Abstract P6-16-01: The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01

Background: The MF07-01 trial is a multicenter phase III randomized controlled trial of treatment naive stage IV BC patients comparing loco-regional surgery (LRS) followed by appropriate systemic therapy (ST) versus ST alone.

Aims: To evaluate the importance of loco-regional tumor burden and surgery on overall survival rate in patients with de novo stage IV breast cancer.

Methods: At initial diagnosis patients were randomized 1:1 to LRS group or ST group. The surgery was a lumpectomy (L) or mastectomy (M) and sentinel lymph node biopsy (SLNB) ± axillary lymph node dissection (ALND). After surgery all patients received systemic treatment + endocrine treatment (ET) and Trastuzumab based on pathology results. The demographic, pathologic, and clinical characteristics of the patients were recorded.

Results:274 patients were accrued; 138 in the LRS group and 136 in the ST group. The groups were comparable regarding age, BMI, HER2 neu, tumor type and size, histologic grade, and bone and visceral metastasis (all p>0.05). In the LRS group 36 patients (26%) had L+ALND, 92 patients (67%) had M+ALND and 10 patients (7%) had M+SLNB, respectively.

The patients and tumor characteristicsPatients and Tumors Characteristics and Surgical TreatmentSurgerySystemic TherapyP ValueAge (mean /year±SD)51.8 ±12.651.5±13.6NSMedian follow-up (25%,75%)41.0 (24,54)37 (18,49) Tumor Size (%)   T18.7 (12) NST252.2 (72) NST321.7 (30) NST417.4 (24) NSHistologic Grade (%)   I4.4 (6)9.6 (10)NSII39.9 (55)31.7 (33)NSIII55.8 (77)58.9 (61)NS    Surgical Treatment   Lumpectomy+ ALND26 (36)--M + SLNB7 (10)--M + ALND67 (92)---SLNB17 (23)--ALND92.8 (128)--pN+89.1 (123)--30-day mortality1.4 (2)1.5 (2)0.98SLNB-Sentinel Lymph Node Biopsy; ALND-Axillary Lymph Node Dissection; M-Mastectomy

The axillary positivity rate was 89.1%. There were 76 (55%) deaths in the LRS group and 101 (74%) in the ST group during the median 40 (20-51) month follow-up. Overall survival (OS) was 34% higher in the LRS group compared to the ST group (HR: 0.66, 95%CI 0.49-0.88: p = 0.005).

Overall survival rate was higher in LN (+) (p=0.01), tumor size<5cm (p<0.0001), and high histologic grade (HG III, p<0.008) patients who underwent axillary surgery than ST group ; OS rate was with a marginal significant level in patients without axillary involvement (pN0) in the LRS group compared with ST group (p=0.05).

Conclusion: In this subgroup analysis, we observed that patients with high grade tumor, without skin or chest wall involvement and positive axilla who underwent surgery for primary breast tumor and axilla had better overall survival than ST in de novo stage IV breast. These results can be considered in clinical research design for stratification.

Citation Format: Ozmen V, Ozbas S, Karanlik H, Muslumanoglu M, Igci A, Canturk Z, Utkan NZ, Ozaslan C, Evrensel T, Uras C, Aksaz E, Soyder A, Ugurlu UM, Col C, Cabioglu N, Bozkurt B, Sezgin E, Dagoglu T, Uzunkoy A, Dulger M, Koksal N, Cengiz O, Gulluoglu B, Unal B, Atalay C, Yildirim E, Erdem E, Salimoglu S, Sezer A, Koyuncu A, Gurleyik G, Alagol H, Ulufi N, Berberoglu U, Soran A. The importance of loco-regional tumor burden and surgery on survival in patients with de novo stage IV breast cancer; post-hoc analyses of protocol MF07-01 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-01.

Abstract P6-07-24: miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer

Background

Circulating microRNAs (miRNAs) as regulators of gene expression have recntly been promising suitable potential biomarkers due to their stability and ease of detection in blood. In this study, we aimed to determine the plasma expression levels of 372 different miRNAs in patients with invasive ductal breast cancer (IDC).

Methods

The expression levels of 372 circulating miRNAs in plasma samples of 20 patients with operable stage 1-III IDC and 10 healthy controls were determined using RT-PCR arrays. Mean ages of patients and healthy controls were 45.9+/-8.8) and 45.4+/- 5) respectively. Of 20 breast tumors, 12 were luminal breast cancer, whereas 8 were non-luminal as pure HER2-neu or triple negative breast cancer. RNA was isolated using miRNeasy Serum/Plasma Kit (Qiagen, Hilden, Germany, Cat. No: 217004). cDNA synthesis was performed according to manufacturer's instructions with miScript II RT Kit (Qiagen,Hilden, Germany, Cat. No: 218161). Serum/Plasma 384 HC PCR arrays with miScript SYBR Green PCR Kit (Qiagen, Hilden, Germany, Cat. No:218076) were used RT-PCR analysis. These assays included 372 miRNAs in additon to housekeeping genes and reaction controls. All reactions were performed in triplicates. Ct values were analyzed via an online software developed by Sabiosciences. P values were calculated using Student's t-test and p values lower than 0.05 were considered significant.

