Inflammation-related proteins as biomarkers of treatment-related behavioral symptoms: A longitudinal study of breast cancer patients and age-matched controls

Background

Behavioral symptoms in breast cancer (BC) survivors have been attributed to cancer treatment and resulting inflammation. However, studies linking behavioral symptoms to BC treatment have observed patients only after some treatment. Our prospective study with pre-treatment baseline investigates post-treatment changes in inflammation-related biomarkers and whether those changes correlate with changes in symptoms.

Methods

Participants were postmenopausal women, newly-diagnosed with stage 0-3 BC before any treatment (n = 173 "patients"), and age-matched women without cancer (n = 77 "controls"), who were assessed on plasma markers [soluble tumor necrosis factor receptor type 2 (sTNF-RII), interleukin (IL)-6, IL-1 receptor antagonist (IL-1RA), C-reactive protein (CRP)]) and symptoms (Physical Functioning, Pain, Attention/concentration, Perceived Cognitive Problems, Fatigue, Sleep Insufficiency, Depression). Participants were assessed again 1 month, 1 year, and 2 years after completing primary treatment or similar interval in controls. Generalized linear mixed models tested 4 treatments (surgery alone or with chemotherapy, radiation, or both) for association with change per marker. Joint models tested change per marker for association with change per symptom. Models considered demographic, socioeconomic, and clinical covariates. False Discovery Rate method controlled risk of error from multiple hypotheses.

Results

At one month post-completion of treatment, sTNF-RII and IL-6 were elevated by all BC treatments, as were IL-1RA and CRP after surgery alone (all, p < 0.05). By 1 year, markers' average values returned to baseline. Throughout 2-year follow-up, increase-from-baseline in sTNF-RII, IL-1RA, and IL-6 coincided with worsened Physical Functioning, and increase-from-baseline in sTNF-RII coincided with increased Pain (all, p < 0.01). These biomarker-symptom associations (excepting IL-6) were exclusive to patients. No other symptoms worsened, and baseline Fatigue and Depression improved in all participants.

Conclusions

BC treatment, even surgery, is associated with transient elevation in inflammatory markers. In patients post-treatment, increase-from-baseline in sTNF-RII accompanies increased Pain and decreased Physical Functioning, suggesting that sTNF-RII merits development as a clinical biomarker in BC patients.

Different Methods of Minimally Invasive Esophagojejunostomy After Total Gastrectomy for Gastric Cancer: Outcomes from Two Experienced Centers

BACKGROUND

Esophagojejunostomy after minimally invasive total gastrectomy (MITG) for gastric cancer (GC) is technically challenging. Failure of the esophagojejunal anastomosis can lead to significant morbidity, leading to short- and long-term quality of life (QoL) impairment or mortality. The optimal reconstruction method following MITG remains controversial. We evaluated outcomes of minimally invasive esophagojejunostomy after laparoscopic or robotic total gastrectomies.

METHODS

We retrospectively reviewed MITG patients between 2015 and 2020 at two high-volume centers in China and the United States. Eligible patients were divided into groups by different reconstruction methods. We compared clinicopathologic characteristics, postoperative outcomes, including complication rates, overall survival rate (OS), disease-free survival rate (DFS), and patient-reported QoL.

RESULTS

GC patients (n = 105) were divided into intracorporeal esophagojejunostomy (IEJ, n = 60) and extracorporeal esophagojejunostomy (EEJ, n = 45) groups. EEJ had higher incidence of wound infection (8.3% vs 13.3%, P = 0.044) and pneumonia (21.7% vs 40.0%, P = 0.042) than IEJ. The linear stapler (LS) group was inferior to the circular stapler (CS) group in reflux [50.0 (11.1-77.8) vs 44.4 (0.0-66.7), P = 0.041] and diarrhea [33.3 (0.0-66.7) vs 0.0 (0.0-66.7), P = 0.045] while LS was better than CS for dysphagia [22.2 (0.0-33.3) vs 11.1 (0.0-33.3), P = 0.049] and eating restrictions [33.3 (16.7-58.3) vs 41.7 (16.7-66.7), P = 0.029] at 1 year. OS and DFS did not differ significantly between LS and CS.

CONCLUSIONS

IEJ anastomosis generated better results than EEJ. LS was associated with a better patient eating experience, but more diarrhea and reflux compared with CS. Clinical and patient-reported outcomes show the superiority of IEJ with the LS reconstruction method in MITG for GC.

NCCN Guidelines Insights: Soft Tissue Sarcoma, Version 1.2021

The NCCN Guidelines for Soft Tissue Sarcoma provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with soft tissue sarcomas. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines, including the development of a separate and distinct guideline for gastrointestinal stromal tumors (GISTs); reconception of the management of desmoid tumors; inclusion of further recommendations for the diagnosis and management of extremity/body wall, head/neck sarcomas, and retroperitoneal sarcomas; modification and addition of systemic therapy regimens for sarcoma subtypes; and revision of the principles of radiation therapy for soft tissue sarcomas.

Disparate and Alarming Impact of Gastrointestinal Cancers in Young Adult Patients

BACKGROUND

The rise in the incidence of gastric cancer (GC) and colorectal cancer (CRC) in young adults (YA) remains unexplained. We aim to identify differences in these malignancies between YA and older patients.

PATIENTS AND METHODS

We retrospectively analyzed the California Cancer Registry for all GC and CRC cases from 2000 to 2012. Pearson's Chi square analysis and stepwise regression model with backward elimination were used to analyze differences in demographic, clinical, and histopathologic features, and log-rank test to compare survival between young (≤ 40 years) and older adults (41-90 years) with GC or CRC, separately.

RESULTS

We analyzed 19,368 cases of GC and 117,415 cases of CRC. YA accounted for 4.6% of GC (n = 883) and 2.8% of CRC (n = 3273) patients. Compared with older patients, YA were more likely to be Hispanic (P < 0.0001) and have poorly differentiated (P < 0.0001), higher histologic grade (P < 0.0001), and signet ring features (P < 0.0001). Synchronous peritoneal metastases were more common in YA patients (32.1% vs. 14.1% GC, 8.8% vs. 5.4% CRC, P < 0.0001). The 5-year overall survival (OS) of YA with CRC or GC was longer than that of older patients with the same stage of malignancy; except YA with stage I GC, who demonstrated poor OS and disease-specific survival (DSS) (65.1% and 67.9%, respectively) which were significantly worse than those of adults aged 41-49 years (70.7% and 76.2%, respectively) and 50-64 years (69.1% and 78.1%, respectively).

CONCLUSIONS

YA with GC or CRC have distinctly worse clinical and histopathologic features compared with older patients and are disproportionately of Hispanic ethnicity. These results contribute to improving understanding of younger versus older GI cancer patients.

Soft Tissue Sarcoma, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

Soft tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Guidelines for STS provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as intra-abdominal/retroperitoneal STS, gastrointestinal stromal tumors, desmoid tumors, and rhabdomyosarcoma. This portion of the NCCN Guidelines discusses general principles for the diagnosis, staging, and treatment of STS of the extremities, superficial trunk, or head and neck; outlines treatment recommendations by disease stage; and reviews the evidence to support the guidelines recommendations.

