Lymph node ratio is superior to AJCC N stage for predicting recurrence in papillary thyroid carcinoma

OBJECTIVE

Recently, lymph node ratio (LNR) has emerged as an alternative to American Joint Committee on Cancer (AJCC) N stage, with superior prognostic value. The utility of LNR in Middle Eastern papillary thyroid carcinoma (PTC) remains unknown. Therefore, we retrospectively analyzed a large cohort of 1407 PTC patients for clinicopathological associations of LNR.

METHODS

Receiver operating characteristics (ROC) curve was used to determine the cut-off for LNR. We also performed multivariate logistic regression analysis to determine whether LNR or AJCC N stage was superior in predicting recurrence in PTC.

RESULTS

Based on ROC curve analysis, a cut-off of 0.15 was chosen for LNR. High LNR was significantly associated with adverse clinicopathological characteristics such as male sex, extrathyroidal extension, lymphovascular invasion, multifocality, bilateral tumors, T4 tumors, lateral lymph node (N1b) involvement, distant metastasis, advanced tumor stage, American Thyroid Association (ATA) high-risk category and tumor recurrence. On multivariate analysis, we found that LNR was a better predictor of tumor recurrence than AJCC N stage (odds ratio: 1.96 vs 1.30; P value: 0.0184 vs 0.3831). We also found that LNR combined with TNM stage and ATA risk category improved the prediction of recurrence-free survival, compared to TNM stage or ATA risk category alone.

CONCLUSIONS

The present study suggests LNR is an independent predictor of recurrence in Middle Eastern PTC. Integration of LNR with 8th edition AJCC TNM staging system and ATA risk stratification will improve the accuracy to predict recurrence in Middle Eastern PTC and help in tailoring treatment and surveillance strategies in these patients.

Abstract 3560: Bcl-Xl over-expression is a poor prognostic marker in papillary thyroid cancer and can be therapeutically targeted to induce apoptosis and autophagy

Bcl-Xl is a member of the Bcl-2 family of proteins that are divided into either pro-apoptotic proteins or anti-apoptotic proteins on the basis of their functionality. All the members of the Bcl-2 family share common domains known as Bcl-2 Homology (BH1-4) domain. The pro-apoptotic family members include proteins that only contain the BH-3 domain and include Bax, Bak, Bid, PUMA, NOXA, Bim and Bad while the anti-apoptotic proteins include members such as Bcl-2, Bcl-Xl and Mcl-1. In normal conditions, there is a balance between the pro- and anti-apoptotic members of the Bcl-2 family. Because of their important role in cell survival, there has been lot of interest in utilizing dysregulation of Bcl-2 family members to counter cancer growth and induce apoptosis. Bcl-Xl is an anti-apoptotic protein that has found to be over-expressed in various cancers including lung cancer, DLBCL and breast cancer. However, the role of Bcl-Xl in papillary thyroid cancer (PTC) from Middle Eastern region has not been fully illustrated. In order to investigate the role of Bcl-Xl in PTC, we examined the expression of Bcl-Xl in a cohort of 1022 PTC clinical cases by immunohistochemistry in a tissue microarray format and found that Bcl-Xl was over-expressed in 51.7% of PTC cases. Bcl-Xl over-expression was significantly associated with aggressive high proliferative markers such as older age (p = 0.0009), extra-thyroidal extension (p<0.0001), tumor size (p = 0.0081), nodal involvement (p = 0.0067), metastasis (p = 0.0013) and showed a poor overall 5 year survival (0.0438). Bcl-Xl over-expression was was also found to be significantly associated with p-AKT (p<0.0001), XIAP (p<0.0001) and proliferative marker Ki67 (p = 0.0041). In vitro, targeting Bcl-Xl expression in PTC cell lines using a small molecular inhibitor of Bcl-Xl; AB141657 (Z36) showed a dose dependent inhibition of cell viability and induction of apoptosis after 48 hours treatment. Using 5 and 10μM Z36, we found that PTC cells not only underwent apoptosis detected by flow cytometry, inactivation of AKT and activation of mitochondrial apoptotic pathway but also autophagy as detected by up-regulation of LC1-3, inactivation of p-mTOR1 and p-mTOR2 and their downstream targets. These data clearly indicate a role of Bcl-Xl in the pathogenesis of PTC as well as the importance of targeting Bcl-Xl using Z36 to induce both; apoptosis and autophagy in Bcl-Xl over-expressing PTC cells.

Citation Format: Azhar R. Hussain, Maqbool Ahmed, Shaham Beg, Rong Bu, Roxanne Melosantos, Zeeshan Qadri, Saif Al-Sobhi, Fouad Al-Dayel, Abdul Khalid Siraj, Khawla S. Al-Kuraya. Bcl-Xl over-expression is a poor prognostic marker in papillary thyroid cancer and can be therapeutically targeted to induce apoptosis and autophagy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3560.