Results

Among 372 miRNAs, 19 were found to be deregulated in plasma samples of patients with IDC. 8 miRNAs were upregulated, and the other 11 were downregulated.

Upregulated and Downregulated Circulating miRNAs in Patients with Invasive Ductal CarcinomaUpregulated miRNAsFold regulationp valueDownregulated miRNAsFold Regulationp valuemiR-29a-3p2.0240.032miR-19b-1-5p-2.3750.048miR-101-3p2.4000.040miR-4732-5p-2.0910.015miR-542-3p2.2910.042miR-4687-5p-4.6230.005miR-199b-3p2.0190.020miR-3135b-2.7920.0005miR-98-5p2.4830.003miR-4770-2.4150.0103miR-424-5p3.0550.034miR-4301-2.6680.007miR-374c-5p2.1100.049miR-1247-5p-2.8130.0003miR-19b-3p3.7590.048miR-1287-5p-2.2020.0007   miR-197-3p-4.090.023   miR-126-5p-2.0520.029   miR-671-3p-2.5350.014Table 1

miR-19b-3p was the most upregulated miRNA with a fold change of 3.759 (95%CI:1.83- 5.68, p=.048) while miR-4687-5p was the most downregulated with a fold change of 0.216 (95%CI:0.00001-0.43, p=.005).

Conclusion

Our findings indicate that these 19 deregulated circulating miRNAs might be promising biomarker candidates for detection of IDC. The two most deregulated miRNAs were miR-19b-3p and miR-4687-5p. miR19b-3p belongs to a cluster of miRNAs which has been shown to function as oncogenes resulting in the downregulation of tissue factor expression in breast cancer cells. Further validation studies are ongoing in order to determine their clinicopathological prognostic value in breast cancer.

Citation Format: Tiryakioglu NO, Cabioglu N, Coskunpinar E, Tukenmez M, Ozturk D, Ozkurt E, Igci A, Pence S, Muslumanoglu M. miR-19b-3p and miR-4687-5p as novel circulating miRNAs as potential prognostic biomarkers in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-24.

The use of Ligasure vessel sealing system in axillary dissection; effect on seroma formation

BACKGROUND

Seroma formation is the most frequent postoperative complication after axillary dissection for breast surgery with an incidence of 10 - 50 %. This prospective clinical randomized study was carried out to evaluate the Ligasure vessel sealing system and its effect on seromaformation and other complications for axillary dissection.

METHODS

Between January 2006 and November 2007, the patients with histopathological diagnosis of breast cancer were analysed prospectively. The patients with positive sentinel lymph node biopsy or clinical axillary involvement were included in the study, and the patients who underwent neoadjuvant therapy or using anticoagulants have been excluded from the study. Patients were divided into two study groups.Axillary dissection was performed in the first group by LigaSure and in the second group by linking and electrocautery.

RESULTS

There were a total of thirty three patients with a mean age of 51.4 +- 13.7. In group one, mean age of patients was 54.1 +- 13.2 and 48.68 +- 14.1 in group two. There was no significant statistical difference between the groups regarding age, body mass index, excised tissue weight,tumour size and number of excised lymph nodes. The use of Ligasure reduced drainage amount and duration of drain till removal, but increased operative time.

CONCLUSION

There were no significant differences between study groups regarding the complications. LigaSure electrothermal bipolar vessel sealing system can be safely used in axillary dissection as an alternative to traditional methods.

Abstract P4-07-08: The predictive and prognostic role of tumoral miRNA expression levels in patients with breast cancer (BC) treated with neoadjuvant chemotherapy (NAC)

