RESUMO
BACKGROUND: Reports demonstrate improved survival of stage IV breast cancer patients with primary cancer resection. This may result from selection for surgery, rather than biological processes. METHODS: We performed matched-pair analysis that minimized potential bias in selecting surgery for primary cancer. Chart review was also performed of 5-year survivors to assess selection bias affecting breast surgery. RESULTS: 19,464 breast cancer patients were identified; 808 (4.2%) were stage IV: 622 were analyzed after eliminating wrong diagnoses or staging, and limiting patients to Massachusetts residents. Matched-pair analysis narrowed or eliminated apparent survival benefit associated with primary site surgery in several comparisons. When the impact of the sequence of systemic and surgical treatments was studied in stage IV patients, 90% 2-year survival occurred in patients receiving chemotherapy first, in contrast to receiving chemotherapy simultaneously with or after surgery, suggesting selection for delayed surgery after excellent response to initial chemotherapy. In bone metastases, the 2-year survival advantage occurred with chemotherapy before surgery; no difference in survival with or without surgery occurred when these treatments were simultaneous. Among 5-year survivors, frequency of primary site surgery after excellent response to systemic therapy, breast surgery in stage III patients incorrectly classified as stage IV, and frequency of oligo metastases all indicated selection bias. CONCLUSIONS: Case selection bias in primary breast cancer resection in state IV patients may explain most, if not all, the apparent survival advantage of such surgery.
Assuntos
Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Mastectomia/estatística & dados numéricos , Análise por Pareamento , Biópsia de Linfonodo Sentinela , Neoplasias da Mama/secundário , Feminino , Seguimentos , Humanos , Metástase Linfática , Massachusetts , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Viés de Seleção , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoAssuntos
Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/secundário , Carcinoma Ductal de Mama/cirurgia , Neoplasias Hepáticas/secundário , Neoplasias Pulmonares/secundário , Linfonodos/patologia , Recidiva Local de Neoplasia/patologia , Biópsia de Linfonodo Sentinela , Axila , Carcinoma Ductal de Mama/patologia , Reações Falso-Negativas , Feminino , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Pulmonares/patologia , Mastectomia/métodos , Pessoa de Meia-Idade , Medição de Risco , SegurançaRESUMO
BACKGROUND: Excising a breast tumor with negative margins minimizes local recurrence. With a positive margin, the standard re-excision consists of excising the whole cavity and all surrounding breast tissue. By marking the sides of the lumpectomy specimen with six different colored inks, the surgeon can limit the re-excision to the involved margin. We compared the local recurrence rate after these two re-excision methods. METHODS: Records were reviewed of 527 women (546 breasts) treated with lumpectomy at two institutions. The log-rank test was used to compare the local recurrence-free survival. RESULTS: Of 546 tumors, 245 (45%) had negative margins on the initial lumpectomy and were not re-excised. Fifty-five percent had a positive or close margin; 181 underwent whole-cavity re-excision, and 120 had ink-directed re-excision. The mean follow-up time was 3.4 years. There was no significant difference in local recurrence for the patients whose initial margin was negative (3.7%) compared with the 243 patients with initially positive margins who underwent a re-excision (3.3%). Eleven of 181 (6%) patients undergoing a whole-cavity re-excision developed a local recurrence, compared with none of 120 (0%) patients with an ink-directed re-excision (P = not significant). Tissue mass excised was significantly smaller in the ink-directed group (23 vs. 83 g, P < .05). CONCLUSIONS: Ink-directed re-excision of lumpectomy specimens with positive margins minimizes the amount of breast tissue removed without increasing the incidence of local recurrence and is therefore preferable to the standard whole-cavity method.
Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Lobular/cirurgia , Mastectomia Segmentar/métodos , Recidiva Local de Neoplasia/patologia , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Lobular/patologia , Corantes , Intervalo Livre de Doença , Feminino , Humanos , Tinta , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de RiscoAssuntos
Neoplasias da Mama , Oncologia/tendências , Neoplasias da Mama/mortalidade , Neoplasias da Mama/prevenção & controle , Neoplasias da Mama/cirurgia , Neoplasias da Mama/terapia , Carcinoma in Situ/prevenção & controle , Carcinoma in Situ/terapia , Feminino , Previsões , Humanos , Excisão de Linfonodo , Metástase Linfática , Mamografia/tendências , Mastectomia/tendências , Terapia Neoadjuvante , PrognósticoAssuntos
Cirurgia Geral/métodos , Oncologia/métodos , Neoplasias/cirurgia , Distribuição por Idade , Fatores Etários , Terapia Combinada , Previsões , Cirurgia Geral/normas , Cirurgia Geral/tendências , Humanos , Metástase Linfática , Oncologia/normas , Oncologia/tendências , Modelos Teóricos , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Neoplasias/tratamento farmacológico , Neoplasias/mortalidade , Neoplasias/radioterapia , Filosofia Médica , Prognóstico , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
Sentinel node biopsy to determine the presence of metastatic disease in regional lymph nodes has been described in a variety of solid tumors. Sentinel node biopsy has proven that drainage of cancer cells to the regional lymph nodes is an orderly process with metastasis predominantly to one or two nodes first before involvement of subsequent nodes. The use of this technique has resulted in the increased identification of regional metastasis suggesting that patients previously identified as node negative may have unidentified regional metastasis. The clinical significance of these microscopic tumor deposits in lymph nodes remains controversial.
Assuntos
Metástase Linfática/patologia , Biópsia de Linfonodo Sentinela/métodos , Humanos , Estadiamento de Neoplasias/métodos , Estadiamento de Neoplasias/normas , Estadiamento de Neoplasias/estatística & dados numéricos , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Biópsia de Linfonodo Sentinela/normas , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Análise de Sobrevida , Resultado do TratamentoAssuntos
Neoplasias da Mama/diagnóstico , Programas de Rastreamento , Adulto , Idoso , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/mortalidade , Feminino , Humanos , Mamografia , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Taxa de Sobrevida , Suécia/epidemiologiaRESUMO
BACKGROUND: Modern breast surgery, as the primary treatment of invasive breast carcinoma, has been evolving over the last century. Aggressive radical surgery, which included chest wall resection, complete axillary clearance and internal mammary node dissection, has slowly changed to a less aggressive approach. This has been based on an improved understanding of the biology of the disease. Over the years, randomized prospective trials, performed at centers all over the world, have demonstrated that axillary dissection does not impact on the overall survival while it helps with loco-regional control of breast cancer. Its major role, at the present time, is limited to staging and prognostication; functions that are equally well served by the limited approach of a sentinel node biopsy. SOURCES: This review is based on the available medical literature involving the biology and organ specificity of the metastatic process, not only in breast cancer but also in other malignancies. In addition, studies pertaining to clinical breast cancer, and the role of surgery in its treatment, were reviewed. The ongoing trials on the role of sentinel node biopsy in the management of the clinically node negative patients are discussed. CONCLUSIONS: This review covers the history, pathophysiology, and clinical basis of the current role of axillary dissection for invasive breast cancer. From the data presented we hope that the medical community will agree that there is no therapeutic role for extended axillary dissection at the current time.
Assuntos
Neoplasias da Mama/patologia , Linfonodos/patologia , Biópsia de Linfonodo Sentinela , Axila , Neoplasias da Mama/mortalidade , Neoplasias da Mama/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Metástase Linfática , Especificidade de ÓrgãosRESUMO
The phosphatase Cdc25A plays an important role in cell cycle regulation by removing inhibitory phosphates from tyrosine and threonine residues of cyclin-dependent kinases, and it has been shown to transform diploid murine fibroblasts in cooperation with activated Ras. Here we show that Cdc25A is overexpressed in primary breast tumors and that such overexpression is correlated with higher levels of cyclin-dependent kinase 2 (Cdk2) enzymatic activity in vivo. Furthermore, in the breast cancer cell line MCF-7, Cdc25A activity is necessary for both the activation of Cdk2 and the subsequent induction of S-phase entry. Finally, in a series of small (< 1 cm) breast carcinomas, overexpression of Cdc25A was found in 47% of patients and was associated with poor survival. These data suggest that overexpression of Cdc25A contributes to the biological behavior of primary breast tumors and that both Cdc25A and Cdk2 are suitable therapeutic targets in early-stage breast cancer.
