Wire-guided localization and surgical resection of non-palpable recurrent of thyroid carcinoma: A STROBE-compliant, retrospective cohort study

BACKGROUND

Information on hook-wire guided (HWG) surgery for non-palpable thyroid carcinoma (TC), locoregional-recurrent disease (LRRD) is scarce. We analyze the results of HWG resection compared with the traditional procedure.

METHODS

Cohort study performed between January 2016 and December 2020. Patients with TC and non-palpable LRRD were included. A "Standard cohort", patients with non-HWG resection and "HWG cohort", with HWG resection of LRRD were defined. Surgical morbidity, re-recurrent/progressive disease (RRD), and re-recurrence-free survival (RRFS) were defined.

RESULTS

43 and 23 patients were assigned to the Standard or HWG cohorts, respectively. Complications occurred in 28 % and 17.3 % of cases, in control or HWG cohorts, respectively. HWG cohort, size of primary TC, 131I dose >150 mCi, and thyroglobulin level >1 ng/ml at detection of LRRD were associated with RRD. HWG cohort, thyroglobulin level at LRRD, 131I treatment, and dose were associated with RRFS.

CONCLUSIONS

HWG surgery of non-palpable TC LRRD had improved results regarding surgical morbidity, RRD, and RRFS.

Multivariate Prognostic Models for Patients with Stages I and Ii Colon Carcinoma: a Strobe-Compliant Retrospective Cohort Study

Background

Colorectal cancer is the most frequent gastrointestinal malignancy worldwide. The value of adjuvant treatment is controversial in Stages I and II.

Objective

The aim of this study was to construct post-operative prognostic models applicable to patients with stages I-II colon carcinoma (CC).

Methods

This is a retrospective cohort study of patients with Stage I-II CC treated over a 25-year period. Exposure was defined as clinical, histopathological, and immunohistochemical factors (including CDX2 and MUC2 expression). Patients were randomly allocated to either a “modeling set” or a “validation set”. Factors associated with recurrence, disease-free survival (DFS), and overall survival (OS) were defined in the “modeling set”. Their performances were tested in the “validation set”.

Results

From a total of 556 recruited patients, 339 (61%) were allocated to the “modeling set” and 217 (39%) to the “validation set”. Three models explaining recurrence, DFS, and OS were described. Tumor location in the left colon (Hazards ratio [HR] = 1.57; 95% Confidence interval [CI] 0.99-2.48), lymphocyte (HR = 0.46; 96% CI 0.27-0.88) and monocyte (HR = 0.99; 95% CI 0.99-1) counts, neutrophil/platelet ratio (HR = 1.3; 95% CI 0.74-2.3, and HR = 2.3; 95% CI 1.3-4.1; for second and third category, respectively), albumin/monocyte ratio (HR = 0.43; 95% CI 0.21-0.87), and microscopic residual disease after surgery (HR = 8.7; 95% CI 3.1-24) were independently associated with OS. T classification and expression of CDX2 and/or MUC2 were not independently associated with recurrence or prognosis.

Conclusion

These models are simple and readily available, and distinguish the risk and prognosis in patients with CC stages I and II; these models require cheaper processes than the use of more sophisticated molecular biology techniques. They may guide either the need for adjuvant therapy versus post-operative surveillance only, as well as aid in the design of clinical trials.

LKB-1 Expression and High-Risk Histopathology are Independent Prognostic Factors for Patients with Oral Cavity Carcinoma

BACKGROUND

The expression of liver kinase B1 (LKB-1) has been associated with prognosis in squamous cell carcinoma of the oral cavity (SCCOC). This study aimed to define the prognostic role of LKB-1 expression for patients with SCCOC and the suitability of its integration into a multivariate prognostic model.

METHODS

A retrospective cohort study of patients with SCCOC was conducted in a cancer center. Expression of LKB-1 was evaluated by immunohistochemistry, and multivariate analysis defined prognostic factors associated with recurrence, recurrence-free survival (RFS), and overall survival (OS). The logistic regression model was used to construct a predictive computer software program.

RESULTS

Of the 201 patients in this study, 104 (51.7%) experienced recurrence of their disease. Lower expression of LKB-1, high-risk histopathology, and advanced tumor-node-metastasis (TNM) stages were independent factors via multivariate analysis associated with the increased recurrence risk, poor RFS, and poor OS. If lack of LKB-1 expression is considered the reference category, the factors independently associated with recurrence were low (odds ratio [OR], 0.157; 95% confidence interval [CI], 0.044-0.557), intermediate (OR, 0.073; 95% CI, 0.017-0.319), and intense (OR, 0.047; 95% CI, 0.007-0.304) expression of LKB-1. This model permitted construction of a computer software program capable of prediction with receiver operating characteristic analysis (area under the curve, 0.925) and led to the definition of five prognostic groups with a biologic gradient.

