Intervention for Hepatic and Pulmonary Metastases in Breast Cancer Patients: Prospective, Multi-institutional Registry Study-IMET, Protocol MF 14-02.

BACKGROUND: One fourth of early-stage breast cancer cases become metastatic during the follow-up period. Limited metastasis is a metastatic disease condition in which the number of metastatic sites and the extent of the disease both are limited, and the disease is amenable to metastatic intervention. This prospective study aimed to evaluate intervention for limited metastases in the lung, liver, or both. METHODS: The study enrolled luminal A/B and/or human epidermal growth factor receptor 2 (HER2)-neu+ patients with operable lung and/or liver metastases in the follow-up assessment after completion of primary breast cancer treatment and patients with a diagnosis of metastasis after 2014. Demographic, clinical, tumor-specific, and metastasis detection-free interval (MDFI) data were collected. Bone metastasis in addition to lung and liver metastases also was included in the analysis. The patients were divided into two groups according to the method of treatment for metastases: systemic therapy alone (ST) group or intervention (IT) group. RESULTS: Until June 2020, 200 patients were enrolled in the study. The demographic data were similar between the two groups. The median follow-up time was 77 months (range 55-107 months) in the IT group (n = 119; 59.5%) and 57 months (range 39-84) in the ST-only group (n = 81; 40.5%). The median MDFI was 40 months (range 23-70 months) in the IT group, and 35 months (range 13-61 months) in the ST-only group (p = 0.47). The groups had similar surgeries for the primary tumor and axilla. Most of the patients had liver metastases (49.5%, n = 99), and 42% (n = 84) of the patients had lung metastases. Both lung and liver metastases were found in 8.5% (n = 17) of the patients. The primary tumor was estrogen receptor/progesterone receptor-positive in 75% (n = 150) of the patients, and 32% (n = 64) of the patients had HER2-neu+ tumors. Metastatic-site resection was performed for 32% (n = 64) of the patients, and 27.5% (n = 55) of the patients underwent metastatic ablative interventions. In the Kaplan-Meier survival analysis, the hazard of death (HoD) was 56% lower in the IT group than in the ST-only group (hazard ratio [HR], 0.44; 95% confidence interval [CI] 0.26-0.72; p = 0.001). The HoD was lower in the IT group than in the ST-only group for the patients younger than 55 years (HR, 0.32; 95% CI 0.17-0.62; p = 0.0007). In the multivariable Cox regression model, HoD was significantly lower for the patients who underwent intervention for metastases and had an MDFI longer than 24 months, but their liver metastases doubled the risk of death compared with lung metastases. CONCLUSION: Metastasis-directed interventions have reduced the risk of death for patients with limited lung/liver metastases who are amenable to interventions after completion of primary cancer treatment. For a select group of patients, such as those with luminal A/B or HER2-neu+ breast cancer who are younger than 55 years with limited metastases to the lung and liver or an MDFI longer than 24 months, surgical or ablative therapy for metastases should be considered and discussed on tumor boards.

In which cases surgical gastrostomy and jejunostomy techniques are inevitable?

PURPOSE: This study investigated the surgical gastrostomy and jejunostomy procedures in cancer patients who needed nutritional support and endoscopy was unattainable. METHODS: Operation time and procedure, anesthesia and tube types, procedure-specific and surgical complications, and tube replacement at the follow up period were retrospectively analyzed. RESULTS: 109 patients (44 female, 65 male, mean age 50.9 years, range 14-87) were subjected to surgical gastrostomy/ jejunostomy. Ninety-three (85.4%) patients had head-neck and gastrointestinal cancers. In 94 (86.2%) patients endoscopy was impossible due to obstruction of the esophagus and stomach. Gastrostomy/jejunostomy was combined with other surgical procedures in 12 (11 %) patients. Procedure- related complications occurred in 22 (20.7%) patients. Early 30-day mortality occurred in 12 (11 %) cases. The median follow up period was 3.6 months (range 0-18). CONCLUSION: Obstructing cancer, obesity or previous laparotomy make the use of endoscopic techniques impossible. For these patients, surgical gastrostomy/jejunostomy is safe with acceptable complication rates and improves the treatment outcomes with nutritional support.

Characteristics and risk factors for colorectal cancer recurrence.

