The impact of treatment on quality of life of patients with head and neck cancer and its association with prognosis.

BACKGROUND: Information is scarce regarding the impact of treatment on Health-Related Quality of Life (HRQL) of patients with Head and Neck (H&N) cancers. We assessed the effect of treatment on HRQL and its association with prognosis in H&N cancer. PATIENTS AND METHODS: Patients with H&N cancer in whom HRQL was assessed before and after treatment. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-H&N35 instruments were used. Association of changes in patients' HRQL after treatment with Loco-Regional Recurrence (LRR) and Overall Survival (OS) was investigated. RESULTS: One hundred sixty patients were included; scales of the baseline assessment of HRQL were moderately associated with LRR and OS, but the impact of treatment on most HRQL scales was strongly associated with OS. By multivariate analysis, baseline assessment of Global Health, Physical, HN Teeth, HN Dry mouth, and HN Cough scales, and impact of treatment on the Physical and Pain scales comprised independent variables associated with LRR. Male gender, positive lymph nodes, baseline assessment of Role, HN Pain, HN Cough, and impact of treatment on Emotion, Pain, Financial, HN Swallowing, HN Social contact, and the interaction of HN Pain-change in Pain scales were associated with OS. Both multivariate models were adjusted by the neoplasm's site of origin. CONCLUSION: Aside from well-known clinical-pathologic prognostic factors in H&N cancers, HRQL assessment, both prior to and after treatment, provides significant prognostic information and should be measured. Design of therapeutic clinical trials in patients with H&N cancers should consider these novel prognostic factors.

Validation of the Mexican-Spanish version of the EORTC QLQ-C30 and BR23 questionnaires to assess health-related quality of life in Mexican women with breast cancer.

The aim of this study was to validate the Mexican-Spanish version of The European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23 questionnaire. The translation procedure followed EORTC guidelines. QLQ-C30 and QLQ-BR23 instruments were completed by Mexican women with breast cancer, attending a teaching referral cancer centre from February 2009 to January 2010. Patients were divided in two groups: (1) Patients with early stage of breast cancer; and (2) Patients with locally advanced breast cancer (LABC). Reliability and validity tests were performed, and validity over time (responsiveness) was conducted in a subset of patients. Two hundred and thirty-four women (mean age, 52.3 years) completed both questionnaires. Convergent and divergent validity was adequate. Cronbach's alpha of all multi-item scales showed values ≥0.7 except for Cognitive and Breast symptoms scales (0.52 and 0.65 respectively). Patients with early stages (n= 77) showed better functional scores and lower symptoms scores than patients with LABC (n= 157). Score means variation after responsiveness analysis demonstrated high sensitivity to change after breast cancer surgery. The Mexican-Spanish version of the EORTC QLQ-BR23 questionnaire is a valid and suitable instrument to estimate HRQL in patients with breast cancer.

Juvenile nasopharyngeal angiofibroma: clinical factors associated with recurrence, and proposal of a staging system.

BACKGROUND: Juvenile nasopharyngeal angiofibroma (JNA) is a vascular tumor of the nasopharynx. Our aim is to analyze prognostic factors, report results obtained with radiation therapy and propose a staging system. MATERIALS AND METHODS: Retrospective study of patients with JNA. Clinical, radiological and therapeutic data were assessed for recurrence- and disease free survival-associated prognostic factors. Bivariate and multivariate analyses were performed. RESULTS: Fifty-four males were analyzed. Invasion to anterior infratemporal fossae (ITF) +/or to pterygomaxillary fossae, to posterior infratemporal fossae, or intracranial extension were associated with recurrences in 2 of 15, in 8 of 18, and in 8 of 12 cases, respectively. Tumors < or > or =6 cm were associated with zero and with 18 recurrences, respectively (P = 0.006). A staging system is constructed considering extension patterns and size. Multivariate analyses conferred significance (P = 0.002) to a model including this staging system and surgical margins. CONCLUSION: Our system stratifies recurrence risk and disease-free survival efficiently. Since radiotherapy at young age has potential to induce malignancies, it should be used with caution. It could be considered as primary treatment in stage IV cases with major invasion to cavernous sinus or orbital apex. Therapy design may be improved.