Multimodality management of locally advanced gastric cancer-the timing and extent of surgery

The optimal treatment for patients with locally advanced gastric adenocarcinoma is multimodal. Surgery is the cornerstone of therapeutic strategies with curative intent. The addition of chemotherapy or chemoradiation decreases rate of recurrence and prolongs survival. Guidelines differ between countries and there is no universal standard of care. Modern studies of patients with locally advanced gastric cancer showed that adjuvant chemotherapy improves survival over surgery alone in Asia. These studies could not be replicated in Europe. Peri-operative chemotherapy strategies, conversely, have been effective in Europe for improving overall and disease free survival. Adjuvant chemoradiation has also demonstrated improved survival when compared to surgery alone, but studies comparing chemotherapy with chemoradiation have not shown significant difference. Trials are ongoing to examine the role of chemoradiation in a neoadjuvant fashion. A D2 extent of lymphadenectomy improves cancer related survival for those who do not undergo distal pancreatectomy/splenectomy. Survival is also associated not only with the extent but also the number of lymph nodes examined. There are ongoing trials related to immunotherapy and targeted therapies, which may also impact or change the treatment paradigm for locally advanced gastric cancer.

Abstract P5-22-12: Oncological safety of nipple-areola sparing mastectomy in comparison with skin sparing and total mastectomy: Results from a NCI-designated comprehensive cancer center

Nipple-areola sparing mastectomy (NSM) may be offered to some women with breast cancer as an alternative to skin sparing (SSM) or total mastectomy (TM) with excellent cosmetic results and acceptable recurrence risk. The aim of this study is to determine the local/regional recurrence rate of NSM in comparison to SSM and TM at our institution and to determine the factors that may be associated with risk of recurrence. Women who underwent NSM (n=148), SSM (n=660) or TM (n=443) at City of Hope National Medical Center between May 2007 and December 2014 for Stage 0-III breast cancer were identified retrospectively. Exclusions were: women with inflammatory breast cancer and those who had mastectomy for recurrent breast cancer. Overall survival (OS) and disease free survival (DFS) were analyzed using Cox regression controlling for age, race/ethnicity, stage, histology, grade, hormone receptor and Her2 receptor status. There were total of 165 NSMs, 704 SSMs and 466 TMs performed for cancer, accounting for the patients with bilateral cancers. The median follow up time was 38, 58 and 55 months for NSM, SSM and TM, respectively. Median (range) age at diagnosis was 49 (23-74) for NSM, 51 (23-90) for SSM and 59 (26-92) for TM. In the NSM group, 76% of patients had invasive ductal cancer (IDC) and 15% had ductal carcinoma in-situ (DCIS); this was comparable to 73% and 13% in the SSM group and 78% and 9% in the TM group, respectively. The majority of patients who underwent NSM had Stage II disease (45%), which was similar to SSM (43%) and TM (44%). Only 3% of NSM patients had Stage III disease compared to 17% of SSM patients and 29% of TM patients. Most of the patients in all 3 surgical groups received adjuvant chemotherapy (NSM 59%; SSM 52%; TM 51%). Of patients who underwent NSM, 20% received neoadjuvant chemotherapy, compared with 29% of SSM patients and 35% of TM patients. The local/regional recurrence rate per breast was 12/165 (7.3%) for NSM, 23/704 (3.3%) for SSM and 11/466 (2.4%) for TM (n=11). Median time to recurrence was 20, 26 and 16 months for NSM, SSM and TM, respectively. Of the NSMs performed only 1 recurrence occurred at the nipple-areolar complex (0.6%), 9 recurrences were at the chest wall (5.5%) and 2 were at the axilla (1.2%). Eight recurrences after NSM had DCIS in addition to IDC at the time of initial diagnosis while 2 had pure DCIS, 1 had pure IDC and 1 had invasive lobular cancer. There were 8 recurrences with estrogen receptor (ER) and progesterone receptor (PR) positivity at the time of initial diagnosis, that converted to ER+, PR-. One third of recurrences after NSM had multifocal disease. There was no significant difference found in adjusted overall survival (p=0.49) and adjusted disease free survival (p=0.10) among NSM, SSM and TM patients. Even though there is higher rate of local/regional recurrence with NSM, there is no difference in overall and disease-free survival at our institution. Presence of DCIS may be an important factor for recurrence. From these data we conclude that NSM is an oncologically acceptable alternative to SSM and TM, with excellent cosmetic results.

Citation Format: Bostanci Z, Wang X, Ottesen R, Nikowitz J, Jones VC, Springer L, Lai L, Taylor L, Vito CA, Paz IB, Niland J, Kruper L, Yim JH. Oncological safety of nipple-areola sparing mastectomy in comparison with skin sparing and total mastectomy: Results from a NCI-designated comprehensive cancer center [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-12.

Association of Fluid Administration With Morbidity in Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy

Importance

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal cancers can be associated with significant complications. Randomized trials have demonstrated increased morbidity with liberal fluid regimens in abdominal surgery.

Objective

To investigate the association of intraoperative fluid administration and morbidity in patients undergoing CRS/HIPEC.

Design, Setting, and Participants

A retrospective analysis of information from a prospectively collected institutional database was conducted at a National Cancer Institute-designated comprehensive cancer center. A total of 133 patients from April 15, 2009, to June 23, 2016, with primary or secondary peritoneal cancers were included.

Exposures

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Main Outcomes and Measures

Morbidity associated with intraoperative fluid management calculated by the comprehensive complication index, which uses a formula combining all perioperative complications and their severities into a continuous variable from 0 to 100 in each patient.

Results

Of the 133 patients identified, 38% and 37% had diagnoses of metastatic appendiceal and colorectal cancers, respectively. Mean age was 54 (interquartile range [IQR], 47-64) years, and mean peritoneal cancer index was 13 (IQR, 7-18). Mitomycin and platinum-based chemotherapeutic agents were used in 96 (72.2%) and 37 (27.8%) of the patients, respectively. Mean intraoperative fluid (IOF) rate was 15.7 (IQR, 11.3-18.7) mL/kg/h. Mean comprehensive complication index (CCI) was 26.0 (IQR, 8.7-36.2). On multivariate analysis, age (coefficient, 0.32; 95% CI, 0.01-0.64; P = .04), IOF rate (coefficient, 0.97; 95% CI, 0.19-1.75; P = .02), and estimated blood loss (coefficient, 0.02; 95% CI, 0.01-0.03; P = .002) were independent predictors of increased CCI. In particular, patients who received greater than the mean IOF rate experienced a 43% increase in the CCI compared with patients who received less than the mean IOF rate (31.5 vs 22.0; P = .02).

Conclusions and Relevance

Intraoperative fluid administration is associated with a significant increase in perioperative morbidity in patients undergoing CRS/HIPEC. Fluid administration protocols that include standardized restrictive fluid rates can potentially help to mitigate morbidity in patients undergoing CRS/HIPEC.

Soft Tissue Sarcoma, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology

Soft tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Guidelines for Soft Tissue Sarcoma (available at NCCN.org) provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as intra-abdominal/retroperitoneal STS, gastrointestinal stromal tumor, desmoid tumors, and rhabdomyosarcoma. This manuscript discusses guiding principles for the diagnosis and staging of STS and evidence for treatment modalities that include surgery, radiation, chemoradiation, chemotherapy, and targeted therapy.