CONCLUSION

These results suggest that LKB-1 expression in patients with SCCOC is of robust prognostic value and complements the TNM staging system. The proposed model requires external validation in prospective observational studies.

Treatment of Unresectable Differentiated Thyroid Carcinoma With Upfront External Radiotherapy and Salvage Surgery: A STROBE-Compliant Retrospective Cohort Study

INTRODUCTION

In patients with unresectable Differentiated thyroid cancer (DTC), the use of external beam radiation therapy (EBRT), leads mostly to palliation. Our aim is to define the role of upfront EBRT, followed or not by salvage surgery, on Progression-free survival (PFS) or Overall survival (OS) in patients with DTC.

METHODS

This is a cohort study of patients with initially unresectable DTC who received EBRT. Cohort A received EBRT followed by rescue surgery and cohort B, EBRT only. The Kaplan-Meier method and Cox model were employed for survival analysis.

RESULTS

Thirty-three patients were included; 69.6% females and 30.3% males. Mean age was 60.6 and mean tumor diameter was 10.4 cm; 17 and 16 patients were included in cohorts A and B, respectively. Belonging to cohort A (Hazard ratio [HR] 0.177, 95% CI 0.05-0.7) and use of intensity modulated radiotherapy (HR 0.177, 95% CI 0.03-1.08) were associated to better PFS, while high-risk histopathology (HR 6.6, 95% CI 0.9-50) and EBRT dose (HR 1.05, 95% CI 1.01-1.08) were independently associated with lower PFS. Patients from cohort A (HR 0.061, 95% CI 0.01-0.3) had improved OS, while high-risk histopathology (HR 5.7, 95% CI 1.1-28.6) and EBRT dose (HR 1.05, 95% CI 1.01-1.09) were independently associated to worse OS.

CONCLUSION

EBRT, and when feasible, salvage surgery, should be an integral part of the therapeutic strategy in initially unresectable DTC.

Prognostic Factors and Differences in Survival of Right and Left Colon Carcinoma: A STROBE Compliant Retrospective Cohort Study

BACKGROUND

Right-colon cancer (RCC) presents differences with Left-colon cancer (LCC) in terms of Overall survival (OS), but certain reports provide conflicting findings. Our objective is to define differences regarding prognostic factors in RCC and LCC by multivariate analysis.

METHODS

Retrospective cohort including patients treated from 1992-2016. The Kaplan-Meier and Cox models were used to define prognostic factors.

RESULTS

871 patients had RCC and 748 LCC; mean age was 58.1. Location was associated with socioeconomic status, body mass, blood hemoglobin, serum albumin, lymphocyte count and Prognostic nutritional index (PNI). Distribution of TNM stages was similar between groups, as well as gender, age, surgical morbidity/mortality; 72.3% of RCC and 83.2% of LCC were well/moderately differentiated (p <0.0001). Mean surgical lymph-node retrieval was 19.3 (SD14.6) for RCC and 15.7 (SD13.1) for LCC (p <0.0001). Median OS was 5.2 (95% CI 3.9-6.5) for RCC, and 3.2 years (95% CI 2.1-4.4) for LCC (p = 0.426). OS was different between RCC and LCC by stratified analyses within PNI, TNM, differentiation and R classification. RCC presents different OS in stages IIIC, and IVB than LCC.

CONCLUSION

Differences between RCC and LCC were mainly by immunonutritional variables. Differences in OS were found after stratified analysis of PNI, TNM stages, differentiation degree, and R classification. Location of the neoplasm in the colon should be considered in the design of clinical trials in patients with colon cancer.

Association of the prognostic nutritional index and overall survival in patients with colorectal cancer: A STROBE compliant retrospective cohort study

BACKGROUND

The TNM classification does not completely reflect the prognosis of patients with colorectal cancer (CRC). Several clinical factors have been used to increase its prognostic value, but factors pertaining to the patient's immunonutritional status have not usually been addressed. The aim of this study is to evaluate the role of Prognostic nutritional index (PNI) and other well-known prognostic factors by multivariate analysis in a cohort of patients with CRC.

METHODS

This is a retrospective cohort study of consecutive patients with CRC managed in a cancer center between January 1992 and December 2016. Cox's model was used to define the association of the PNI and other factors with Overall survival (OS).