Concurrent chemoradiation with carboplatin for elderly, diabetic and hypertensive patients with locally advanced cervical cancer.

INTRODUCTION: Chemoradiation based on cisplatin is the standard treatment of locally advanced cervical cancer, however, a subset of patients are either elderly and/or have comorbidities such as diabetes and hypertension. These conditions may compromise the administration of cisplatin. We report our Institution experience with weekly carboplatin as a radiosensitizer for the management of this subset of patients. PATIENTS AND METHODS: We reviewed the files of 59 patients with locally advanced cervical cancer who were treated with primary chemoradiation with weekly carboplatin. Response rate, toxicity and survival were analyzed. RESULTS: Mean age was 62 years (range, 36-83 years). The majority of cases were squamous cell carcinoma (88.14%), and distribution according to FIGO Stage was IB2 8.4%, IIA 13.5%, IIB 52.5%, IIIA 3.3% and IIIB 18.6%; Overall, 100% and 91% of patients completed external beam and intracavitary therapy. Seventy-nine percent received from five to six planned cycles of weekly carboplatin. Complete responses were achieved in 49 (83.05 %) patients, whereas ten patients (16.95%) had either persistent or progressive disease. The most common toxicities were grades 1 and 2 hematological and gastrointestinal. At median follow-up (20 months; range 2-48 months), 16 patients (32.65%) have relapsed. Estimated 30-month overall survival is 63%. CONCLUSIONS: Weekly carboplatin concurrent with pelvic radiation is well tolerated in patients with locally advanced carcinoma of the cervix who are older than 70 years and/or have diabetes mellitus and/or high blood pressure, however, the apparently slighty lower survival observed cautions against its routine use.

An audit of nasopharyngeal fibromas.

BACKGROUND: Nasopharyngeal angiofibroma (NA) is a vascular tumor of the nasopharynx of young males which presents rarely. Our aim was to analyse outcome and prognostic factors of a case series of NA. MATERIALS AND METHODS: We conducted a retrospective study of patients with diagnosis of NA treated at a single institution from 1981 to 2003. We evaluated clinical, radiological and therapeutic data for recurrence- and disease-free survival-associated prognostic factors. Bi- and multivariate analyses were performed. RESULTS: Fifty-four males with NA constitute our study group. Age varied from 12 to 35 years (mean, 18.5 years; standard deviation [SD], 4.9). There were 18 recurrences; localization in nasopharynx, nasal fossae or maxillary antrum was not associated with recurrences. Invasion to pterygomaxillary fossae, to infratemporal fossae or to skull base and/or intracranial extension were associated with recurrences in two of 14, in five of 12, and in 11 of 18 cases, respectively. Tumors < or >or=6 cm were associated with zero and with 18 recurrences, respectively (p<0.01). Multivariate analyses conferred statistical significance (p<0.01) to a model including patterns of extension, tumor size in pterygomaxillary or anterior infratemporal fossa invasion, and surgical margins. CONCLUSION: Recurrence factors for NA are defined and consequently treatment design is suggested. Endoscopic approaches could be considered in patients with minor lateral extensions, while wide surgical approaches are indicated in invasive cases. Radiotherapy could be applied alone or combined with surgery for extensive intracranial involvement.

Prognostic factors in maxillary sinus and nasal cavity carcinoma.