Laparoscopy Can Safely Be Performed in Frail Patients Undergoing Colon Resection for Cancer

The present study aims to evaluate the role of laparoscopy in frail patients undergoing colorectal surgery for colorectal cancer. A review of the 2011 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was performed to identify frail patients (using a frailty index), who underwent resection for colorectal cancer. Univariable and multivariable analyses were performed to evaluate 30-day mortality and Clavien-Dindo grade IV (CD-IV) complications. A total of 52,087 patients with colorectal cancer were identified, of which frailty accounted for 2.63 per cent (index score ≥5). Patients above the age 85 were considered frail 6.8 per cent of the time and accounted for 24.5 per cent of patients with frailty. Laparoscopic surgery was performed in 32.9 and 53.1 per cent of patients with and without frailty (P < 0.001). Patients with frailty were less likely to die within 30 days of surgery if younger (P = 0.004), performed electively (P < 0.001), or laparoscopically (P < 0.001). On multivariate analysis, laparoscopy and elective surgery were associated with better perioperative survival; whereas, older age, male sex, and tobacco use were associated with 30-day mortality. Laparoscopy and lower body mass index were associated with fewer Clavien-Dindo grade IV complications. Although laparoscopy is performed less commonly in the frail, this study indicated better perioperative outcomes for patients undergoing elective surgery who were <85 years old.

Laparoscopy Can Safely be Performed in Frail Patients Undergoing Colon Resection for Cancer

The present study aims to evaluate the role of laparoscopy in frail patients undergoing colorectal surgery for colorectal cancer. A review of the 2011 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was performed to identify frail patients (using a frailty index), who underwent resection for colorectal cancer. Univariable and multivariable analyses were performed to evaluate 30-day mortality and Clavien–Dindo grade IV (CD-IV) complications. A total of 52,087 patients with colorectal cancer were identified, of which frailty accounted for 2.63 per cent (index score ≥5). Patients above the age 85 were considered frail 6.8 per cent of the time and accounted for 24.5 per cent of patients with frailty. Laparoscopic surgery was performed in 32.9 and 53.1 per cent of patients with and without frailty (P < 0.001). Patients with frailty were less likely to die within 30 days of surgery if younger (P = 0.004), performed electively (P < 0.001), or laparoscopically (P < 0.001). On multivariate analysis, laparoscopy and elective surgery were associated with better perioperative survival; whereas, older age, male sex, and tobacco use were associated with 30-day mortality. Laparoscopy and lower body mass index were associated with fewer Clavien–Dindo grade IV complications. Although laparoscopy is performed less commonly in the frail, this study indicated better perioperative outcomes for patients undergoing elective surgery who were <85 years old.

Base Excess as a Predictor of Complications in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Base excess is important in assessing metabolic status. Postoperative management in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies can be a challenge, and we therefore sought to investigate perioperative predictors of overall morbidity in CRS/HIPEC patients at our institution.

METHODS

Patients who underwent CRS/HIPEC from 2012 to 2016 were identified retrospectively from a prospectively collected institutional database. Patient demographics and perioperative variables were obtained and the comprehensive complication index (CCI) was calculated for each patient in order to assess perioperative morbidity. Stepwise linear regression analyses were performed, with CCI as the outcome variable.

RESULTS

A total of 72 CRS/HIPEC patients had recorded base excesses in the first 48 h postoperatively. Mean immediate postoperative base excess was -6.0 mmol/L (interquartile range [IQR] -8 to -4.1), mean delta base excess at 48 h was +4.3 mmol/L (IQR +2.1 to +6.2), and mean CCI was 25.2 (IQR 8.7-36.7). On multivariate analysis, delta base excess was the only significant predictor of CCI, demonstrating a protective effect (p = 0.001). In patients who experienced less than the mean delta base excess of +4.3 mmol/L, lower delta base excess was an independent predictor of complications (p < 0.001).

CONCLUSIONS

Delta base excess is an independent predictor of morbidity in patients undergoing CRS/HIPEC. A delta base excess of greater than +4.3 mmol/L at 48 h may be an appropriate goal for resuscitation of CRS/HIPEC patients in the immediate postoperative period. Standardized protocols to correct the base deficit in CRS/HIPEC patients during the early postoperative period can potentially help mitigate perioperative morbidity.

Inflammatory Biomarkers, Comorbidity, and Neurocognition in Women With Newly Diagnosed Breast Cancer

BACKGROUND

Neurocognitive dysfunction is reported in women with breast cancer even prior to receipt of adjuvant therapy; however, there is little understanding of underlying mechanisms. We tested the hypothesis that pretreatment neurocognitive dysfunction in newly diagnosed patients is related to immunological activation, as indexed by pro-inflammatory cytokines.

METHODS

One hundred seventy-four postmenopausal patients with newly diagnosed breast cancer underwent a comprehensive neuropsychological evaluation (assessment of cognitive function, mood, and fatigue) and measurement of key cytokine levels prior to surgery. Age-matched control participants without cancer were evaluated concurrently. Multivariable regression analyses examined the contribution of circulating Interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1ra), and soluble TNF receptor type two (sTNF-RII) in predicting neurocognitive performance in patients after controlling for key factors thought to impact functioning. All tests of statistical significance were two-sided.

RESULTS

Memory performance was statistically significantly reduced, in patients compared with controls (P = .02). Of the three cytokines measured, only IL-1ra was statistically significantly elevated in cancer patients when compared with control participants (mean ± SD, 375 ± 239 pg/mL vs 291 ± 169 pg/mL, P = .007). After controlling for age, education, race, mood, fatigue, body mass index, and comorbidity, cytokines independently explained 6.0% of the total variance in memory performance (P = .01) in cancer patients but not control participants, with higher sTNF-RII associated with worse functioning. Exploratory analyses found that comorbidity statistically significantly explained variance in processing speed and executive functioning (P = .03 and P = .03, respectively).

CONCLUSION

An association of TNF with memory, previously reported in patients after exposure to chemotherapy, was found prior to initiation of any treatment, including surgery. This association requires further investigation as sTNF-RII was not higher in cancer patients relative to control participants.

Gastrointestinal stromal tumors, version 2.2014

Gastrointestinal stromal tumors (GIST) are the most common soft tissue sarcoma of the gastrointestinal tract, resulting most commonly from KIT or platelet-derived growth factor receptor α (PDGFRα)-activating mutations. These NCCN Guideline Insights highlight the important updates to the NCCN Guidelines for Soft Tissue Sarcoma specific to the management of patients with GIST experiencing disease progression while on imatinib and/or sunitinib.

Evaluation of expert criteria for preoperative magnetic resonance imaging of newly diagnosed breast cancer

Despite 2 randomized trials reporting no reduction in operations or local recurrence at 1 year, preoperative magnetic resonance imaging (MRI) is increasingly used in diagnostic workup of breast cancer. We evaluated 5 utilization criteria recently proposed by experts. Of women (n = 340) newly diagnosed with unilateral breast cancer who underwent bilateral MRI, most (69.4%) met at least 1 criterion before MRI: mammographic density (44.4%), under consideration for partial breast irradiation (PBI) (19.7%), genetic-familial risk (12.9%), invasive lobular carcinoma (11.8%), and multifocal/multicentric disease (10.6%). MRI detected occult malignant lesion or extension of index lesion in 21.2% of index, 3.3% of contralateral, breasts. No expert criterion was associated with MRI-detected malignant lesion, which associated instead with pre-MRI plan of lumpectomy without PBI (48.2% of subjects): Odds Ratio 3.05, 95% CI 1.57-5.91 (p adjusted for multiple hypothesis testing = 0.007, adjusted for index-vs-contralateral breast and covariates). The expert guidelines were not confirmed by clinical evidence.