RESULTS

A total of 3301 patients were included: 47.7% were female and 52.3% were male, with a mean age of 58.7 years. By bivariate analysis, PNI was strongly associated with OS (Risk ratio [RR] 0.968, 95% Confidence interval [CI] 0.962-0.974; P < 0.001). On multivariate analysis, PNI was an independent explanatory variable (as continuous variable and as categorized variable; RR 0.732, 95% CI 0.611-0.878; RR 0.656, 95% CI 0.529-0.813 and RR 0.646, 95% CI 0.521-0.802, for quintiles 2, 3, and 4-5, respectively); a biological gradient effect was demonstrated. The final prognostic model included PNI, location of the neoplasia in the colorectum, basal hemoglobin, lymphocyte count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, TNM stage, differentiation degree, R classification, and postoperative complications.

CONCLUSIONS

PNI is a significant and independent prognostic factor in patients with CRC. Its prognostic value adds precision to the TNM staging system including specific subgroups of patients with CRC; it should be evaluated in prospective clinical studies.

Prognostic Impact of Direct 131I Therapy After Detection of Biochemical Recurrence in Intermediate or High-Risk Differentiated Thyroid Cancer: A Retrospective Cohort Study

Background: Patients treated for intermediate- or high-risk differentiated thyroid carcinoma (DTC) and Thyroglobulin (TG) elevation during follow-up, require a diagnostic whole-body scan (DWBS) and if positive, ¹³¹I treatment. This approach can lead to a delay in treatment and increased costs. The purpose of this study is to compare the oncologic outcomes associated to administration of direct therapy with ¹³¹I at first biochemical recurrence. Methods: Retrospective cohort study of patients with intermediate- or high-risk DTC treated with total thyroidectomy, ¹³¹I ablation and who developed TG elevation during follow-up, between January 2007 and December 2015. Cohort A included patients who underwent a DWBS with 5 mCi of ¹³¹I, and if negative an MRI and/or ¹⁸FDG PET-CT prior to the therapeutic dosage, and cohort B included those who only received a therapeutic dosage of ¹³¹I, without a DWBS or extensive image studies. Main outcomes were second recurrence (SR) and disease-free survival (DFS). The diagnostic accuracy of DWBS was analyzed. Results: Cohorts A and B had 74 and 41 patients, each. By multivariate analysis, age, differentiation grade, TN classification, ablation dose, and performed DWBS (odds ratio 55.1; 95% CI 11.3-269) were associated with SR (p < 0.0001); age, male gender, ablation dose and performed DWBS (hazard ratio 7.79; 95% CI 3.67-16.5) were independent factors associated with DFS (p < 0.0001). DWBS diagnostic accuracy was 36.48%. Conclusion: ¹³¹I treatment in patients with DTC biochemical recurrence and no DWBS or extensive image studies is associated with a significantly lower frequency of SR and an increased DFS. The diagnostic accuracy of DWBS is low, and its clinical efficiency should be defined in prospective phase III studies.

Baseline serum albumin and other common clinical markers are prognostic factors in colorectal carcinoma: A retrospective cohort study

The aim of the present study was to define the prognostic role of baseline serum albumin (BSA) in colorectal cancer (CRC) across tumor-node-metastasis (TNM) stages and other well defined prognostic factors. Many prognostic models in medicine employ BSA to define or refine treatments in very specific settings; in CRC, BSA has been found to be a prognostic factor as well. A retrospective cohort study of consecutive patients with CRC demonstrated by biopsy, who attended a cancer center during a 7-year period. Multivariate analysis was utilized to define prognostic factors associated with overall survival (OS) employing the Cox model. In this retrospective cohort study, 1465 patients were included; 46.6% were females and 53.4% males (mean age, 59.1 years). Mean BSA was inversely correlated with TNM stages. By multivariate analysis, it was an independent explanatory variable. TNM stages, "R" classification, age, lymphocyte count, neutrophil/platelet ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, postoperative morbidity, and BSA were independently associated with OS. Morbidities, surgery type, chemotherapy, and radiotherapy were considered confounders after adjusting by TNM stages. BSA is a significant and independent prognostic factor in patients with CRC, and its effect is maintained across TNM strata and other well known clinical prognostic factors. It can be easily used in prognostic models and should be employed to stratify prognosis in therapeutic randomized clinical trials.

Validation of the Mexican Spanish version of the EORTC QLQ-H&N35 instrument to measure health-related quality of life in patients with head and neck cancers

BACKGROUND

Health-related quality of life (HRQL) is an important outcome measurement in oncology. Our aim was to validate the Mexican Spanish version of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-H&N35 questionnaire to measure HRQL in patients with head and neck cancers.

METHODS

The QLQ-C30 and QLQ-H&N35 instruments were applied to Mexican patients with head and neck cancer at a cancer referral center. Reliability and validity tests were performed. Test-retest was carried out in selected patients.