AIMS: The aim of the present study is to define prognostic factors, particularly the impact of treatment on paranasal sinus and nasal cavity malignancies. MATERIAL AND METHODS: Retrospective study of patients with maxillary antrum and nasal fossae malignancies. A maxillectomy classification as performed to treat malignancies in our institution is described. Multivariate analysis of prognostic factors was done using the Cox's model. RESULTS: One hundred and nine patients were evaluated. Squamous cell carcinoma was found in 62 cases and in 95 patients the epicentre of the tumour was located in the maxillary antrum. Ten patients were treated with surgery only, 39 patients with surgery and adjuvant radiation therapy, 37 cases received only radiotherapy, and 18 received radiotherapy followed by surgery; in five cases a combination of chemo-radiotherapy was used. Multivariate analysis identified T classification, orbit invasion, N classification, site of origin of tumour in nasal fossae, and no surgical resection as independent prognostic factors (p=0.0001). CONCLUSION: T4 tumours with orbit invasion present bad prognosis as compared to other T4 tumours. Surgical resection should be included in the treatment strategy. Because of the high frequency of lymph-node metastasis, neck treatment should be considered in T4 tumours.

The role of pretherapeutic laparoscopy in the selection of treatment for patients with gastric carcinoma: a proposal for a laparoscopic staging system.

BACKGROUND: A pretherapeutic staging system to design nonoperative or neoadjuvant treatments in gastric cancer is required. In this study, a simple staging system based on laparoscopic findings to define a treatment algorithm was developed. METHODS: A retrospective cohort study was conducted of 151 patients allocated into four stages based on laparoscopic findings. The depth of tumor invasion and the presence of metastasis based on laparoscopic findings were used to construct these stages. Laparoscopic findings were compared with histopathology. RESULTS: An excellent agreement of the laparoscopy-defined depth of invasion and the surgical pathology standard was found (weighted kappa 0.85). The likelihood ratios for a positive and negative laparoscopic diagnosis of metastasis were 40.4 and 0.015, respectively (98.5% sensitivity, 97.6% specificity). Those for positive and negative diagnosis of resectability were 2.6 and 0.03, respectively (98.4% sensitivity, 62% specificity). The laparoscopic stages presented significant prognostic value. Two-year survival was 93%, 69%, 60%, and 17%, respectively. Surgical resection was possible in 100%, 100%, 49%, and 12%, respectively. CONCLUSIONS: The proposed laparoscopic staging system is a simple and reproducibLe way for selection of a suitable therapy. It allows for adequate stratification of the main risk factors in the setting of clinical trials evaluating preoperative treatments.

[Early gastric carcinoma. Analysis of 21 cases]. / Carcinoma gástrico incipiente. Análisis de 21 casos.

BACKGROUND: Early gastric carcinoma (EGC) is defined as a neoplasm confined to the mucosa and submucosa regardless of the presence of metastasis. This lesion is found in approximately 3% of cases in Mexico. The aim of this study is to describe our experience with EGC, emphasizing early detection as the most useful method to decrease mortality. METHODS: Retrospective review of records of patients with EGC treated at an oncologic referral center over a 12-years period. RESULTS: Twenty-one cases of EGC were retrieved. Mean age was 58.1 years (range, 33 to 84). Twelve were women and nine, men. Lymph node or distant metastasis were not found. Overall 5-year survival was 66.4%. Twenty patients underwent radical gastrectomy and only one underwent wedge resection of the gastric wall. Two patients (9.5%) presented recurrence and cancer-related death. Mean follow-up was 8.3 years. CONCLUSION: The prognosis of EGC in our hospital is lower than in countries other than Mexico and this lesion is found with low frequency. Increasing the detection EGC is the best method to reduce GC-related mortality.

[Laparoscopic partial hepatectomy. Report of the first case in Mexico]. / Hepatectomía parcial por laparoscopia. Informe del primer caso en México.

The authors report the case of a 47-year-old female patient referred to the Instituto Nacional de Cancerología with abdominal pain and a focal liver lesion in the left lateral segment. After a careful tumor work-up, a laparoscopic left lateral segmentectomy was performed. The postoperative course was uneventful and the patient was discharged at the 2nd postoperative day. Histologic examination revealed focal nodular hyperplasia. In a search of the literature we find this to be the first case treated by this approach in Mexico.