Over the last decade, miRNA's have gained considerable interest due to the accumulating evidence regarding their relevant regulatory functions on cancer initiation, proliferation and progression. Furthermore, there are data showing that miRNA's can have a predictive role in response to NAC. The aim of this study is to evaluate the association between miRNA expression profile and response to NAC in patients with BC. 21 patients who received NAC consisting of 4 cycles of antracycline and cyclophosphamide (EC), followed by 4 cycles of docetaxel (T) were included in this study. Tumor core biopsies and blood specimens were collected before initiation, before the 5th cycle and after the completion of NAC for pathologic evaluation, miRNA expression and circulating correlative miRNA levels. The miRNA profile consisted of 9 miRNA's that were previously shown to be related to anthracycline and taxane resistance, as well as those associated with various intracellular functions. Associations with miRNA expression and clinical and pathologic variables, including response were evaluated by the Spearmann Correlation test. Response assessment was carried out every couple of cycles by physical examination, and radiologic evaluation after 4 and 8 cycles, respectively. Clinical response to EC was complete regression in 4.76% (n:1), PR in 66.7% (n:14), minimal response in 23.8% (n:5); and progression in 4.76% (n:1); all patients responded to docetaxel with 1 having CR and 20 PR. Pathologic response evaluation revealed CR in 7 patients (33.3%), good PR (defined as more than 50% regression in the viable tumor cells) in 8 (38.1%) and minimal PR in 6 (28.6%). Baseline levels of miRNA expression before initiation of NAC from the lowest to the highest level were as follows: miR10b (mean relative value (MRV): 0.24), miR-200c, miR34a, miR-11, let7a, miR-200c, miR-21, miR-195 and miR-221 (MRV: 132.5). Although each miRNA tested were in positive correlation with each other (p<0.05), there was no association with any miRNA with known clinic-pathologic variables, such as ER, PR, Her-2/neu or Ki67 levels. All miRNA's showed higher levels in patients presenting with stage 2 disease compared to those with stage 3 disease, which was marginally significant for miR-155 and miR-21 (p:0.05). After 4 cycles of EC miR-21 and miR-195 expression decreased significantly (mean decrease 500 times the initial level) (p<0.05), which was more evident in patients with earlier stage at presentation (stage 2 versus stage 3 disease (p:0.03)). There were no significant correlations seen with any miRNA and response to taxane-based NAC, since all patients showed a response. Furthermore, there was no correlation between pCR and the miRNA's tested. Nevertheless, there was a trend for higher pre-treatment miR-34 levels predictive for a good clinical response to EC, which was defined as more than 50% regression in the largest tumor diameter (p:0.07). In this preliminary study, we have shown that a substantial decrease in miR-155, -21,and -195 expressions after 4 cycles of EC may be associated with clinical response to anthracycline-based NAC. Furthermore, a higher miR-34 expression may predict for athracycline responsiveness.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-07-08.

Male breast cancer: a retrospective study of 15 years

PURPOSE

To retrospectively evaluate the 15-year experience with breast cancer in males at a single institution.

METHODS

The data from 25 male patients who had undergone surgery for breast cancer at a single center were retrospectively analysed. Their medical records were studied for clinical characteristics, therapeutic modalities used and factors associated with disease free (DFS) and overall survival (OS), like local recurrence/distant metastasis.

RESULTS

The median patient age was 67 years (range 38-83). The most frequent presenting symptom was a palpable lump. Eighteen (72%) patients underwent modified radical mastectomy (MRM), while sentinel lymph node biopsy (SLNB) was performed in 14 (56%) cases. Of 25 patients, 21 (84%) underwent axillary lymph node dissection (ALND) and 15 (71.4%) of them had pathological axillary lymph node involvement. Two of 25 (8%) patients with bone and liver metastases underwent toilet mastectomy due to breast ulceration. Estrogen receptor (ER) was positive in 15 (60%) patients, while progesterone receptor (PR) and C-erbB2 (HER-2) were positive in 10 (40%) and 2 (8%) patients, respectively. Ten patients (40%) had both ER(+) and PR(+). The median follow-up period was 19 months (range 3-102). Local recurrence developed in one (4%) patient and distant metastasis in 4 (16%). Five-year OS and DFS were 53 and 49%, respectively. In univariate and multivariate analysis, pathological tumor size (<2 vs. >2 cm), pathological lymph node involvement and preoperative skin involvement over the breast were not associated with breast recurrence. Only in univariate analysis local recurrence/distant metastasis were associated with poor OS.

CONCLUSION

Large cooperative studies are needed using strict clinical and laboratory criteria to advance the understanding of this disease and to identify the most effective treatment approaches.

Trastuzumab use and survival in HER2 (+) nonmetastatic breast cancer among Turkish women

56

Background: HER2 overexpression observed in 10-25% of breast cancers is associated with rapid proliferation. HER2-targeted trastuzumab has been used in metastatic breast cancer, and since 2004 in early breast cancer. However, trastuzumab therapy is expensive and long lasting resulting sometimes in cardiac side effects. In this study we tried to find out whether there was a subgroup of early breast cancer patients trastuzumab could be omitted.