Long-term survival after high-dose chemotherapy followed by peripheral stem cell rescue for high-risk, locally advanced/inflammatory, and metastatic breast cancer

Patients with high-risk locally advanced/inflammatory and oligometastatic (≤3 sites) breast cancer frequently relapse or experience early progression. High-dose chemotherapy combined with peripheral stem cell rescue may prolong progression-free survival/relapse-free survival (PFS/RFS) and overall survival (OS). In this study, patients initiated high-dose chemotherapy with STAMP-V (carboplatin, thiotepa, and cyclophosphamide), ACT (doxorubicin, paclitaxel, and cyclophosphamide), or tandem melphalan and STAMP-V. Eighty-six patients were diagnosed with locally advanced/inflammatory (17 inflammatory) breast cancer, and 12 were diagnosed with oligometastatic breast cancer. Median follow-up was 84 months (range, 6-136 months) for patients with locally advanced cancer and 40 months (range, 24-62 months) for those with metastatic cancer. In the patients with locally advanced cancer, 5-year RFS and OS were 53% (95% CI, 41%-63%) and 71% (95% CI, 60%-80%), respectively, hormone receptors were positive in 74%, and HER2 overexpression was seen in 23%. In multivariate analysis, hormone receptor-positive disease and lower stage were associated with better 5-year RFS (60% for ER [estrogen receptor]/PR [progesterone receptor]-positive versus 30% for ER/PR-negative; P < .01) and OS (83% for ER/PR-positive versus 38% for ER/PR-negative; P < .001). In the patients with metastatic cancer, 3-year PFS and OS were 49% (95% CI, 19%-73%) and 73% (95% CI, 38%-91%), respectively. The favorable long-term RFS/PFS and OS for high-dose chemotherapy with peripheral stem cell rescue in this selected patient population reflect the relative safety of the procedure and warrant validation in defined subgroups through prospective, randomized, multi-institutional trials.

Prediction of the adequacy of lymph node retrieval in colon cancer by hospital type

BACKGROUND

Examination of 12 or more regional lymph nodes (LNs) is the accepted minimum for nodal staging in colon cancer and serves as a surrogate for adequate resection.

OBJECTIVE

To determine the contributing role of the hospital in the number of LNs retrieved. Design/

SETTING

We retrospectively reviewed colon resections in 83 patients by 2 surgical oncologists at a National Comprehensive Cancer Network (NCCN) hospital or at community-based hospitals from January 1, 2002, through December 31, 2007.

PATIENTS

We included all patients undergoing colectomy for primary colon cancer and excluded patients with recurrence, rectal cancer, or preoperative chemotherapy.

MAIN OUTCOME MEASURES

Total number of LNs retrieved. We also analyzed clinical factors accounting for differences.

RESULTS

The median number of LNs examined at the NCCN hospital (42 patients) vs the community hospitals (41 patients) were 17.8 vs 7.0 (P < .001), and the frequency of an inadequate number of LNs examined (<12) was 11 of 42 cases (26%) vs 35 of 41 cases (85%) (P < .001). Potential predictive factors for LNs retrieved were grouped into modifiable (hospital type, surgeon, and surgical approach [laparoscopic vs open]) and nonmodifiable (age, sex, and tumor location). On multivariate analysis of the factors, hospital type was the only modifiable factor predictive of LNs reported (P < .001).

CONCLUSIONS

Our study is the first, to our knowledge, to demonstrate that the number of LNs removed in colectomies performed by the same 2 surgeons depends on the hospital type (NCCN vs community) in which the resection occurred. We postulate that the number of LNs retrieved may be related to the institution's pathological review in addition to the extent of surgical resection.

Totally laparoscopic gastric resection with extended lymphadenectomy for gastric adenocarcinoma

BACKGROUND

Laparoscopic gastric resection with extended lymphadenectomy is being evaluated in North America for the surgical treatment of gastric cancer. The aim of this study is to compare short-term postoperative and oncologic outcomes of laparoscopic and open resection for gastric cancer at a single cancer center.

METHODS

The study population consisted of patients with gastric adenocarcinoma who underwent a completely abdominal intervention with curative intent. Laparoscopic and open gastric resections were compared. A totally laparoscopic technique was employed with a robotic extended lymphadenectomy in a subset of patients.

RESULTS

A total of 78 consecutive patients were evaluated, including 30 laparoscopic and 48 open procedures. An extended lymphadenectomy was performed in 58 patients and was executed robotically in 16 of these. There was no difference in the mean number of lymph nodes retrieved by laparoscopic or open approach (24 +/- 8 vs. 26 +/- 15, P = .66). Laparoscopic procedures were associated with decreased blood loss (200 vs. 383 mL, P = .0009) and length of stay (7 vs. 10 days, P = .0009), but increased operative time (399 vs. 298 minutes, P < .0001).

CONCLUSION

Completely laparoscopic gastric resection yields similar lymph node numbers compared with open surgery for gastric cancer. It was found to be advantageous in terms of operative blood loss and length of stay. Minimally invasive techniques represent an oncologically adequate alternative for the surgical treatment of gastric adenocarcinoma.

Effectiveness of Decentralized Community-Based Screening, Detection, and Treatment of Breast Cancer in Low-Income, Uninsured Women

Different systems exist currently in the provision of breast care to low-income, uninsured women. We assessed the efficacy of screening, diagnosis, and treatment of breast cancer in this patient population through a decentralized network of providers. We retrospectively reviewed charts of all patients referred for evaluation and treatment under the Cancer Detection Program: Every Woman Counts (CDP:EWC), the California equivalent of the National Breast and Cervical Cancer Detection and Prevention Program, in a suburban area of Los Angeles County. A total of 972 CDP:EWC screening mammograms was performed in the Antelope Valley during a 7-year study period (2000 to 2007). Sixty-two screened women aged 40 to 64 years were referred for further evaluation. Breast cancer detection rate per screening mammogram was 0.8 per cent; 80 per cent were early-stage breast cancer. The majority of the women (nine of 15) underwent breast conservation surgery. The axilla was staged using sentinel lymph node dissection and/or axillary lymph node dissection. Adjuvant chemotherapy and radiation were administered to all eligible patients. Compliance with published practice guidelines was high. This suggests that a decentralized community-based network of providers may be an effective model to deliver breast care to a low-income, uninsured patient population.

Effectiveness of decentralized community-based screening, detection, and treatment of breast cancer in low-income, uninsured women

Different systems exist currently in the provision of breast care to low-income, uninsured women. We assessed the efficacy of screening, diagnosis, and treatment of breast cancer in this patient population through a decentralized network of providers. We retrospectively reviewed charts of all patients referred for evaluation and treatment under the Cancer Detection Program: Every Woman Counts (CDP:EWC), the California equivalent of the National Breast and Cervical Cancer Detection and Prevention Program, in a suburban area of Los Angeles County. A total of 972 CDP:EWC screening mammograms was performed in the Antelope Valley during a 7-year study period (2000 to 2007). Sixty-two screened women aged 40 to 64 years were referred for further evaluation. Breast cancer detection rate per screening mammogram was 0.8 per cent; 80 per cent were early-stage breast cancer. The majority of the women (nine of 15) underwent breast conservation surgery. The axilla was staged using sentinel lymph node dissection and/or axillary lymph node dissection. Adjuvant chemotherapy and radiation were administered to all eligible patients. Compliance with published practice guidelines was high. This suggests that a decentralized community-based network of providers may be an effective model to deliver breast care to a low-income, uninsured patient population.