Preoperative multivariate prediction of morbidity after gastrectomy for adenocarcinoma.

BACKGROUND: Gastrectomy remains the only curative treatment for gastric cancer. However, surgical morbidity and mortality remains high. Our aim was to identify the risk factors that determine operative morbidity and mortality and to describe a simple method for preoperative stratification of morbidity outcome. METHODS: Retrospective review of patients who underwent gastrectomy for gastric cancer. Multivariate analysis was used to define risk factors for surgical morbidity and mortality. RESULTS: A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19 surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin (RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR, 1.51) were the most important risk factors for morbidity. However, location of the tumor, serum albumin level, and lymphocyte count were the most important preoperative risk factors that determine the appearance of surgical complications. Receiver operating characteristic analysis of this model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and 52.4%, respectively). CONCLUSIONS: A new method for preoperative calculation of the probability of surgical complications was developed. It must be validated prospectively and in different settings to be used in preoperative interventions designed to reduce that risk.

Survival benefit of D2 lympadenectomy in patients with gastric adenocarcinoma.

BACKGROUND: A definite resolution to the controversy on the optimal extension of lymph node dissection (LND) in gastric cancer has not been achieved. Surgical morbidity and survival of D1 and D2 LND are compared by multivariate analysis. METHODS: A retrospective cohort study of 219 patients with gastric cancer and curative resection performed according to Japanese rules. D1 dissection was performed in 106 cases and D2 in 113. The logistic regression model was used to define risk factors for surgical morbidity and the Cox model to determine prognostic factors. RESULTS: Surgical morbidity occurs in 16.9% and 19.5% in D1 and D2 LND, respectively (P = .7). The morbidity determinants were operation blood loss, splenectomy, pancreaticosplenectomy, antrum location, low serum albumin, total gastrectomy, and metastatic nodal ratio (P < .0001), but not D2 LND. Five-year survival was 35.1% for D1 and 64% for D2 LND (P < .039). The prognostic factors were T stage, N stage, serum albumin level, total gastrectomy, D2 LND, and comorbidity (P < .0001). CONCLUSIONS: The increment of surgical morbidity and mortality rates attributed to D2 LND is largely caused by the effect of splenectomy and pancreaticosplenectomy. A significant survival benefit because of D2 LND was found. The results support the value of extended LND in the surgical treatment of gastric cancer.

Neoadjuvant chemotherapy with P-ELF (cisplatin, etoposide, leucovorin, 5-fluorouracil) followed by radical resection in patients with initially unresectable gastric adenocarcinoma: a phase II study.

BACKGROUND: Gastric cancer is the most frequent gastrointestinal cancer in Mexico. Only 33% of cases are resectable. Our aim was to determine the activity and toxicity of the cisplatin, etoposide, leucovorin, and 5-fluorouracil combination in initially unresectable tumors and to determine its ability to permit resection. METHODS: Sixty patients with unresectable gastric adenocarcinoma were treated with cisplatin 80 mg/m2, etoposide 80 mg/m2, leucovorin 25 mg/m2, and 5-fluorouracil 800 mg/m2 by central intravenous catheter for 4 consecutive days. Two courses of this combination were followed by surgical resection. RESULTS: The overall response rate was 36.8% (20 partial responses and one complete response). By using logistic regression analysis, the tumor, node, and metastasis stage (risk ratio, 2.04; 95% confidence interval, 1.03-4.02; P = .039) was identified as the response determinant to chemotherapy. Major toxicity was grade 3 or 4 neutropenia in 67% of patients. Ten resections were performed (17.5%); five were curative and five palliative. Operative morbidity and mortality rates were 40% and 10%, respectively. The median length of survival was 7.46 and 13.3 months for nonresponders and responders, respectively (P = .011). CONCLUSIONS: The cisplatin, etoposide, leucovorin, and 5-fluorouracil combination is active in advanced gastric cancer and the toxicity level is acceptable. This treatment permits a 17.5% resection rate in previously unresectable tumors. A randomized trial of surgery vs. neoadjuvant chemotherapy plus surgery is warranted.