Methods: Records of patients treated for HER2-positive breast cancer in Istanbul Medical School between Jan 2000 and Sept 2009 were retrospectively evaluated. Disease-free survival (DFS) and overall survival (OS) were calculated either from follow-ups, or by calling. Kaplan meier and LogRank tests have been used for comparison (P<0.05, 95% CI).

Results: Follow up period was 32.2±14.9mo for trastuzumab group (TG, n:87) compared to 47.4±20.8mo for non-trastuzumab group (NTG, n:63) (P=0.0001). Groups were similar for age, menopausal status, size (T), histological grade and type, location, hormone responsiveness, presence of lymphovascular invasion, surgery, and use of local/systemic/hormonal therapy. NTG had more N0 cases (44.4% vs. 12.6%, P=0.0001), breast related deaths (15.9% vs. 5.7%, P=.042) and systemic metastases (27% vs. 13.8%, P=.043). Number of local recurrences was similar. Mean DFS and OS were significantly less in TG (P<0.0001). However differences between DFS and OS of groups were not significant despite a considerable increase for both in TG at fifth year (P=0.147, P=0.450). No difference in DFS and OS between TG and NTG was observed when patients who had chemotherapy and/or radiotherapy and/or hormonotherapy were compared to those who did not. OS was not different between TG and NTG for T1, T2, and T3 tumors and for patients ≤35y. But in N2 and N3 tumors, use of trastuzumab increased OS significantly (P=0.007).

Conclusions: Both number of events and systemic relapses were less in TG but we could not find a significant difference in DFS and OS between TG and NTG in Turkish nonmetastatic cancers. Prolonged follow up might be necessary to search for the subgroup who would not benefit, if any, as an incremental benefit in both DFS and OS was observed with trastuzumab use at fifth year.

Breast conserving surgery in patients with multifocal/multicentric breast cancer

PURPOSE

To retrospectively evaluate the outcome of patients with multifocal (MF) and multicentric (MC) breast cancer treated with conservative surgery.

METHODS

We evaluated 59 patients who had undergone breast conserving surgery (BCS) for MF/MC cancer between 1998-2008. We used sentinel lymph node (SLN) biopsy for all 59 patients and we performed axillary lymph node dissection in those with positive SLN. Local control, overall survival (OS), disease-free survival (DFS) and identification of predictive factors for recurrence were evaluated.

RESULTS

Twenty patients with modified radical mastectomy because of persistent positive margins were excluded from the study. Evaluated were 55 patients with MF (93.2%) and 4 (6.8%) with MC disease. Thirty-four patients (57.6%) had 2, 20 patients (33.9%) had 3 and 5 (8.5%) had 4 or more tumor foci. Median follow up time was 20 months (range 2- 97). The projected 5- and 8-year OS were 95% and 89% respectively, and DFS 92.3%. At multivariate analysis, overexpression of human epidermal growth factor receptor 2 (HER-2) was associated with a higher ipsilateral breast cancer recurrence. Menopausal status, MF/MC disease, number of tumor foci (2 vs. ≥3), histological grade, extracapsular extension (ECE), lymphovascular invasion (LVI), and hormone receptor status were not associated with ipsilateral breast cancer recurrence.

CONCLUSION

Our study demonstrates that in selected patients with MF/MC breast cancer, wide conservative surgery is a safe therapy.

Axillary sentinel node biopsy after neoadjuvant chemotherapy

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear.

PATIENTS AND METHODS

Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively.

RESULTS

SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus <or=2 cm; p=0.004), positive extra-sentinel lymph node extension (versus negative; p=0.002) were more likely to have metastatic non-SLN(s).

CONCLUSIONS

SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.

Complications of local/regional treatment of breast cancer and quality of life

e11597

The aim of this prospective clinical study was to evaluate early and late complications of different surgical procedures, and compare conservative surgical treatments (breast conserving surgery, sentinel lymph node biopsy) to more radical ones (mastectomy, axillary lymph node dissection), and find factors that were related to these complications. 218 early stage breast cancer patients (stage I and II) were enrolled in this study. Physical complications (restrictions in shoulder motions, shoulder functional capacity, pain, lymphedema and sensory loss), psychological complications and the factors related to these complications were studied in patients after breast cancer surgery and/or radiotherapy at first week, at 9th-12th months and at mean follow up time of 34 months. Lymphedema rates after surgery were 14.7 %, 24.8% and 17.0% at first week, 9th-12th months, and long term respectively. In early postoperative period, pain and functional capacity of the effected shoulder were worse than preoperatively measured values and all axis of motion of shoulder joint were effected significantly. On the other hand, at 9th-12th months, only internal flexion was still affected. At the long term period, all axis of motion of shoulder joint, pain and functional capacity were in normal range as before treatment. The factors related to lymphedema were axillary lymph node dissection (p=0.002), radiation therapy to axillae (p<0.001). The patients who had both axillary lymph node dissection and axillary radiotherapy had more lymphedema than the patients who only had axillary lymph node dissection or sentinel lymph node biopsy (p=0.004). The factors related to postoperative depression at early period were cigarette smoking (p=0.008), axillary lymph node dissection (p=0.045) and arm lymphedema (p=0.005). At long term period they were axillary lymph node dissection (p=0.021), mastectomy (p=0.036), drain usage (p=0.028) and sensory loss (p=0.027). The patients who had sentinel lymph node biopsy, axillary dissection without axillary radiotherapy had better quality of life. The patients with cigarette smoking, axillary lymph node dissection, mastectomy, drain, lymphedema and sensory loss had increased incidence of depression than others, these results were statistically significant.