Malignant phyllodes tumor of the breast: local control rates with surgery alone

PURPOSE

Patients with malignant phyllodes tumors of the breast (MPTB) are routinely treated with surgery alone. We performed a retrospective study to determine local control rates based on tumor size and type of surgery performed.

METHODS AND MATERIALS

We reviewed records of 478 patients with MPTB treated between March 1964, and August 2005. The data were extracted from the IMPAC National Oncology Database consisting of merged tumor registries from 130 hospitals.

RESULTS

Median follow-up was 64 months (range, 0-410 months). Actuarial 5-year local control rates were 79.4% for 169 lumpectomy patients and 91.2% for 207 mastectomy patients treated by surgery alone. Five-year local control rates for lumpectomy based on tumor size were 91% for 0-2 cm tumors, 85% for 2-5 cm tumors, and 59% for 5-10 cm tumors. For mastectomy patients, 5-year local control rates were 100% for 0-2 cm tumors, 95% for 2-5 cm tumors, 88% for 5-10 cm tumors, and 85% for 10-20 cm tumors. Multivariate analysis of overall survival found several factors to be significant including advancing age with each decade after 50 years of age, appearance of distant metastases, larger primary tumor size, and local control vs. local recurrence (Hazard Ratio [HR] 2.5, p < 0.05).

CONCLUSIONS

Malignant phyllodes tumors of the breast local recurrence rates are 15% or greater for patients with tumors >2 cm treated by lumpectomy alone and tumors >10 cm treated by mastectomy alone. Adjuvant radiation therapy should be evaluated for these patients. This may be especially important because our study showed that local recurrence impacted on survival rates.

Impact of a full-time preceptor on the institutional outcome of laparoscopic colectomy

BACKGROUND

Laparoscopic assisted colectomy (LAC) is a difficult operation with long learning curves and conversion rates inversely proportional to the surgeon's experience. Methods to help train surgeons outside of residency or fellowship programs have been poorly analyzed. This study was undertaken to assess the impact of an experienced laparoscopic surgeon preceptor on the outcome of LAC in a single institution

METHODS

In September 2004, a fellowship-trained laparoscopic surgeon joined our department of surgery. This surgeon served as a LAC preceptor for six inexperienced staff surgeons and four surgical oncology fellows. Clinical and pathologic data from all attempted LAC for the 22 months preceding the arrival of the trained laparoscopic surgeon were compared with those for the 18 months following the recruitment.

RESULTS

Before the addition of the expert surgeon, 28 LAC were performed in our institution, compared with 63 during the preceptor program. These represented 59% and 95% of eligible operations for each time period, respectively (P = 0.005). Overall conversion rates before and after the preceptor's arrival decreased from 44% to 14%, respectively (P < 0.05). The chances of conversion were strongly affected by the presence or absence of the preceptor in the operating room (7% vs. 30%, respectively, P = 0.003). Overall complication rates, hospital stay, blood loss, operative time and number of lymph nodes retrieved were not affected by the presence of the preceptor. Operations completed laparoscopically resulted in significantly lower blood loss and length of stay compared with converted ones.

CONCLUSIONS

A shared departmental preceptor can positively affect the institutional outcome of laparoscopic colectomy. This model may help improve training and patient care in inexperienced centers.

Soft Tissue Sarcoma Guidelines

Soft tissue sarcomas are the most frequent sarcomas; the annual incidence for 2007 in the United States is estimated at about 9220 cases, with an overall mortality rate of approximately 3560 cases per year. Important updates for the 2007 version of the guidelines include the addition of epirubicin (single agent) and the combination of epirubicin, ifosfamide, and mesna as generally accepted systemic therapy. Imatinib was added as an option for desmoid tumors.

For the most recent version of the guidelines, please visit NCCN.org

Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer

BACKGROUND

With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Because of its high operating cost, however, robotic surgery should be reserved to procedures in which the technology can be of maximum benefit, usually when precise dissections in confined spaces are required. Because conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the DaVinci robotic system in laparoscopic low anterior resections for cancer of the rectum.

METHODS

Between November 2004 and May 2005 robotic-assisted low anterior resection with total mesorectal excision was performed on six consecutive patients with rectal cancer. These cases were compared with six consecutive low anterior resections performed with conventional laparoscopic techniques by the same surgeon.

RESULTS

There were no conversions in either group. Operative and pathological data, complications, and hospital stay were similar in the two groups. Robotic operations appeared to cause less strain for the surgeon.

CONCLUSIONS

Robotic-assisted laparoscopic low anterior resection for rectal cancer is feasible in experienced hands. This technique may facilitate minimally invasive radical rectal surgery.

Paint-Only Is Equivalent to Scrub-and-Paint in Preoperative Preparation of Abdominal Surgery Sites

BACKGROUND

Antiseptic preoperative skin site preparation is used to prepare the operative site before making a surgical incision. The goal of this preparation is a reduction in postoperative wound infection. The most straightforward technique necessary to achieve this goal remains controversial.

STUDY DESIGN

A prospective randomized trial was designed to prove equivalency for two commonly used techniques of surgical skin site preparation. Two hundred thirty-four patients undergoing nonlaparoscopic abdominal operations were consented for the trial. Exclusion criteria included presence of active infection at the time of operation, neutropenia, history of skin reaction to iodine, or anticipated insertion of prosthetic material at the time of operation. Patients were randomized to receive either a vigorous 5-minute scrub with povidone-iodine soap, followed by absorption with a sterile towel, and a paint with aqueous povidone-iodine or surgical site preparation with a povidone-iodine paint only. The primary end point of the study was wound infection rate at 30 days, defined as presence of clinical signs of infection requiring therapeutic intervention.

RESULTS

Patients randomized to the scrub-and-paint arm (n = 115) and the paint-only arm (n = 119) matched at baseline with respect to age, comorbidity, wound classification, mean operative time, placement of drains, prophylactic antibiotic use, and surgical procedure (all p > 0.09). Wound infection occurred in 12 (10%) scrub-and-paint patients, and 12 (10%) paint-only patients. Based on our predefined equivalency parameters, we conclude equivalence of infection rates between the two preparations.

CONCLUSIONS

Preoperative preparation of the abdomen with a scrub with povidone-iodine soap followed by a paint with aqueous povidone-iodine can be abandoned in favor of a paint with aqueous povidone-iodine alone. This change will result in reductions in operative times and costs.

Major palliative amputations

The role of major amputations in the palliative care of cancer patients remains controversial. Major amputations result in loss of function, frequently require prolonged recovery, and are associated with major morbidity or mortality. Therefore, it may seem that major amputations should be rarely recommended for the palliation of cancer patients. Hence, we attempt to establish the indications,management, and outcomes of major amputations in the palliative management of cancer patients.