[Multiorgan resection in T4 colonic adenocarcinoma. Report of a case]. / Resección multiorgánica en adenocarcinoma de colon T4. Informe de un caso.

BACKGROUND: Colorectal cancer is the second among gastrointestinal malignancies in Mexico Locally advanced disease or metastatic lesions are frequently found. To resect or not such a tumor is a difficult decision. OBJECTIVE: To report a case of colon cancer with multivisceral invasion resected and to review the published information. CLINICAL MATERIAL: A 43 year-old Mexican male with rectal bleeding and weight loss with a tumor located in transverse colon with direct invasion to stomach. CT scan demonstrated invasion to spleen and pancreas. En-bloc radical-extended right colectomy, total gastrectomy, distal pancreatectomy, splenectomy and left adrenalectomy was performed. Adjuvant chemotherapy was used. At 12-month follow-up he is asymptomatic, without neoplasic activity and with good quality of life. CONCLUSION: An aggressive multiorganic resection in T4 colorectal tumors is justified in selected cases. The high morbidity and mortality of these procedures must be evaluated individually, and if permissive must be performed.

[Indications and results of hepatic resection in benign and malignant tumors]. / Indicaciones y resultados de la resección hepática en tumores benignos y malignos.

OBJECTIVE: The authors analyze the indications and results in 75 consecutive liver resections. BACKGROUND: In recent years, the morbidity and mortality of this procedure have been reduced at specialized centers due to better control of intraoperative bleeding and improved perioperative management. METHODS: The clinical records of 72 patients who had a liver resection over a 4-year period were reviewed. RESULTS: Fifty-two were females and 23, males. Ages ranged between 15 and 88 years (X: 50 +/- 22 years). The indications for surgery were liver, secondary in 28, gallbladder or bile duct cancer in 17, benign liver tumors in 16, and primary malignant liver tumors in 14. Forty-seven major liver resections were performed and included 25 right hepatectomies, 13 left hepatectomies, five right trisegmentectomies, and four left trisegmentectomies. Additionally, 28 minor resections included 12 resections of the left lateral segment, nine bisegmentectomies, five segmentectomies and two resections of the caudate lobe. Operative time ranged from 60-540 min (X: 260 +/- 97 min); the mean operative bleeding was 1439 +/- 660 mL (range 20-5,000 mL). The pringle maneuver was used in 63 patients and ranged from 20-100 min (X: 42 +/- 25 min). Twenty-five patients presented complications (33%), the most frequent being hepatic failure, postoperative bleeding, ascitis and bilomas. Six patients died (8%) due to hepatic and multiorganic failure in four pneumonia and myocardial infarct in one, and systemic sepsis in the other. CONCLUSIONS: Liver resection is an excellent therapeutic alternative in patients with benign and malignant liver focal lesions.

[Prognostic factors in 793 cases of gastric cancer in an oncologic referral center]. / Factores pronósticos en 793 casos de cáncer gástrico en un centro de referencia oncológico.