No significant financial relationships to disclose.

Predictive factor for residual tumor after lumpectomy for close margins

e11538

Background: It is critical to obtain clear margins to minimize local recurrence after breast conserving surgery(BCS). When re-excisions are performed, there is often no residual disease in the new specimen, calling into question the need for re-excision(s) or mastectomy. The aim of the present study was to identify factors predicting a histologically positive re-excision specimen. Methods: Our prospective breast cancer database was queried for all invasive breast cancer patients who underwent a re-excision lumpectomy for either close or positive margins after an attempt at BCS. Close margins are defined as ≤ 2 mm for invasive carcinoma and presence of ductal carcinoma in situ(DCIS). Clinicopathologic features were correlated with the presence of residual disease in the re-excision specimen. Results: Between February 1997 and August 2008, 2054 patients with early breast cancer underwent surgical treatment in our breast unit. 939(45.7%) of them had BCS. In 543 patients(26.4%), re-excision required due to close margins on the permanent section analysis of their initial surgical specimens. 186 patients(34.3%) had previous excisional biopsy in other clinics. Median age of 543 patients was 50 years. In 290 patients(53.4%), mastectomy was performed due to positive surgical margin or poor cosmetic results. There were no residual tumors in re-excision(65.6 %) or mastectomy(42.4%) specimens of patients. The factors associated with tumor positive re-excision specimen were, age ≤50 years(p=0.044), lymphovascular invasion (p=0.029), multifocality(p<0.001), tumor size >2cm(p=0.008), presence of DCIS(p=0.018), focal margin positivity(p<0.001), DCIS at resection margin(p=0.008) and node positivity (p<0.001). Conclusions: Most of our patients with early breast cancer had unnecessary re-excisions or mastectomy to obtain clear surgical margins. In subset group of patients, re-excision or mastectomy may not be required.

No significant financial relationships to disclose.

Is the sentinel lymph node biopsy accurate for patients with initially clinically axilla-positive locally advanced breast cancer after neoadjuvant chemotherapy?

Abstract #5123

Background: Approximately one third of patients with locally advanced breast cancer (LABC) have no axillary metastatic lymph node(s) after neoadjuvant chemotherapy (NAC). Axillary dissection could be omitted in these patients if SLNB is negative. The aim of this study is to evaluate the accuracy of sentinel lymph node biopsy (SLNB) after NAC for LABC.&#x2028; Materials and Methods: Between January 1992 to May 2008, a total of 69 patients with clinical or radiological positive axilla (N1 or N2) in LABC were enrolled in this study. After NAC, all patients underwent SLNB followed by complete axillary lymph node dissection. SLNB was performed with either a combined detection using blue dye and radiocolloid or blue dye alone. All the sentinel lymph nodes were examined by multisection hematoxylin eosin staining and cytokeratin- immunohistochemistry, whereas the non-sentinel nodes were examined by routine histology.&#x2028; Results: Sentinel lymph nodes were successfully identified in 58 patients among 69 patients (85%). The median age was 46 (range 25 to 76). The clinical stages before chemotherapy were as follows: IIB:46%, IIIA: 22%, and IIIB: 32%, respectively. All of 58 patients had either clinically or radiologically suspicious node-positive disease based on ultrasound findings before neoadjuvant chemotherapy. Pathologic complete response were obtained in 5 patients (9%). The false negative rate was found to be 17.4 % (8/46), whereas the accuracy rate was 86.2% (50/58) among patients with succesful lymphatic mapping.&#x2028; Conclusion: The accuracy of the SLNB procedure seems to be not reliable in patients with locally advanced disease with a positive axilla before NAC therapy due to its high false negative rates. Therefore, complete axillary dissection is still required in patients with a positive-axilla before chemotherapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5123.