RESULTS

One hundred ninety-three patients were included in this cohort; tumor locations included the following: oral cavity 45 (23.3 %); larynx 35 (18.1 %); thyroid carcinoma invasive to aerodigestive tract 32 (16.6 %); oropharynx 17 (8.8 %); hypopharynx 12 (6.2 %); nasal cavity and paranasal sinuses 11 (5.7 %); salivary glands 11 (5.7 %); nasopharynx 8 (4.1 %); eye and adnexa 7 (3.6 %); cervical metastases of unknown origin 5 (2.6 %); primary sarcoma of the head and neck region 5 (2.6 %); maxillary antrum carcinoma 4 (2.1 %); and retinoblastoma 1 (0.5 %). Questionnaire compliance rates were high, and the instrument was well accepted; the internal consistency tests demonstrated good convergent and divergent validity. Cronbach's α coefficients of 8 of 9 multi-item scales of the QLQ-C30 and 6 of 8 scales of the QLQ-H&N35 instruments were >0.7 (range 0.22-0.89). Scales of the QLQ-C30 and QLQ-H&N35 instruments distinguished among clinically distinct groups of patients; some were highly sensitive to change over time.

CONCLUSIONS

The Mexican Spanish version of the QLQ-H&N35 questionnaire is reliable and valid for the assessment of HRQL in patients with head and neck cancers and can be used in clinical trials in Mexican communities.

Selection of best candidates for multiorgan resection among patients with T4 gastric carcinoma

BACKGROUND AND OBJECTIVE

Indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to define prognostic factors to select those patients with best chance to benefit from multiorgan resection.

MATERIALS AND METHODS

A cohort of patients with T4 GC treated in a 19-year period. Surgical morbidity-associated factors were identified by logistic regression analysis. Prognostic factors were defined by Kaplan-Meier and Cox methods.

RESULTS

Seven hundred eighteen patients were included (gastrectomy performed in 169). Surgical morbidity and mortality were 39% and 10.7%, respectively. Surgical morbidity were associated to extent of gastrectomy, age, serum albumin, and lymphocyte count (P = 0.0001). Presence of metastasis (hazard ratio [HR], 1.68; 95% confidence interval [95% CI], 1.19-2.36), albumin <3 g/dl plus lymphocytes <1,000 cells/mm(3) (HR, 2.9; 95% CI, 1.8-4.6), presence of ascites (HR, 2.1; 95% CI, 1.06-4.2), age >or=50 (HR, 1.37; 95% CI, 1.02-1.8), and unresectable disease (HR, 2.6; 95% CI, 1.7-4.1) defined poor survival (P = 0.00001).

CONCLUSION

Performing a multiorgan resection must be balanced between chances for long-term survival and surviving a potentially fatal operation. Absence of metastases, serum albumin levels >3 g/dl, and accomplishment of R0 resection select patients with high probability of benefit from multiorgan resection.

Validation of the Mexican Spanish version of the EORTC C30 and STO22 questionnaires for the evaluation of health-related quality of life in patients with gastric cancer

Health-related quality of life (HRQL) is a fundamental outcome in surgical oncology and culturally valid tools are essential for this purpose. Our aim was to validate the Mexican-Spanish versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire QLQ-C30 and the QLQ-STO22 disease-specific questionnaire module in Mexican patients with gastric cancer (GC). The translation procedure followed EORTC guidelines. Both instruments were completed by patients with GC and analyses were performed within three clinically distinct groups: (1) patients undergoing palliative treatment, (2) patients undergoing treatment with curative intent, and (3) GC survivors. Tests for reliability and validity were performed. One hundred and fifty patients (mean age 54.2 years) completed both questionnaires. Sixty-seven, 55, and 28 patients were allocated to groups 1, 2, and 3, respectively. Compliance rates were high, and questionnaires were well-accepted. Survivors of treatment for GC reported better functional HRQL scores and lower symptom scores than patients in group 2 who were currently undergoing treatment. Patients selected for potentially curative treatment had better HRQL than group 1 (palliative treatments). Scales in the QLQ-C30 and QLQ-STO22 distinguished between other clinically distinct groups of patients. Cronbach's alpha coefficients of 14 scales of both questionnaires were >0.7. Multitrait scaling analysis demonstrated good convergent and discriminant validity. Test-retest scores were consistent. We conclude that the Mexican-Spanish versions of EORTC QLQ-C30 and QLQ-C22 questionnaires are reliable and valid for HRQL measurement in patients with GC and are therefore recommended for use in clinical trials of Mexican community.

Experience of surgical morbidity after palliative surgery in patients with gastric carcinoma

BACKGROUND

Indications for palliative surgery in gastric carcinoma (GC) are controversial. Our aim was to describe the results of palliative surgery in GC in terms of operative morbidity and survival.

METHODS

We conducted a retrospective cohort study of patients with GC, who were divided into three groups: resection with microscopic residual disease (R1), palliative resection with macroscopic residual disease (R2), and gastrojejunostomy. Comparisons were tested with analysis of variance (ANOVA) or chi(2) test, and the Kaplan-Meier method was used for survival analysis.