Prognostic factors in the surgical management of pericardial effusion in the patient with concurrent malignancy

BACKGROUND

Pericardial effusion in the patient with cancer presents a unique management problem. Although multiple methods of operative and nonoperative drainage of pericardial effusions have been described, surgical pericardial window remains the standard approach to long-term drainage. Selecting the patient who may benefit from an operative approach presents a difficult challenge. In the present study, we retrospectively analyzed the clinical outcome of 63 consecutive patients with malignancy who underwent surgical pericardial window for symptomatic pericardial effusion between January 1, 1990, and July 1, 2001, at City of Hope National Medical Center in order to try to determine whether the type of cancer, the presence of malignant cells in pericardial fluid, or tissue specimens or the method of surgery influenced the incidence of recurrent pericardial effusion or duration of survival.

METHODS

The cohort was comprised of 15 patients with non-small cell lung cancer (NSCLC), 22 patients with breast cancer, 17 patients with hematologic malignancy, and 9 patients with other solid tumors. Pertinent clinical, laboratory, hospital stay, and outcome data including long-term follow-up were recorded. Patients were followed up until the time of last clinical follow-up or death. Univariate survival analyses were performed to determine significant clinical factors contributing to outcome.

RESULTS

Median follow-up was 6.6 months for the group and 8.3 months for those alive at last follow-up. Median survival rates for patients with lung, breast, hematologic, and other solid-tumor malignancies were 3.2 months, 8.8 months, 17 months, and 16.4 months, respectively. Preoperative factors that negatively correlated with survival included a diagnosis of NSCLC (p = 0.0014), the presence of a pleural effusion (p = 0.003), or positive pathologic (p = 0.02) or cytologic findings (p = 0.02).

CONCLUSIONS

A surgical approach to pericardial drainage is effective (< 5% failure rate) and provides an opportunity for continued therapy with the potential for relief of dyspnea and improvement in quality of life and survival in selected patients.

The role of pelvic exenteration in the management of recurrent rectal cancer

BACKGROUND

Use of extirpative surgery in the setting of recurrent rectal cancer is controversial given the poor overall outcome of such patients and the morbidity associated with exenteration.

METHODS

A retrospective review of patients treated for recurrent rectal cancer from 1990 to 2002 was performed.

RESULTS

Twenty-two patients underwent pelvic exenteration. Seventeen underwent potentially curative resection, 5 were for palliation only. There was 1 operative death. Fifteen suffered at least 1 complication; 9 suffered multiple complications. Ten patients required readmission to the hospital. The overall disease-free interval was 11 months. Potentially curative and palliative resections resulted in median survivals of 20.4 and 8.4 months, respectively (P = 0.049).

CONCLUSIONS

While patients may derive oncologic and palliative benefits from exenteration, the price in terms of operative morbidity remains high. Newer measures of operative morbidity are necessary to better appraise the value of this radical approach to recurrent rectal cancer.

A carcinoembryonic antigen-secreting adenocarcinoma arising within a retrorectal tailgut cyst: clinicopathological considerations

Retrorectal tailgut cysts (TGC) develop from postanal fetal gut remnants. They have specific radiological and histopathological features that distinguish them from dermoid cysts, enteric duplication cysts, and teratomas. We report a patient with a carcinoembryonic antigen-producing adenocarcinoma arising within a TGC who underwent resection through a combined anterior laparotomy/posterior pelvic approach. Despite complete resection and delayed but complete functional recovery, diffusely metastatic disease was encountered 6 months after resection. Diagnostic, therapeutic, histopathological, and oncological implications of this illustrative case are discussed. It seems possible to use carcinoembryonic antigen measurements for treatment planning and for assessing treatment response for this rare disease. The described outcome also suggests that TGC can develop malignant degeneration and should be resected at the time of diagnosis.

Mediastinal germ cell tumor in a child with precocious puberty and Klinefelter syndrome

An 8-year-old boy presented with precocious puberty and a mediastinal mass. A computer search showed that this rare presentation is most common with germ cell tumor of the mediastinum in children with Klinefelter syndrome. The tumor was completely resected after preoperative chemotherapy, and the patient is well 2 years after the operation. In patients with Klinefelter syndrome, germ cell tumors are 50 times more common than in patients without Klinefelter syndrome, usually contain nonseminomatous elements, present at an earlier age, and are seldom testicular in location.

Visceral varicella-zoster after bone marrow transplantation: report of a case series and review of the literature

OBJECTIVES

Infection with varicella-zoster virus after bone marrow transplantation (BMT) is a common cause of morbidity and mortality. Visceral involvement with varicella-zoster may be incorrectly ascribed to graft-versus-host disease, resulting in delayed diagnosis and misguided therapy.

METHODS

A 4-yr retrospective chart review was performed to determine the presenting symptoms and clinical outcome of visceral varicella-zoster virus infection in BMT recipients.

RESULTS

Ten BMT recipients who subsequently developed visceral varicella-zoster virus infection were identified. The mean age at diagnosis was 40 yr (range 27-56 yr). Primary hematological malignancies were leukemia (N = 7), myelodysplasia (N = 2), and myelofibrosis (N = 1). Bone marrow transplants in affected patients were autologous (N = 2), related allogeneic (N = 5), or matched unrelated allogeneic (N = 3). The mean time interval from BMT to symptomatic visceral varicella-zoster virus infection was 153 days (range 60-280 days). Presenting symptoms included abdominal pain in all patients, nausea (60%), fever > 38 degrees C (60%), vomiting (50%), pneumonitis (50%), skin rash (40%), and diarrhea (30%). All patients had moderately or profoundly elevated aminotransferases and most had elevated pancreatic enzymes (80%). The mean time interval from the development of abdominal pain to the characteristic skin rash and then diagnosis was 6 and 7 days, respectively (range 4-10 and 4-14 days). Active graft-versus-host disease had previously been documented in five of the eight allogeneic BMT recipients. Immunosuppressive medications were increased at the onset of the abdominal pain in seven of these eight patients for suspected exacerbation of graft-versus-host disease. After recognition of varicella infection, antiviral therapy was promptly initiated; despite this, mortality was still 50%.

CONCLUSIONS

Visceral involvement with varicella-zoster virus infection can occur as a late complication after both allogeneic and autologous BMT. In these cases, symptoms of severe abdominal pain with associated nausea, vomiting, and diarrhea and elevated liver and pancreatic enzymes preceded the vesicular skin eruption and were confused with graft-versus-host disease. With the increasing application of high-dose chemotherapy followed by stem cell rescue for both hematological and solid tumors, clinicians should be aware of this potentially treatable and often lethal complication.