Prognostic and predictive factors after surgical treatment for locally recurrent rectal cancer: a single institute experience

OBJECTIVE

Resection of locally recurrent rectal cancer (LRRC) after curative resection represents a difficult problem and a surgical challenge. The aim of this study was to evaluate the results of resecting the local recurrence of rectal cancer and to analyze factors that might predict curative resection and those that affect survival.

PATIENTS AND METHODS

A retrospective review was performed in 50 patients who underwent surgical exploration with intent to cure LRRC between April 1998 and April 2005. All of the patients had previously undergone resection of primary rectal adenocarcinoma. Of these patients' charts, operation and pathology reports were reviewed. Primary tumor and treatment details, hospital of initial treatment and TNM stage were registered. The following data were collected concerning the detection of the local recurrence; date of recurrence, symptoms at the time of presentation and diagnostic work-up. Perioperative complication and date of discharge were also gathered. The recurrent tumors were classified as not fixed (F0), fixed at one site (F1) and fixed to two or more sites (F2) according to the preoperative and peroperative findings. Microscopic involvement of surgical margins and localization of recurrence were noted based on pathology reports.

RESULTS

The median time interval between resection of primary tumor and surgery for locally recurrent disease was 24 (4-113) months. In a statistical analysis, initial surgery, complaints of patients, increasing number of sites of the recurrent tumor fixation in the pelvis, location of the recurrent tumor were associated with curative surgery. Curative, negative resection margins were obtained in 24 (48%) of patients; in these patients a median survival of 28 months was achieved, compared to 12 months (p=0.01) in patients with either microscopic or gross residual disease. Primary operation and CEA level at recurrence were also found to be important factors associated with improved survival. There was no operative mortality and, the complication rate was 24%.

CONCLUSIONS

This study demonstrated that many patients with LRRC can be resected with negative margins. The type of primary surgery, symptoms, location, and fixity of recurrent tumor are associated with the increased possibility of carrying out curative resection. Previous surgery and curative surgery are significant predictors of both disease-specific survival and overall survival.

Histologic and clinical outcome after laparoscopic Nissen fundoplication for gastroesophageal reflux disease and Barrett's esophagus

BACKGROUND

The effectiveness of laparoscopic Nissen fundoplication for the regression of Barrett's esophagus in gastroesophageal reflux disease remains controversial. The aim of this study, therefore, was to review endoscopic findings and clinical changes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease, particularly for patients with Barrett's esophagus.

METHODS

From September 1995 through June 2004, 127 patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication. All the patients had clinical and endoscopic follow-up evaluation. We further analyzed the course of 37 consecutive patients with Barrett's esophagus (29% of all laparoscopic fundoplications performed in our institution) using endoscopic surveillance with appropriate biopsies and histologic evaluation. The median follow-up period for all the patients after fundoplication was 34 months (range, 3-108 months). The median follow-up period for the patients with Barrett's esophagus was 19 months (range, 3-76 months).

RESULTS

During the 9-year period, 70 women (55 %) and 57 (45%) men were treated with laparoscopic Nissen fundoplication. The median age of these patients was 42 years (range, 7-81 years). The clinical results were considered excellent for 67 patients (53%), good for 51 patients (40%), fair for 7 patients (6%), and poor for 2 patients (1%). Endoscopic surveillance showed regression of the macroscopic columnar segment in 23 patients with Barrett's esophagus (62%). Regression at a histopathologic level occurred for 15 patients (40%). The histopathology remained unchanged for 14 patients with Barrett's esophagus (38%).

CONCLUSION

Laparoscopic Nissen fundoplication effectively controls intestinal metaplasia and clinical symptoms in the majority of patients with Barrett's esophagus.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (<or=0.2 mm) and 130 patients (87.8%) with macrometastases (>0.2 cm). Five patients had isolated tumor cells detected by IHC (<or=0.2 mm, N(0i)). Patients with tumor size more than 2 cm (T1, 29.8% versus T2, 51.6%; OR=2.31, 95% CI, 1.50-3.56) and lymphovascular invasion (LVI-, 30.3% versus LVI+, 51.3%; OR=2.07, 95% CI, 1.34-3.19) were more likely to have positive SLNs in both univariate and multivariate analyses. Among patients with a positive SLN biopsy, those with T2 tumors (versus T1; 63.1% versus 36.9; OR=2.93, 95% CI, 1.43-6.04), macrometastases in SLNs (versus micrometastases; 88.9% versus 11.1%; OR=8.83; 95% CI, 1.82-42.87) and extracapsular node extension (versus without extracapsular node extension; 65.4% versus 34.6%; OR, 2.23; 95% CI, 1.05-4.72) were more likely to have non-SLN metastases in both univariate and multivarite analyses. These results indicate that clinicopathologic factors might be helpful to select patients who were less likely to have negative SLN or non-SLNs. However, additional factors are still needed to be identified to omit surgical axillary staging.