RESULTS

One hundred and thirty-two patients were included in the study: 21 had R1, 71 had R2, and 40 had gastrojejunostomy. Surgical morbidity was recorded in 4 patients (19%), 23 patients (32.4%), and 1 patient (2.5%) in each of the three groups, respectively (P = 0.001). Operative mortality occurred in 6 patients (8.5%) from the R2 group and in 1 (2.5%) patient from the gastrojejunostomy group (P = 0.406). Median survivals of the R1, R2, and gastrojejunostomy groups were 22.8 months (95% confidence interval [CI], 16.4-29.3), 12.4 (95% CI, 9.01-15.8) months, and 6.4 months (95% CI, 0-14.6), respectively (P = 0.078)

CONCLUSION

R1 resections and gastrojejunostomy were associated with low surgical morbidity and mortality, unlike R2 resection; in this group, surgical morbidity and mortality was high. Therefore, the benefit of palliative resection in the presence of extensive residual disease should be balanced against the risk of surgical morbidity.

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.

Treatment of the Adenocarcinoma of the Esophagogastric Junction at a Single Institution in Mexico

BACKGROUND

Adenocarcinoma of the esophagogastric junction (EGJ) is rapidly increasing in the west. Our aim is to define the prognostic factors and treatment of EGJ carcinoma in Mexico, particularly the location after the Siewert's classification.

METHODS

A retrospective cohort of patients suffering from EGJ adenocarcinoma treated from 1987 to 2000. The Kaplan-Meier and the Cox's models were used to define prognostic factors.

RESULTS

Two hundred and thirty-four patients were included, 90 females and 144 males. Surgical resection was possible in 68 cases only (29%). Significant prognostic factors were tumor node metastasis (TNM) stage [stages I-II: risk ratio (RR) is 1; stage III RR is 1.3, 95% confidence interval (CI) 0.75-2.4; stage IV RR, 2.04, 95% CI 1.1-3.7], gender (male RR = 1.47, 95% CI 1.05-2.05), metastatic lymph node ratio (no resection: RR = 1; ratio 0.2-1 RR=0.67, 95% CI 0.39-1.14; ratio 0-0.19 RR = 0.42, 95% CI 0.23-0.76) and seralbumin (3 mg/dL or less RR = 2.05 95% CI 1.3-3.2; 3.1-3.4 mg/dL RR = 1.9 95% CI 1.2-3.03; 3.5-3.8 mg/dL RR = 1.3 95% CI 0.8-1.9; 3.9 mg/dL or more: RR = 1) (model P = 0.0001).

CONCLUSIONS

EGJ adenocarcinoma is a highly lethal neoplasia and the location after the Siewert' classification is not a prognostic factor. In Mexico, TNM clinical stage, serum albumin, gender, surgical resection and metastatic lymph node ratio are significant prognostic factors. Curative treatment is infrequent but radical resection is associated to longer survival. Consequently, the management must consider quality of life and surgical morbidity.

Multivariate prediction of the probability of recurrence in patients with carcinoma of the parotid gland

BACKGROUND

Parotid gland carcinoma is an infrequent tumor, and series that report on these neoplasms are relatively scarce in the literature. The objective of the current study was to identify prognostic factors in patients with parotid gland carcinoma and to develop a method for defining the probability of recurrence.

METHODS

Patients with parotid gland carcinoma who were treated at the authors' institution from January 1981 through December 2004 and who completed treatment constituted the study group. Disease-free survival was calculated by using the Kaplan-Meier method. Logistic regression analysis was employed to define the recurrence-associated prognostic factors.

RESULTS

One hundred twenty-seven patients were included (64 men and 63 women); their mean age was 53 years. Mucoepidermoid carcinoma was diagnosed in 34.6% of patients, adenoid cystic was diagnosed in 15.7% of patients, adenocarcinoma was diagnosed in 14.3% of patients, and acinic cell carcinoma was diagnosed in 9.4% of patients. The median disease-free survival was 8.3 years (95% confidence interval [95% CI], 4.3-12.2 years). Logistic regression analysis confirmed tumor classification, facial nerve palsy, grade of tumor differentiation, patient age, and surgical margins as recurrence-associated factors (P < .00001). Using this model, 3 postoperative risk groups were defined-high-risk, intermediate-risk, and low-risk-that had recurrence frequencies of 71.4%, 43.1%, and 8.8%, respectively (P = .0001). The 5-year disease-free survival rates for these groups were 18.7%, 53.9%, and 99.9%, respectively (P = .00001).