Detection of human papillomavirus DNA and oncoprotein overexpression are associated with distinct morphological patterns of tonsillar squamous cell carcinoma

Human papillomavirus (HPV) DNA has been detected in approximately 15% of squamous cell carcinomas (SCCs) of the head and neck. Recent studies have shown a predilection of HPV for certain anatomical sites, especially the tonsillar region, with viral DNA identified in approximately 60% of SCCs of the Waldeyer's tonsillar ring. This study was undertaken to determine whether there are differences in morphology or in oncogene expression in SCC of the tonsil with and without detectable HPV DNA. Twenty-two SCCs of the tonsil were analyzed for the presence of HPV DNA by polymerase chain reaction (PCR) using both a consensus primer set (My09/My11) and type-specific primers. Viral transcription was established in both primary and metastatic tumors by RNA in situ hybridization. The morphology of invasive SCC was classified into three subtypes: well keratinized (K-SCC), intermediate keratinized (I-SCC), and poorly keratinized (P-SCC). Expression of p53, pRB, and cyclin D1 (bcl-1) were studied by immunohistochemistry. In these cases (6 K-SCCs, 2 I-SCCs, and 14 P-SCCs), HPV DNA was detected in 14 (64%), with 11 containing HPV-16 (10 P-SCCs, 1 I-SCCs, and 0 K-SCCs) and 1 each containing HPV-33, HPV-59, and an unclassified HPV type (all P-SCCs). Viral oncoprotein E6/E7 transcription was demonstrated in 7 of 7 HPV-16-positive tumors. Cyclin D1 protein overexpression was detected in the majority of HPV-negative tumors (7 of 8 cases), whereas it was minimal or absent in 13 HPV-positive tumors. Overexpression of p53 protein was detected in 3 HPV-negative K-SCCs. In the HPV-positive tumors, fewer malignant cells expressed pRB and the staining was less intense than in the HPV-negative cancers. HPV DNA and E6/E7 expression, especially HPV-16, is detected in the majority of tonsillar SCCs and is almost exclusively associated with a poorly keratinized tumor histology. Decreased expression of cyclin D1, pRB, and p53 in tumors with HPV DNA is consistent with the known effects of the viral oncoproteins on the cellular protein. The morphology of the HPV-positive tumors suggests that HPV may have a predilection for a population of nonkeratinizing squamous cells or that the virally transformed cells inhibit keratinization of the tumor cells. Well keratinized tonsillar SCCs lack HPV DNA and are associated with overexpression of cyclin D1 protein and/or p53, suggesting that mechanisms that alter the cell cycle regulatory proteins, either by interaction with viral oncoproteins or by changes in the cellular proteins themselves, is critical for tumorigenesis of tonsillar SCC.

Human papillomavirus (HPV) in head and neck cancer. An association of HPV 16 with squamous cell carcinoma of Waldeyer's tonsillar ring

BACKGROUND

Certain strains of human papillomavirus (HPV) have been shown to be etiologically related to the development of uterine cervical and other genital cancers, but their role in the development of malignancies at other sites is less well established. Previous studies have shown HPV DNA in tumors of the head and neck, but its prevalence has varied depending on the detection methods and the types of tumor and/or tissue examined. This study was undertaken to estimate the frequency of HPV DNA in squamous cell carcinoma (SCC) at different sites of the esophagus, head and neck and to compare the clinical behavior of HPV positive and negative tumors.

METHODS

DNA was extracted from frozen tissue of 167 SCCs of the esophagus, head and neck. The DNA was screened for HPV sequences by polymerase chain reaction with two sets of consensus primers, one to a conserved region in the L1 gene (MY09/ MY11) and the other to a conserved region in the E1 open reading frame (IU/IWDO). The products were run on agarose gels, detected by ethidium bromide staining, and then the gels were subjected to Southern blot analysis and hybridized with probes specific to HPV 6, 16, and 18. All tumors found to be HPV positive with the consensus primers were amplified with type specific primers, and in selected cases the presence of HPV DNA was confirmed by restriction enzyme digestion of the tumor DNA with conventional Southern blot analysis.

RESULTS

Overall, HPV sequences were found in 25 of 167 tumors (15%), but HPV was detected most frequently in tumors in Waldeyer's tonsillar ring. In that area, 9 of 15 (60%) were HPV positive. No HPV DNA was detected in 11 esophageal SCCs, 7 tumors of the pharynx/hypopharynx, or 6 pyriform sinus carcinomas. HPV DNA was detected in the following tumor sites: 1 of 28 (3.6%) in the larynx, 1 of 10 (10%) in the oral cavity, 5 of 39 (12.8%) in the tongue, 2 of 15 (13.5%) in the floor of the mouth, 3 of 21 (14.3%) supraglottic, and 1 of 7 (14.3%) in the lip. A high incidence of HPV DNA was also found in metastatic tumors located in cervical lymph nodes for which no primary site was clinically identified (3 of 8, 37.5%). With respect to age, gender, and tobacco and alcohol consumption, analysis of clinical data obtained by retrospective review showed no difference between patients with HPV DNA in their tumors and those in which no HPV was detected. However, HPV positive patients had larger tumors (P = 0.09) and a higher incidence of lymph node metastasis (P = 0.003). In spite of the higher stage of disease at presentation in HPV positive patients, there was no significant difference in 3-year survival rates between HPV positive patients and HPV negative patients (43.1% vs. 48.8%, respectively). Median follow-up was 27 months.

CONCLUSIONS

In the head and neck, HPV-associated SCC had site specificity with the viral DNA frequently found in tumors in Waldeyer's tonsillar ring. Patients with HPV positive tumors presented with a higher stage of disease than patients with HPV negative tumors, but there was no significant difference in the 3-year survival rates between these two groups of patients.

Primary lymphoepithelioma-like carcinoma of the lung in a child. Report of an Epstein-Barr virus-related neoplasm

Lymphoepithelioma-like carcinoma (LEC), an undifferentiated carcinoma with pronounced lymphocytic infiltration, often is seen in the nasopharynx as well as in other areas. But such primary pulmonary lung neoplasms in children are rare, and we present the first reported case of primary pulmonary LEC in a child.

Local recurrence in breast cancer: implications for systemic disease

BACKGROUND

Recurrence in breast carcinoma follows a pattern of growth marked by local, regional, or widespread dissemination. Local recurrence may be the harbinger of systemic disease or failure of local control. Delineation of these processes may have implications in treatment.

METHODS

A retrospective review found 1,171 patients with stages I and II breast cancer from 1978 to 1990 treated at the City of Hope Medical Center.

RESULTS

Twenty-seven percent (n = 313) of patients developed recurrences. These were classified as local, including chest wall and regional nodes (n = 40), local and distant (n = 63), and distant (n = 210). Mean follow-up was 60 months. Multivariate analysis demonstrates tumor size was not different between the three groups, but the presence of positive lymph nodes was: local = 51%, local and distant = 78%, and distant = 64%. The disease-free interval was longest in the local group (42 months) versus the local and distant group (23 months) and distant group (39 months). Median survival was calculated from the time of recurrence: local = 90 months, local and distant = 26 months, and distant = 16 months.

CONCLUSIONS

A group of patients with local recurrence have improved survival and do not develop distant disease. This group may benefit from aggressive surgical treatment to control local disease. These data suggest that a subset of breast tumors can act locally aggressive without metastatic potential.

Treatment of perianal infection following bone marrow transplantation

PURPOSE

Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life-threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT.

METHODS

The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner.

RESULTS

Over a ten-year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty-four patients were diagnosed with perianal infections following their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms were Escherichia coli, Bacteroides, Enterococcus, and Klebsiella. For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing.

CONCLUSIONS

Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.

Survey of physicians' attitudes relative to the field of surgical oncology

BACKGROUND

Surgical oncology as a distinct field of expertise is fairly young. The current study was designed to gain a better understanding of the attitude of practicing physicians toward the field of surgical oncology.