Inflammatory pseudotumour of the liver presenting with obstructive jaundice

Inflammatory pseudotumours are rare benign tumours characterized by an inflammatory process and can occur in any system. We present a case of inflammatory pseudotumours of the liver presenting with obstructive jaundice due to a mass forming lesion in the left lobe of the liver which was treated by left hepatic lobectomy. Inflammatory pseudotumour of the liver is a benign lesion and diagnosis with an image examination is difficult. Surgical management depends on the location of the lesion. Peripheral hepatic pseudotumours may be treated with simple observation or conservative therapy. In contrast to this, those involving the porta hepatis require treatment for obstructive jaundice.

The role of sentinel lymph node biopsy with blue dye alone in breast cancer patients with excisional biopsy

PURPOSE

Sentinel lymph node biopsy (SLNB) appears to offer an excellent alternative method to routine axillary lymph node dissection for staging patients with breast cancer. The aim of this study is to evaluate the effect of excisional biopsy on identification and false negative rate of sentinel lymph node biopsy with blue dye alone in breast cancer patients with clinically negative axilla.

MATERIAL AND METHODS

From March 1998 to March 2003, 266 consecutive sentinel lymph node biopsies (SLNB) were performed using isosulfan blue dye alone. Patients were divided into two groups. One hundred and four patients (39.1%) had previously undergone an excisional biopsy (Group I); in 162 patients (60.9%), pre-operative diagnosis was obtained by either fine-needle aspiration biopsy (FNAB) or core biopsy (Group II). Following sentinel lymph node biopsy, all patients had axillary lymph node dissection (ALND). Data concerning patients, sentinel lymph nodes and the status of the axilla were collected and compared using Fisher's exact test. A p value of less than 0.05 was considered statistically significant.

RESULTS

The sentinel lymph node was successfully identified by blue dye in 94.3% (251/266) of patients. Mean lymph nodes removed from the axilla was 19 (range 11-36) and the mean number of sentinel nodes was 2 (range 1-5). The identification and false negative rate were unrelated to size, type or location of the tumour, or a previous surgical biopsy.

CONCLUSIONS

SLNB with blue dye for evaluation of the axilla is a rapid and accurate technique that provides increased efficacy in the detection of lymphatic metastasis when careful pathologic evaluation with serial sections is performed. The risk-benefit analysis of lymphatic mapping with blue dye provides improvement in staging, with reduced morbidity and hospital stay, and the elimination of general anaesthesia. The technique may also be used safely and accurately in breast cancer patients with excisional biopsy.

Breast conserving surgery after primary chemotherapy in locally advanced breast cancer

PURPOSE

Primary chemotherapy is being given in the treatment of locally advanced breast cancers (LABC), but a major concern is local recurrence after therapy. The aim of this study was to assess the role of breast conserving surgery (BCS) in patients with locally advanced breast cancer.

MATERIAL AND METHODS

Twenty-eight patients, presenting LABC (T any, N 012, M0) were treated with primary chemotherapy comprising of cyclophosphamide, doxorubicin and fluorouracil and then BCS followed by radiotherapy were examined between the years 1992-2002 retrospectively. Before neoadjuvant chemotherapy, seven patients (25%) were Stage IIB, 19 patients (68%) Stage IIIA and two patients (7%) Stage IIIB. Survival times and curves were established according to the Kaplan-Meier method and compared by means of the log-rank test. The chi-square test and log rank test were performed for univariate statistical analysis of each prognostic factor. P values in multivariate analysis were carried out by the Cox's proportional hazards regression model. All p values were two-sided in tests and p values <0.05 were considered significant.

RESULTS

Clinical down staging was obtained in 25 (89%) of patients. Three (11%) patients had complete clinical response, 22 (78%) patients with partial response and 3 (11%) had stable disease. The primary tumour could not be palpated after chemotherapy in 6 (21%) of 28 patients presenting with palpable mass, therefore needle localization was performed for BCS. Median follow-up was 51.9 months (ranging 10 to 118 months). Local recurrence was detected in 4 (14%) patients. Distant metastasis developed in 5 (18%) patients. Three of the patients died of distant metastases and two of them are alive at 49 months. Five-year survival rate was 66%. Statistically, there were no significant factors in terms of local recurrence. Histological grade and menopause status were significantly associated with overall survival (p = 0.018) and nuclear grade was the one significant factor on distant disease-free survival in univariate analysis (p = 0.006). In multivariate analysis, there were no significant factors in terms of overall and distant disease-free survival

CONCLUSIONS

Negative margin is more important than the clinical and histological parameters, such as pretreatment stage, clinical response rate, ER and PR in terms of local recurrence. BCS can be performed safely by achieving free surgical margin in patients who have small sized tumour and with either N2 axillary involvement or skin invasion.

