, median age 61 years) with DTC had EBRT of the neck and mediastinum as part of the multimodal treatment of pT4 tumor (63 cases pT4a, 28 cases pT4b) from the year 1973 to 2015. Data on clinical factors, histopathology and recurrence were collected. Disease-free, disease-specific and overall survival was calculated. Results Median tumor size was 5 cm (range 1-30 cm). Out of 91 patients, 23 had distant and 38 regional metastases. A total or near-total thyroidectomy, lobectomy, subtotal thyroidectomy and lymph node dissection was performed in 70%, 14%, 2% and 30% of cases, respectively. Thirteen percent of patients were not treated with surgery. All patients had EBRT and 39 had chemotherapy. Radioiodine (RAI) ablation of thyroid remnant and RAI therapy was applied in 90% and 40% of cases, respectively. Recurrence was diagnosed in 29/64 patients without a persistent disease: locoregional and distant in 16 and 13 cases, respectively. Five-year and ten-year disease-free survival rate was 64% and 48%, respectively. Conclusions The majority of patients with DTC and pT4 tumors who were treated with EBRT of the neck and mediastinum region as part of multimodal treatment have long-lasting locoregional control of the disease.

The role of neoadjuvant chemotherapy in patients with advanced (stage IIIC) epithelial ovarian cancer.

BACKGROUND: Primary treatment of patients with advanced epithelial ovarian cancer consists of chemotherapy either before (neoadjuvant chemotherapy, NACT) or after primary surgery (adjuvant chemotherapy). The goal of primary treatment is no residual disease after surgery (R0 resection) what is associated with an improvement in survival of patients. There is, however, no evidence of survival benefits in patients with R0 resections after prior NACT. METHODS: We retrospectively reviewed the records of patients who were treated with diagnosis of epithelial ovarian cancer at Institute of Oncology Ljubljana in the years 2005-2007. The differences in the rates of R0 resections, progression free survival (PFS), overall survival (OS) and in five-year and eight-year survival rates between patients treated with NACT and patients who had primary surgery were compared. RESULTS: Overall 160 patients had stage IIIC epithelial ovarian cancer. Eighty patients had NACT and eighty patients had primary surgery. Patients in NACT group had higher rates of R0 resection (42% vs. 20%; p = 0.011) than patients after primary surgery. PFS was 14.1 months in NACT group and 17.7 months after primary surgery (p = 0.213). OS was 24.8 months in NACT group and 31.6 months after primary surgery (p = 0.012). In patients with R0 resections five-year and eight-year survival rates were 20.6% and 17.6% in NACT group compared to 62.5% and 62.5% after primary surgery (p < 0.0001), respectively. CONCLUSIONS: Despite higher rates of R0 resections achieved by NACT, survival of patients treated with NACT was inferior to survival of patients who underwent primary surgery. NACT should only be offered to patients with advanced epithelial cancer who are not candidates for primary surgery.

Surgical treatment of breast cancer in patients aged 80 years or older--how much is enough?

BACKGROUND: The population of elderly people is increasing and so is the population of breast cancer patients aged ≥80 years. The aim of our retrospective study was to identify independent prognostic factors for the duration of breast cancer-specific survival of surgically treated patients aged ≥80 years. The secondary aim was to determine the appropriate surgical treatment of breast cancer in patients aged ≥80 years. METHODS: We reviewed the medical records of 154 patients aged ≥80 years with early-stage breast cancer (mean age 83 years) who underwent surgery at the tertiary cancer center in the period from 2000 to 2008. Tumor stage was pT1/pT2 and pT3/pT4 in 75% and 25%, respectively. Surgical treatment comprised: quadrantectomy (in 27%), mastectomy (in 73%), axillary dissection (in 57%), and sentinel lymph node biopsy (in 18%), while 25% of patients had no axillary surgery. RESULTS: During a median follow-up of 5.3 years, 31% of patients died of breast cancer, while 28% of patients died of other causes. Half of our patients with poorly differentiated breast cancer or estrogen receptor-negative tumor died of breast cancer. Multivariate statistical analysis showed that the pathological T-stage, pathological N-stage and estrogen receptors were independent prognostic factors for the duration of breast cancer-specific survival of patients. CONCLUSION: Short breast cancer-specific survival indicates that, in patients aged ≥80 years, breast cancer with metastases in axillary lymph nodes can be an aggressive disease.