CONCLUSIONS

In this study, the authors identified several significant prognostic factors. Consequently, they have proposed a prognostic score categorization that allows for a straightforward calculation of the risk of recurrence for a given patient that may help to define therapeutic strategies, target patient counseling, and design future trials.

Serum albumin as a significant prognostic factor for patients with gastric carcinoma

BACKGROUND

The definition of prognostic factors in gastric carcinoma (GC) remains controversial. The potential of serum albumin as a prognostic factor for GC is emphasized because the technique to measure it is simple as well as being cheap and widely available. Our aim was to define the prognostic role of serum albumin in GC.

METHODS

A cohort treated from January 1987 to December 2002 was studied. Relevant clinical, pathological and therapeutic variables were recorded. Kaplan-Meier and Cox's methods were used to define prognostic factors associated with cancer-related survival.

RESULTS

One thousand and twenty-three patients were included. Serum albumin did impact survival, showing a dose-response effect. This effect was present after adjustment for other prognostic factors, including Tumor-Node-Metastasis (TNM) stage, surgical resection and type of lymphadenectomy. In multivariate analysis, TNM stage [Stage Ia and Ib Hazard Ratio [HR] 1, Stage II HR 1.6 (95% confidence interval [CI], 0.56-4.7), Stage IIIa HR 4.4 (95% CI 1.7-11.3), Stage IIIb HR 5.6 (95% CI 2.6-17.2), Stage IV HR 6.8 (95% CI 2.7-17.5), high albumin HR 1, medium albumin HR 1.2 (95% CI 0.8-1.7), low albumin HR 1.2 (95% CI 0.8-1.8), very low albumin HR 1.8 (95% CI 1.3-2.6), D2 dissection HR 1, D1 dissection HR 1.9 (95% CI 1.3-2.97), and no resection HR 3.7 (95% CI 2.4-5.7)] were the most significant prognostic factors associated to survival (model P = 0.00001).

CONCLUSION

Pretherapeutic serum albumin level is a significant prognostic factor, which should be evaluated along with other well-defined prognostic factors in decisions concerning therapy for GC.

Functional Evaluation After Reconstruction With Myocutaneous and Fasciocutaneous Flaps for Conservative Oncological Surgery of the Extremities

BACKGROUND

Limb-preservation surgery has evolved during the last two decades through application of pedicled and free flaps and has obtained oncological results similar to those with amputation for malignant neoplasms of the extremities. However, functional evaluation has not been performed comprehensively after these advanced reconstructive procedures. The aim of this study was to describe the oncological, surgical, and functional outcomes achieved in these patients.

METHODS

Patients had malignant neoplasms of the extremities and/or shoulder and hip girdle, underwent resective surgery and reconstruction with limb-preservation purposes, and were treated from 1997 to 2002. Survival analysis was performed, and functional evaluation after resection was performed with the Enneking system 1 year after surgery.

RESULTS

Thirty-two patients were included. The mean overall survival of the cohort was 5.6 years. Functional evaluation mean rating percentages for the upper and lower extremities were 86.5% and 75.2%. Functional outcomes were better for reconstruction with free flaps than with pedicled flaps in the lower extremities (rating percentages, 67% and 79.6%, respectively; P = .018).

CONCLUSIONS

Limb-preservation surgery is a safe treatment for malignant neoplasms. It can be performed with low morbidity and good oncological outcomes. Functional results in our series were good. Lower limb preservation has superior scores with free flap reconstructions because of their potential to cover extensive defects, and better results were obtained in walking, gait, and weight bearing.

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.

[Use of median fronto-naso-orbital flap to decrease the incidence of complications in patients undergoing craniofacial resection]

BACKGROUND

Resection of malignant neoplasms invading the anterior cranial base is performed with craniofacial resection (CFR) with acceptable results in complication rates and oncologic outcomes. However, still there are series with major morbidity in up to 40% of patients, and mortality of 5%. A retrospective study was performed to evaluate the results in terms of morbidity, mortality, function and aesthetics using a median fronto orbital flap (MFOF).

METHODS

The MFOF was used in 28 consecutive patients who presented to the Head and Neck Service from 1992 to 1999, in the Instituto Nacional de Cancerología, Mexico City, and was combined with a superior rhinotomy for en bloc resection of the ethmoid complex in the last 12 cases. 89% of patients had malignant neoplasms.

RESULTS

1 death occurred in this series (3%) and the global morbidity was 35%. Aesthetics and function were good to excellent. Percentages of tumor-free survival for malignant lesions was 76% and 41% at 2 and 5 years follow up, respectively.

CONCLUSION

CFR is a safe approach for treatment of neoplasms of the anterior skull base. MFOF mobilization decreases complication rates and gives superb exposure for en bloc resection of tumors invading the ethmoidomaxillary complex specially when combined with a superior rhinotomy. A positive impact on quality of life was obtained.