OBJECTIVE: To describe the 12-year experience with Gastric Cancer (GC), with special emphasis in prognostic factors. BACKGROUND: GC is the most common gastrointestinal malignancy and is the second cause of cancer-related mortality in Mexico. Poor results have been reported, and new treatments have not improved the life expectancy. The available information regarding GC in our country is limited. METHODS: Retrospective cohort study of 793 patients with gastric adenocarcinoma treated in an oncologic referral center in Mexico City. Demographic and clinical data, and the results of surgical treatment are presented. Survival curves by TNM stage and other prognostic factors are described. RESULTS: Sixty two percent of the patients presented in stage IV, with a median survival of 8.6 months. Only 33% of the whole group underwent surgical resection. One hundred and sixty two subtotal, 86 total and 12 proximal gastrectomies were performed, 74% with curative intention and in 26% for palliation. Operative morbidity and mortality were 23.3% and 10.9%, respectively. The multivariate analysis showed that the independent prognostic factors were TNM stage (Risk ratio 1.49; 95% CI 1.26-1.76; p < 0.0001), operative morbidity (RR 6.05; 95% IC 3.74-9.7; p < 0.0001), seralbumin (RR 1.26; 95% CI 1.03-1.5; p < 0.03), age (RR 1.01; 95% CI 0.9-1.02; p < 0.057), type of lymphadenectomy (RR 1.59; 95% CI 0.97-2.59; p < 0.06) and gastrectomy performed (RR 1.9; IC 95% 0.9-4.2; p < 0.06). CONCLUSION: The TNM staging system was the most important prognostic factor. The high rate of GC in advanced stages affects directly the results. Better survival may be expected if the relative frequency of stages I and II increase. Endoscopy is warranted to patients with dispeptic symptoms who present no response to treatment or recurrence. Our experience reflects the importance of this health problem in México.

[Experience with 14 cases of pancreatic pseudocyst]. / Experiencia con 14 casos de pseudoquiste pancreático.

INTRODUCTION: Pseudocyst of the pancreas (PP) develops in 2 to 5% the cases of acute pancreatitis (AP). Most cases of PP regress spontaneously. PP has been misdiagnosed as a malignant pancreatic cyst neoplasm, reason why the patients are referred to specialized institutions. OBJECTIVE: To describe the cases of PP treated in a 15 year-period. MATERIAL AND METHODS: Review of clinical records of 14 cases treated from 1975 to 1989. RESULTS: There were 5 men (36%) and 9 women (64%) Mean age was 41 years (range 18 to 77). In 50% of the cases the patient had a history of severe alcoholic abuse, cholelithiasis in 28% and abdominal trauma in 15%. Five patients (35%) had AP. The period between AP symptoms and the diagnosis of PP was a mean of 5.7 months. Abdominal pain and abdominal mass were present in all of the cases, in all cases, ultrasonography and CT scan made the diagnosis of PP. Thirteen cases were treated by surgery, 12 with internal drainage, one by resection and one by external drainage. An enterocutaneous fistula (7%) was recorded in one case. There were no operative mortality. The mean follow-up time was of 10 years and 4 months. CONCLUSIONS: PP is a uncommon pathology in oncologic centers. Internal drainage was the most frequent treatment. The diagnosis of cystic neoplasms of the pancreas should be ruled out.

[Management of digestive system carcinoid tumors and carcinoid syndrome]. / Manejo del tumor carcinoide del aparato digestivo y del síndrome carcinoide.

INTRODUCTION: Carcinoid tumors are rare, most of the publications are case reports and the clinical series are uncommon. The quality of life and survival time of these patients depend on the adequate control of tumor growth and good palliation of their symptoms. AIMS: The purpose of this study is to inform epidemiological data and forms of management for these tumors and the Carcinoid Syndrome at the National Institute of Cancerology (INCan) at Mexico City in the last 15 years. METHODS: A retrospective review of the clinical records of patients diagnosed and treated at the INCan with carcinoid tumors from 1982 to 1997 was performed. RESULTS: The most common origin place was the gastrointestinal tract (GI), and the majority involved the right colon and the appendix. The longest survivors were patients with tumors originated in the appendix, tumors smaller than 2 cm or localized. At the time of diagnosis 47% of patients had metastatic disease that was also a poor prognostic factor. The experience in our hospital seem to support the use of interferon alone or in combination with octreotide or debulking surgery for the palliation of carcinoid syndrome. CONCLUSIONS: Carcinoid tumors are rare, and have a slow growth and less aggressive biological nature than noncarcinoid tumors. Treatment should be focused on trying to cure the small or localized lesions or to find the best palliative method for those symptomatic advanced lesions.