Lower tumour burden and better overall survival in melanoma patients with regional lymph node metastases and negative preoperative ultrasound.

BACKGROUND: The purpose of the study was to evaluate the ability of ultrasound (US) and fine needle aspiration biopsy (FNAB) in reducing the number of melanoma patients requiring a sentinel node biopsy (SNB); to compare the amount of metastatic disease in regional lymph nodes in SNB candidates with clinically uninvolved lymph nodes and of those with US uninvolved lymph nodes; and to compare the overall survival (OS) of both groups. METHODS: Between 2000 and 2007, a SNB was successfully performed in 707 patients with melanoma. The preoperative US of the regional lymph node basins was performed in 405 SNB candidates. In 14 of these patients, the US-guided FNAB was positive and they proceeded directly to lymph node dissection. In 391 patients, the preoperative US was either negative (343 patients) or suspicious (48 patients) (US group). In the remaining 316 patients the preoperative US was not performed (non-US group). RESULTS: The proportion of macrometastatic sentinel lymph nodes (SN), number of metastatic lymph nodes per patient and proportion of nonsentinel lymph node metastases were found to be lower in the US group compared to the non-US group. The smaller tumour burden of the US group was reflected in a significantly better OS of patients with SN metastases. CONCLUSIONS: The preoperative US of regional lymph nodes spares some patients with melanoma from undergoing a SNB. Patients with regional metastases and a negative preoperative US have a significantly lower tumour burden in comparison to those with clinically negative lymph nodes, which is also reflected in a better OS.

Prognostic heterogeneity after the excision of lymph node metastases in patients with cutaneous melanoma.

BACKGROUND: The aim of this study was to compare the overall survival (OS) of different groups of AJCC 2002 stage III cutaneous melanoma patients and to prove that patients with positive sentinel lymph node (SN) are heterogenic group with very different survival rates. METHODS: A total of 325 patients with stage III melanoma were identified from the prospective melanoma database at the Institute of Oncology Ljubljana, Slovenia; 164 had delayed therapeutic lymph node dissection (DLND), 111 had a positive sentinel lymph node biopsy followed by completion lymph node dissection (CLND) and 50 had synchronous primary melanoma and regional lymph node metastases that were treated with radical excision of the primary tumor and therapeutic lymph node dissection (TLND). Univariate and multivariate analyses were used for the assessment of the factors associated with OS and for comparison of OS between different subgroups of patients. RESULTS: The worst 5-year OS had the patients with synchronous primary melanoma and regional lymph node metastases. The patients with SN metastases with a diameter of 5.0mm or less had significantly better OS than those with DLND, while the patients with SN metastases with a diameter of more than 5.0mm had similar survival to those patients with synchronous primary melanoma and regional lymph node metastases. CONCLUSION: Melanoma patients within AJCC 2002 stage III group have very different survival rates. The group of patients with positive SN is also prognostically heterogenic because it contains patients that have better survival than those after DLND as well as patients with more aggressive disease, that have similar survival as those with synchronous primary melanoma and regional lymph node metastases.

Papillary thyroid microcarcinoma: prognostic factors and treatment.

BACKGROUND AND OBJECTIVES: Within the group of patients with papillary thyroid microcarcinoma (PTMC), the prognostic factors have not been well defined and the optimal treatment has not been proved. The aim of this study was to find out the factors associated with the tumor recurrence in the patients with PTMC. METHODS: A total of 228 patients with PTMC (189 females, 39 males; age 14-85 years, median 46 years) were treated at our Institute between 1975 and 2006. The data on patients' gender, age, extent of disease, pathomorphological characteristics, therapy, locoregional control, disease-free survival and disease-specific survival were collected. Statistical correlation between possible prognostic factors and the duration of disease-free interval was analyzed by univariate and Cox's multivariate survival analysis. RESULTS: The tumor diameter ranged from 0.1 to 10 mm (mean 6.1 mm). The median length of observation was 84 months (range 1-385). During the follow-up period, the recurrence was diagnosed in 7 patients (6 locoregional and 1 distant). Multivariate analysis showed that tumor size and lymph node metastases were independent prognostic factors for disease-free interval. CONCLUSIONS: Longer disease-free interval was found in the patients with a tumor diameter < or =6 mm and without lymph-node metastases.