PURPOSE: To evaluate the characteristics of recurrence and examine the clinicopathological factors related to disease- free (DFS) and overall survival (OS) of patients with colorectal cancer (CRC) recurrence. METHODS: One hundred and sixteen CRC patients with stage II and III disease that had been resected curatively in our clinic between 1999 and 2006 were retrospectively evaluated. The parameters evaluated were gender, age, preoperative CEA levels, tumor localisation, duration of surgery, the units of perioperative blood transfusion, tumor differentiation, TNM stages and adjuvant therapies. The presence of preoperative intestinal obstruction, radical abdominopelvic lymph node (RAPL) dissection and lymphatic, vascular and perineural invasion were also evaluated. RESULTS: With 36.6+/-2 months follow-up, 49 (42%) patients developed local recurrence and/or distant metastases. Twenty-three (19.8%) patients presented with isolated local recurrence. Thirteen of 49 patients with local recurrence were successfully operated with R0 curative resection. The OS survival rates for those with curatively and palliatively resected recurrences were 29 and 19 months, respectively. In multivariate analysis, the factors related to DFS were tumor localisation and differentiation, neurovascular invasion, blood transfusion and RAPL dissection. Among these factors, only RAPL dissection was not statistically significant for OS. CONCLUSION: The factors increasing local recurrence rates of CRC should be clearly described. Local and systemic treatment modalities, like preoperative chemoradiotherapy should be planned for patients carrying these risk factors.

Prognosis in hormon receptor negative breast cancer patients according to ERBB2 status.

Breast carcinomas represent a heterogenous group of tumors and recent studies have demonstrated several subtypes of breast cancer by gene expression profiles. This study aimed to compare hormon receptor negative (ER-/PR-/ERBB2+) and triple negative (ER-/PR-/ERBB2-) patients in terms of prognosis and to show that molecularly defined subtypes can be distinguished by conventional laboratory methods. Patients treated between 2001-2007 for hormon receptor negative breast cancer were retrospectively studied. In addition to the conventional prognostic factors, effect of ERBB2 status of the patients on disease-free and overall survival was evaluated. Hormon receptor and ERBB2 status were determined by immunuhistochemistry and fluorescence in-situ hybridization. 141 patients were eligible for the study. Number of patients with ERBB2 positive and triple negative tumors was 70 and 71, respectively, and two groups were comparable in terms of study parameters. Tumor size, grade, axillary status, patient groups, and adjuvant chemotherapy and radiotherapy showed significant impact on disease-free survival and overall survival was significantly dependent on axillary status, type of surgery, and patient groups in univariate analysis. In multivariate analysis, patient groups, tumor grade, and axillary status were independent prognostic factors for disease-free survival whereas patient groups, extent of surgery, and axillary status were independent prognostic factors for overall survival. This study has indicated that ERBB2 negative patients had worse survival among hormon receptor negative breast cancer patients and showed that molecularly defined subtypes of breast cancer can be differentiated by immunuhistochemistry in terms of prognosis.

Results of treatment in 182 consecutive patients with genital fistulas.

OBJECTIVES: To evaluate genital fistulas with the aim of improving strategies to prevent them. METHOD: An institutional, retrospective, clinical analysis. One hundred eighty-two patients with genital fistulas managed consecutively between 1970 and 1993 were analyzed. RESULTS: About 60% of all fistulas were attributable to obstetric traumas whereas gynecologic surgery constituted only 24.7% of cases. The contribution of gynecologic surgery increased from 11.1% in 1970-75 to 60.6% in 1988-93. Approximately half of the patients had vesico-vaginal fistulas. Of the 45 patients with fistulas occurring following gynecologic surgery, 19 had undergone simple hysterectomy and eight had undergone radical hysterectomy. All cesarean sections had been performed after failed labor. Hysterectomy was performed due to myoma in nine patients, endometrial hyperplasia in two patients and pelvic relaxation in eight patients. As regards management of fistulas, the transvaginal approach was chosen in the vast majority of patients. The overall success rate after the primary repair of fistulas was 91.5% (162/177). Fifteen patients with failure of the primary repair were subjected to repeat repairs. The second repair was successful in 11 patients but the remaining four needed further repairs. The maximum was seven repairs to a recto-vaginal fistula before a satisfactory result could be achieved, which had initially occurred after a cesarean section. CONCLUSION: Although the results of reparative surgery are promising, it would be more useful to encourage national measures to prevent in particular obstetric trauma.

Pregnancy in infertile PCOD patients. Complications and outcome.