Assuntos
Neoplasias da Mama/enzimologia , Quinases relacionadas a CDC2 e CDC28 , Fosfatases cdc25/metabolismo , Neoplasias da Mama/genética , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Quinase 2 Dependente de Ciclina , Quinases Ciclina-Dependentes/metabolismo , Bases de Dados Factuais , Ativação Enzimática , Feminino , Regulação Neoplásica da Expressão Gênica , Histocitoquímica , Humanos , Immunoblotting , Hibridização In Situ , Oligonucleotídeos Antissenso/genética , Fosforilação , Testes de Precipitina , Proteínas Serina-Treonina Quinases/metabolismo , RNA Mensageiro/análise , RNA Mensageiro/genética , Estudos Retrospectivos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Fase S/genética , Taxa de Sobrevida , Fatores de Tempo , Transfecção , Células Tumorais Cultivadas , Fosfatases cdc25/antagonistas & inibidores , Fosfatases cdc25/genéticaAssuntos
Adenocarcinoma Folicular/epidemiologia , Carcinoma Papilar/epidemiologia , Neoplasias da Glândula Tireoide/epidemiologia , Adenocarcinoma Folicular/diagnóstico , Carcinoma Papilar/diagnóstico , Diagnóstico Diferencial , Alemanha/epidemiologia , Humanos , Incidência , Prognóstico , Neoplasias da Glândula Tireoide/diagnóstico , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976. METHODS: Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base. RESULTS: Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hürthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall). CONCLUSIONS: In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes.
Assuntos
Adenocarcinoma Folicular/cirurgia , Carcinoma Papilar/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Adenocarcinoma Folicular/patologia , Adulto , Idoso , Biópsia por Agulha , Carcinoma Papilar/patologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Fatores de Risco , Neoplasias da Glândula Tireoide/patologia , Resultado do TratamentoRESUMO
It is increasingly important for the surgical oncologist and surgeons to have a thorough understanding of the advantages and limitations of adjuvant systemic chemotherapy, hormonal therapy, and adjuvant radiotherapy in various resectable cancers. Justification for the field of surgical oncology should include the fact that enough knowledge has been acquired about these adjunctive treatments for patients with cancer that they can be integrated into overall management. Too often in the recent past, surgeons, after the technical surgical resection, turned over the entire management of patients to the medical oncologist or the radiotherapist. Comprehensive management for surgeons and surgical oncologists should maintain their voice in management policy so that the patients can be served best by the application of adjuvant treatment or by the avoidance of adjuvant treatment, systemic or local, when it is not appropriate or significantly helpful. The overall justification for the field of surgical oncology is that the surgeon not only knows how to use medical treatments in advanced cancers, but also knows how to select minimal surgical procedures in early cancers and how to manage and direct the application of adjuvant treatments, regionally and systemically.
Assuntos
Neoplasias/cirurgia , Neoplasias da Mama/cirurgia , Neoplasias Colorretais/cirurgia , Cirurgia Geral , Humanos , Oncologia , Melanoma/cirurgia , Padrões de Prática Médica , Neoplasias Gástricas/cirurgiaRESUMO
The Breast Health Center, a component of the program in Women's Oncology at Women & Infants Hospital, is a multidisciplinary center devoted to the treatment and study of benign and malignant breast diseases. The philosophy, structure, and function of The Breast Health Center are described along with its specific components. The Breast Health Center's three fundamental missions of patient care, education, and research are discussed.