Reconstructive management of advanced breast cancer

To evaluate morbidity, quality of life, and oncological outcomes of patients with advanced breast cancer, recurrence, or sequelae secondary to radiotherapy, the authors present their experience with 21 patients at the Instituto Nacional de Cancerología in Mexico City, who underwent resection of the lesion and reconstruction using thoracoepigastric fasciocutaneous, rectus abdominis, or latissimus dorsi musculocutaneous flaps. Complications included partial flap necrosis and bronchopleural fistulae in 2 of 7 patients with whole-thickness chest wall resection. The remaining patients progressed nicely, with a short recovery period. The patients and the surgical team evaluated results in terms of aesthetics and function using questionnaires. The results were from fair to good according to Sneeuw's scale. Pedicled musculocutaneous and fasciocutaneous flaps are an excellent reconstructive option in patients with advanced, recurrent breast cancer and in those with radionecrotic complications, which sometimes require resection of the whole-thickness chest wall.

Accuracy of Fine-Needle Aspiration Biopsy of the Thyroid Combined with an Evaluation of Clinical and Radiologic Factors

Fine-needle aspiration biopsy (FNAB) of thyroid nodules is an operator-interpreter-dependent procedure whose diagnostic accuracy has deficiencies, especially concerning indeterminate and negative results. There are reports in the literature of up to a 15% definitive diagnosis of carcinoma in the first category of cytology and an 11% false-negative rate in the second category. With these facts in mind, a prospective study was done at the Instituto Nacional de Cancerología, Mexico City, to determine whether one or several clinicoradiologic factors were associated with a final pathologic diagnosis of carcinoma, thereby increasing the diagnostic accuracy of thyroid FNAB. In total, 200 cases were reviewed, and 159 patients underwent surgery. Our study group comprises these 159 patients. The only clinical factor associated with false-negative results was size ≥ 4 cm, with no statistical significance for the other factors analyzed. A comparison was done between clinical factors of patients who had indeterminate results in the aspirate and those of patients who had a definitive diagnosis by permanent section of the thyroid carcinoma, where an association was found between malignancy and tumor size ≥ 4 cm, irregular borders, fixed lesions, and heterogeneity on ultrasound. We conclude that in the presence of a negative cytology result, with tumor size ≥ 4 cm, close follow-up is indicated, and a new thyroid FNAB should be performed in 6 months. If the nodule persists or grows, a surgical procedure should be considered. In the case of an indeterminate cytology result and in the absence of those factors associated more frequently with a pathologic result of carcinoma, a conservative approach could be indicated with clinical follow-up and repeat thyroid FNAB in 6 months to 1 year.

Accuracy of fine-needle aspiration biopsy of the thyroid combined with an evaluation of clinical and radiologic factors

Fine-needle aspiration biopsy (FNAB) of thyroid nodules is an operator-interpreter-dependent procedure whose diagnostic accuracy has deficiencies, especially concerning indeterminate and negative results. There are reports in the literature of up to a 15% definitive diagnosis of carcinoma in the first category of cytology and an 11% false-negative rate in the second category. With these facts in mind, a prospective study was done at the Instituto Nacional de Cancerología, Mexico City, to determine whether one or several clinicoradiologic factors were associated with a final pathologic diagnosis of carcinoma, thereby increasing the diagnostic accuracy of thyroid FNAB. In total, 200 cases were reviewed, and 159 patients underwent surgery. Our study group comprises these 159 patients. The only clinical factor associated with false-negative results was size > or = 4 cm, with no statistical significance for the other factors analyzed. A comparison was done between clinical factors of patients who had indeterminate results in the aspirate and those of patients who had a definitive diagnosis by permanent section of the thyroid carcinoma, where an association was found between malignancy and tumor size > or = 4 cm, irregular borders, fixed lesions, and heterogeneity on ultrasound. We conclude that in the presence of a negative cytology result, with tumor size > or = 4 cm, close follow-up is indicated, and a new thyroid FNAB should be performed in 6 months. If the nodule persists or grows, a surgical procedure should be considered. In the case of an indeterminate cytology result and in the absence of those factors associated more frequently with a pathologic result of carcinoma, a conservative approach could be indicated with clinical follow-up and repeat thyroid FNAB in 6 months to 1 year.