OBJECTIVE: To evaluate the complications and outcome of pregnancy in women with polycystic ovary disease (PCOD). STUDY DESIGN: The course and outcome of 47 singleton pregnancies in women with well-documented PCOD were compared with those in 100 healthy controls. RESULTS: Women with PCOD had a significantly higher body mass index as compared to the control group (P < .05); however, the proportion of lean versus obese subjects in the two groups was similar. The incidence of an abnormal glucose challenge test, gestational diabetes mellitus and pregnancy-induced hypertension was significantly increased in pregnant women with PCOD (P < .05). When lean PCOD subjects were compared with lean control subjects, the difference in the incidence of the above complications was still significant (P < .05). The incidence of pregnancy complications was similar when obese PCOD subjects were compared with obese controls. CONCLUSION: Women with PCOD were at increased risk of gestational diabetes and pregnancy-induced hypertension, and this risk appeared to be independent of body mass index.

Skinning vulvectomy for the treatment of vulvar intraepithelial neoplasia 2-3: a study of 21 cases.

Twenty-one cases of patients with vulvar intraepithelial neoplasia (VIN) 2-3 were reviewed. The mean age at diagnosis was 45.4 years. All of the patients presented with vulvar pruritus. Five of the patients had hypertension, two had coronary heart disease and two had diabetes mellitus as complicating medical illnesses. None of the patients had history or evidence of vaginal intraepithelial neoplasia (VAIN) or cervical intraepithelial neoplasia (CIN), and only one patient had invasive cervical cancer at diagnosis. Provided the histology confirmed VIN, the patients were subjected to a skinning vulvectomy procedure. Of the patients, 15 (71.4%) had VIN 2, and the remaining 6 (28.6%) had VIN 3 at preoperative evaluation. Histologic analysis of skinning vulvectomy specimens revealed no evidence of neoplasia in three patients (14.2%). Multifocality was observed in only three patients (14.2%). The areas involved were the perineum in four patients, labia in 15 and clitoris in two patients. Associated vulvar pathologies were condyloma acuminata in one, squamous vulvar hyperplasia in three and lichen sclerosus with squamous hyperplasia in one patient. The complications of the procedure included febrile morbidity in three patients and minor wound break-down in one patient. None of the patients in this series experienced recurrence. Skinning vulvectomy seems to have a high success rate in treatment of VIN 2-3 with minimal postoperative complications and satisfactory cosmetic results. However, observation of only three patients with multifocal lesions as well as no patient with invasive cancer adds credence to an ablative procedure after appropriate evaluation under colposcopy.

Uterine rupture following hysteroscopic lysis of synechiae due to tuberculosis and uterine perforation.

A patient with genital tuberculosis who conceived with in-vitro fertilization and embryo transfer following hysteroscopic synechiolysis complicated by a fundal uterine perforation subsequently presented with uterine rupture at 36 weeks gestation. Immediate Caesarean section and repair of the ruptured uterus were performed. Women with a history of uterine perforation should be counselled regarding the risk of uterine rupture during their subsequent pregnancies.

Fifty-one Kaposi sarcoma patients

INTRODUCTION: Kaposi sarcoma (KS) is a mesenchymal tumor originating from lymphatic endothelial cells. Immunosuppressive patients have higher risk for KS. HHV-8 has a role in immunopathogenesis of KS. Aim Evaluation of demographical properties with tumor characteristics and treatment modalities of KS. MATERIAL AND METHOD: Histopathologically documented KS patients were evaluated retrospectively. Anti-HIV seroprevalence was also evaluated with patient and tumor characteristics besides treatment regimens. RESULTS: Fifty-one patients were included between September 1998 and February 2009. Male/female ratio was 3.25 (39/12). Median age was 68 (31-94). Lower extremity was the most common site whereas excisional biopsy was the most common diagnostic procedure. Smoking rate was 42.8%. Twenty percent had family history for cancer. Anti- HIV seropositivity rate was 1.9%. Thirty eight percent had local monotherapy, and radiotherapy was most common (26%). Multidisciplinary approach rate was 44%. Most of them had surgery and radiotherapy combination. Two-third of the patients had radiotherapy alone or with other modalities. Rates were as 12% for chemotherapy and 6% for interferon. Vincristine-bleomycin-doxorubicin combination was the most preferred regimen (60%). CONCLUSION: Male patients in the sixth decade seem to have higher risk for KS. Smoking rate was almost as high. Local therapy might be sufficient in most of the patients. However, we may also consider systemic chemotherapy for selected patients, including vincristine, bleomycin and doxorubicin (AU)