Laparoscopic myotomy for oesophageal achalasia--adding an antireflux procedure is not always necessary

Laparoscopy is the access of choice for functional surgery of the gastroesophageal junction, and oesophagocardiomyotomy, as the conventional surgical treatment of achalasia, is one of the favourable indications for laparoscopic surgery. Laparoscopic anterior myotomy technique is highly effective and secure for relieving dysphagia with minimal risk of gastroesophageal reflux. Fifteen patients with the diagnosis of achalasia were treated with laparoscopic anterior face oesophagocardiomyotomy without a concomitant antireflux procedure. There was not any perioperative complication and no procedure was converted to open operation. Oesophageal cineradiography, manometry and 24-h pH monitoring were repeated postoperatively. Manometry showed a significant reduction of the resting tone (48-34.4 to 18-3.2 mmHg), and patients were free of symptoms for reflux and dysphagia at the follow-up between 8 and 96 (median 42) months. Only one patient needed pneumatic dilation, 1 year after the operation for mild dysphagia, and one patient had moderate reflux, which was managed by medication. Thanks to minimal invasive technique of laparoscopic surgery and intraoperative endoscopy, oesophagocardiomyotomy can safely be performed in a length needed without dividing lateral and posterior phrenoesophageal ligamentous attachments. Consequently, adding an antireflux procedure routinely is not necessary. We advocate laparoscopic anterior oesophagocardiomyotomy alone as the first-line treatment for achalasia.

Laparoscopic treatment of mesenteric cysts

Mesenteric cysts are rare intraabdominal tumors. We review the diagnosis, laparoscopic management, patient's outcome and follow-up of evaluation for three cases of mesenteric cyst that presented to Istanbul University, Istanbul Medical School, Department of Surgery, from 1999 to 2002. All of the patients presented with nonspecific abdominal symptoms such as constipation, abdominal discomfort, and anorexia. Preoperative evaluation for differentiating mesenteric cyst from malignancy is made by abdominal ultrasound and computed tomography. The procedure was completed laparoscopically using three trocars in three patients. In one patient retroperitoneal resection was performed. There were no intraoperative or postoperative complications. The follow-up periods ranged from 6 to 36 months, and there were no recurrences. Currently, the surgical treatment of mesenteric cyst should be performed by laparoscopy, which offers significant advantages in terms of reduced morbidity and hospital stay. For appropriate cases in which cyst arises from mesenterium of colon, the retroperitoneal approach should be applied.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Surgical treatment of hepatic hydatid disease

The results of surgery in 38 patients with hepatic hydatid disease are described. Cystectomy was done in four patients with small peripheral cysts. For them the mean postoperative stay was 8.2 days. Partial cystectomy, introflexion and omentoplasty were performed in 28 patients with uncomplicated large cysts. The mean postoperative stay for these patients was 8.6 days. One patient in this group died of massive hemorrhage and disseminated intravascular coagulation. Exploration of the common bile duct and choledochoduodenostomy were required in three patients who had large cysts complicated by rupture into the biliary tree. This complication resulted in a mean postoperative stay of 11.5 days. Three patients who had cysts complicated by pyogenic infection were treated with tube drainage. They were discharged with their tubes in place after a mean hospital stay of 26.5 days. Hydrogen peroxide 10% was used as a scolicidal agent and was successful in preventing dissemination. All patients underwent ultrasonography 3 months after surgery, and 28 (74%) were followed up by annual examination. There was no recurrence after a mean follow-up of 2.7 years. The results suggest that surgical treatment of hepatic hydatid disease should be governed by the size, location and complications of the cyst. The combination of partial cystectomy, introflexion and omentoplasty was safe and effective therapy for patients with large hepatic cysts uncomplicated by pyogenic infection.

Adenocarcinoma of the gallbladder associated with congenital choledochal cyst and anomalous pancreaticobiliary ductal junction. Case report

In a 61-year-old woman, villous adenocarcinoma of the gallbladder was associated with a congenital choledochal cyst and anomalous pancreaticobiliary ductal junction. The patient had a history of congenital choledochal cyst treated by cystoduodenostomy 27 years previously. The condition was demonstrated by intraoperative cholangiography and histologically confirmed. Extended cholecystectomy, regional lymph node dissection, excision of the cyst and hepaticojejunostomy were performed successfully.