Oromandibular reconstruction for oncological purposes

The authors compared different vascularized bone grafts in 15 patients with different oncological diagnoses that were treated with hemimandibulectomy in 9 patients, total mandibulectomy in 1 patient, resection of the mandible involving the anterior arch and the symphysis in 3 patients, 1 patient who underwent a segmental mandibular resection, and 1 patient in whom the entire hemimandible was reconstructed because of mandibular hypoplasia diagnosed during the resection of a parotid neoplasm. The flaps used included fibular free flaps in 11 patients, iliac crest in 3 patients, and a radial forearm osteocutaneous flap in 1 patient. Two patients had major complications and 1 patient experienced recurrence of the primary tumor. The fibular free flap was the preferred method in this series due to the size of the defect, which in most patients did not require extensive soft-tissue reconstruction, and due to the nature of the bone defect involving the symphysis and condyle in 9 patients. The different vascularized bone grafts provided adequate osseous and soft tissue for oromandibular reconstruction.

Accuracy of combined clinical findings and fine needle aspiration cytology for the diagnosis in palpable breast tumors

OBJECTIVE

A prospective study to evaluate the confidence level and predictive value of the fine needle aspiration biopsy was performed in the Oncology Service, "Hospital 20 de Noviembre, ISSSTE", Mexico City.

MATERIAL AND METHODS

The cases with a palpable breast tumor, histologically confirmed who presented from 1992 to 1994 were included. One aspirate was done in each patient and these were reviewed by the same pathologist. We determined sensitivity, specificity and predictive value of the test. Age, border characteristics, size and mobility of the tumor were evaluated by Bayesian analysis.

RESULTS

From 213 aspirates, 199 were elegible for diagnosis, 98 (46%) had a diagnosis of carcinoma, 13 were acellular and one suggestive. The acellular diagnoses were considered negative and suggestive positive, for analysis purposes. Mean age and tumor size were: 46.6 years (range 14-90) and 3.7 cm. (range 1-13) respectively. Sensitivity (0.932), specificity (0.973) and positive predictive value (96.9%) were estimated. We observed a high probability of true positive [P(D+/T+)] > 0.8 results in patients between 40 and 60 years of age, irregular borders, size > 2 cm and fixed lesions.

CONCLUSIONS

The test has a high confidence level and in presence of two or more of the clinical factors mentioned, definitive decisions regarding treatment could be taken, without need of histologic confirmation.

The impact of preoperative tracheotomy on T3 transglottic carcinomas of the larynx

To evaluate the impact of the practice of a preoperative tracheotomy and different prognostic factors reported in the literature in patients with transglottic carcinoma of the larynx, a retrospective study was performed in the Instituto Nacional de Cancerologia, Mexico City. In all, 90 cases with T3 transglottic squamous cell carcinoma requiring a total laryngectomy as primary treatment were studied. Prognostic factors such as the Karnofsky index, tumor differentiation, surgical margins and preoperative tracheotomy were analyzed by a Cox's proportional hazards model. The Kaplan-Meier method and log rank test were used to evaluate the disease-free intervals and survival curves. Thirty-two patients had preoperative tracheotomies, while 58 did not. Eighty percent of the patients in the non-preoperative tracheotomy group were alive after 5 years versus 20% of those with preoperative tracheotomies (P < 0.001). Although possibly controversial, our findings indicate that a pretreatment tracheotomy should be avoided in T3 transglottic obstructive lesions. In patients with these lesions and a subglottic extension < or = 3 cm we recommend an emergency total laryngectomy when possible to increase survival and decrease surgical morbidity.

Staging and treatment of nasopharyngeal angiofibroma

To analyze the prognostic value of clinical-radiologic staging, morbidity, mortality and results of treatment used in the Instituto Nacional de Cancerologia, Mexico, a retrospective study of angiofibroma was performed. Charts were reviewed from patients who attended the institute from 1977 to 1993. History and physical examination, rhinoscopy and fiber-optic nasopharyngolaryngoscopy were done in every patient. Radiologic evaluation was done with computed tomography, after which Chandler's staging system was used. Disease-free interval curves were estimated for patients who had presented with stage III or IV tumors. Thirty-one patients were treated with surgery and/or radiotherapy. Most of the patients had stage III (70.9%) or stage JV (25.8%) disease. Surgical procedures included lateral rhinotomies (15 cases), transpalatal dissections (11 cases), transantral degloving (3 cases), median rhinotomies (2 cases), infratemporal transzygomatic dissections (2 cases), frontotemporal craniotomy (1 case) and suprahyoid pharyngotomy (1 case). Radiotherapy (as 3000-5500 cGy) was administered to 16 patients: 7 patients with stage III persistent or recurrent tumor and 8 patients as initial treatment for stage IV disease. The disease-free interval of patients with stage III and IV disease was 80.3% and 19%, respectively, after 36 months of follow-up. Findings demonstrated that surgery was the treatment chosen in patients with stage II and III disease, with low morbidity and mortality, and good results in disease control. In contrast, radiotherapy was usually the treatment in stage IV disease, but had low effectiveness, indicating the need to carefully investigate the value of craniofacial approaches in these tumors.