METHODS

Three hundred twenty-seven physicians in the San Gabriel Valley (a suburban area adjacent to Los Angeles) responded to an anonymous survey of opinions regarding surgical oncology. Responses were placed into a computerized database.

RESULTS

Of those responding, 179 were primary care physicians, 52 were general surgeons, 78 were gynecologists, and 18 were medical oncologists. Overall, 89% of physicians were familiar with the field of surgical oncology, but only 47% had ever heard of The Society of Surgical Oncology (SSO). Ninety-four percent of the respondents felt that a surgical oncologist should care for patients with complex cancer, and 63% of respondents felt that surgical oncologists should care only for patients with complex cancer. Familiarity with the field of surgical oncology and with the SSO correlated with the percentage of the physicians practice that was cancer related. Only 22% of physicians felt that the field of surgical oncology is redundant to the general surgical specialties.

CONCLUSIONS

Results of the survey indicate that there is considerable recognition of the unique expertise of the surgical oncologist by the medical community. Unfortunately, many physicians are not familiar with the SSO. Educating physicians in the community about the SSO may help to further expand the role of the surgical oncologist in the care of the patient with cancer, standardize the expectations of the skills and training of a surgical oncologist, and set a benchmark for the surgical subspecialty.

Heat shock protein 84 forms a complex with mutant p53 protein predominantly within a cytoplasmic compartment of the cell

Cellular DNA damage results in the increased expression and accumulation of the p53 tumor suppressor protein within the nucleus which leads to cell cycle arrest or apoptosis. In some cases, however, wild-type p53 and some mutant forms of p53 reside in the cytoplasm of cancer cells. To understand the mechanism responsible for its cytoplasmic retention, studies were undertaken to determine if unique proteins form a complex with mutant p53 within the cytoplasm of transformed cells. One protein, with an apparent molecular mass of 92 kDa (p92), was observed to form a complex with a temperature-sensitive mutant p53 (TSp53(Val-135)) in the cytoplasm of transformed rat embryo fibroblasts at the non-permissive temperature. p92 copurified with TSp53(Val-135) on a p53-specific immunoaffinity column and a gel filtration column. The protein was purified to homogeneity and identified as hsp84 by partial amino acid sequence analysis. hsp84 is a member of the hsp90 class of proteins. At the non-permissive temperature, TSp53(Val-135) and hsp84 colocalized in the cytoplasm near the nuclear envelope. At the permissive temperature, TSp53(Val-135) resides in the nucleus and expresses a "wild-type like" conformation. Under these conditions hsp84 continued to reside in the cytoplasm and little or no hsp84 formed a complex with p53. The results suggest that hsp84 binds mutant p53 in a spatial and/or conformation dependent manner.

Compartment syndrome of the leg secondary to leukemic infiltration: a case report and review of the literature

Leukemic infiltration of muscle is an unusual cause of compartment syndrome. High index of suspicion with early fasciotomy may be the only way to save the leg and prevent life-threatening complications. Biopsy of the muscle should be done when the etiology of the compartment syndrome is not clear. The probable mechanisms and treatment approaches are discussed.

Characterization of human placental insulin-like growth factor-I/insulin hybrid receptors by protein microsequencing and purification

Protein microsequencing of human placental IGF-I receptors purified by immunoaffinity chromatography using IGF-I receptor specific monoclonal antibody revealed amino acid sequences of both IGF-I and insulin receptors. Since this finding indicated the presence of IGF-I/insulin receptor hybrids, hybrid receptors were further purified by immunoaffinity chromatography using insulin receptor specific monoclonal antibody. The molecular size of the nonreduced hybrid receptor was approximately 350K, indicating that the IGF-I and insulin receptor alpha beta halves were disulfide-linked. The ratio of IGF/insulin binding activity of purified hybrid receptors was approximately 25 when measured using tracer amounts of radioactive ligands. 125I-IGF binding to these receptors was inhibited by IGF-I and insulin with IC50s of approximately 2 and approximately 1000 nM, respectively. 125I-Insulin binding to these receptors was similarly inhibited by IGF-I and insulin with IC50 of approximately 3 nM. Autophosphorylation and kinase activities of the hybrid receptor were stimulated by IGF-I more effectively than insulin in a dose-dependent manner. Thus, the present studies indicate that hybrid receptors purified from human placenta have the functional properties of an IGF-I receptor.

Two new monoclonal antibodies against the alpha subunit of the human insulin-like growth factor-I receptor

Recently, we have reported three monoclonal antibodies (mAbs) against purified human placental insulin-like growth factor (IGF)-I receptors. These antibodies, in contrast to the well-studied mAb alpha IR-3, stimulate binding of IGF-I and IGF-II to the receptor and DNA synthesis as well [Xiong, et al., Proc. Natl. Acad. Sci. U.S.A. 1992(89), 5356]. Here we describe two additional mAbs, 1H7 and 2C8, against the IGF-I receptor that have characteristics different from either alpha IR-3 or our previously reported mAbs. Both 1H7 and 2C8 bind to the alpha subunit of the IGF-I receptor as determined by immunoblotting. MAb 1H7 inhibited the binding of IGF-I and IGF-II to the IGF-I receptor while 2C8 had no effect on the binding of either ligand to the receptor. When their effects on DNA synthesis were examined using NIH 3T3 cells expressing human IGF-I receptors, 1H7 inhibited basal and IGF-I- or IGF-II-stimulated DNA synthesis whereas 2C8 stimulated basal DNA synthesis but provided no synergism in the presence of IGF-I or IGF-II.

Human insulin receptor beta-subunit transmembrane/cytoplasmic domain expressed in a baculovirus expression system: purification, characterization, and polylysine effects on the protein tyrosine kinase activity

We have expressed, purified, and characterized the insulin receptor protein tyrosine kinase (PTK) retaining the transmembrane and downstream domains. The proteins expressed in insect cells using a baculovirus expression system were identified as membrane-bound by immunofluorescence staining and biochemical characterization. One-step purification by immunoaffinity chromatography from Triton X-100 cell extracts resulted in a approximately 360-fold increase in the specific kinase activity with a yield of approximately 50%. An appMr = approximately 60,000 protein was the major component identified by both silver staining of the purified enzyme and immunostaining of the crude extracts after separation by sodium dodecyl sulfate-polyacrylamide gel electrophoresis under reducing conditions. Using nondenaturing conditions, the molecular weight was estimated to be approximately 250,000 and approximately 500,000 by glycerol gradient centrifugation and gel permeation chromatography, respectively, suggesting that oligomers of the beta-subunit domains such as tetramers and octamers are formed. The basal PTK activity of this enzyme was much higher than those of previously reported soluble-form insulin receptor PTKs expressed in insect cells or the native receptor. Km and Vmax for two substrates, src-related peptide and poly(Glu, Tyr) (4:1), were 2.4 mM and 2.5 mumol min-1 mg-1 and 0.26 mM and 1.2 mumol min-1 mg-1, respectively. Specific activities measured under two previously reported conditions using histone H2B as a substrate were 100 or 135 nmol min-1 mg-1, in contrast to those of soluble PTKs which were reported to be 20 or 70 nmol min-1 mg-1, respectively. The purified enzyme was autophosphorylated at Tyr residues. Autophosphorylation activated the enzyme approximately 3-fold.(ABSTRACT TRUNCATED AT 250 WORDS)