Role of X-Linked Inhibitor of Apoptosis as a Prognostic Marker and Therapeutic Target in Papillary Thyroid Carcinoma

CONTEXT

Papillary thyroid cancer (PTC) is the second most common cancer in females in Saudi Arabia. However, the pathogenesis of PTC is still not fully elucidated.

OBJECTIVE

To identify potential genes that play important role in progression of PTC, we studied the role of X-linked inhibitor of apoptosis protein (XIAP) as a potential prognostic marker and therapeutic target in a large cohort of PTC samples and cell lines.

DESIGN

A DNA microarray chip was used to screen for gene copy number. XIAP expression was assessed by immunohistochemistry in a tissue microarray format on a cohort of 1022 clinical samples. In vitro and in vivo studies were performed using Embelin and/or LY294002 on PTC cell lines.

RESULTS

XIAP was found to be amplified in 14 of 29 and overexpressed in 48.8% of PTC cases. XIAP overexpression was significantly associated with old age, extrathyroidal extension, tumor size, nodal involvement, tall-cell variant, advanced stage disease, and significantly poor disease-free survival (P = .0341). XIAP was also significantly associated with phosphorylated AKT (P < .0001), Bcl-Xl (P < .0001), and Ki67 (P = .0006) proteins. Embelin treatment caused growth inhibition and apoptosis in PTC cell lines and induced tumor regression in PTC xenograft in nude mice. Finally, the combination of suboptimal doses of Embelin and LY294002 induced a synergistic apoptotic response in PTC cells.

CONCLUSION

XIAP dysregulation in PTC confers an aggressive phenotype with poor outcome. In vitro and in vivo studies using an XIAP inhibitor suggest that this subgroup of PTC with overexpression of XIAP can be therapeutically targeted, either alone or in combination, to induce efficient apoptosis in these cancers.

FoxM1 and its association with matrix metalloproteinases (MMP) signaling pathway in papillary thyroid carcinoma

CONTEXT

Forkhead boxM1 (FoxM1) transcription factor has been shown to promote pathogenesis of several malignancies. FoxM1 has also been shown to be associated with matrix metalloproteinases (MMP) in various cancers. However, little is known about its function in papillary thyroid carcinoma (PTC).

OBJECTIVE

In this study, we investigated the role of FoxM1 in pathogenesis in a large series of PTC in a tissue microarray format followed by in vitro and in vivo studies using PTC cell lines and nude mice.

DESIGN

Expression of FoxM1 and its associated proteins were investigated in Middle Eastern PTC samples by immunohistochemistry. Apoptosis was measured by flow cytometry and immunoblotting. Invasion and migration studies were performed using 8-μm Transwell plates.

RESULTS

FoxM1 was overexpressed in 28.4% of PTC and significantly associated with activated matrix metalloproteinase-9 (MMP-9) (P = 0.0004), X-linked inhibitor of apoptosis protein (XIAP) (P = 0.0024), and B-cell lymphoma-extra large (Bcl-XL) (P = 0.0014) expression. Treatment of PTC cell lines with thiostrepton, an inhibitor of FoxM1, resulted in inhibition of cell viability via induction of apoptosis. In addition, thiostrepton treatment of PTC cells or expression of FoxM1-specific small interfering RNA down-regulated expression of FoxM1 accompanied with decreased MMP-2 and MMP-9 expression. Furthermore, inhibition of FoxM1 attenuated migration and invasion of PTC cells. Interestingly, overexpression of FoxM1 rescued the effects of thiostrepton in PTC cell lines. Finally, treatment of PTC cell line xenografts with thiostrepton resulted in growth inhibition of tumors in nude mice via down-regulation of FoxM1 and MMP-9 and MMP-2.

CONCLUSION

Altogether, this is the first study showing that FoxM1 and its associated signaling pathway play a critical role in the pathogenesis of PTC and may be a potential target for therapeutic intervention for treatment of these cancers.

Abstract 1016: Bortezomib (Velcade) induces p27Kip1 expression through S-phase kinase protein 2 degradation in papillary thyroid cancer

S-phase kinase protein 2 (SKP2), an F-box protein, targets cell cycle regulators including cycle-dependent kinase inhibitor p27Kip1 via ubiquitin-mediated degradation. SKP2 is frequently overexpressed in a variety of cancers. In this study, we investigated the role of SKP2 and its ubiquitin-proteasome pathway in Papillary Thyroid Cancer (PTC) in a panel of PTC cell lines, a large cohort PTC patient samples and NUDE mouse model using tissue microarray, MTT, flow cytometry and DNA fragmentation assays and western blotting. Our data showed that bortezomib caused a dose-dependent growth inhibition in all cell lines studied. The IC 50 was 83.7nM and 61.4nM for B-CPAP1 and TPC-1 respectively. Cell cycle assay showed that the sub-G1 population of B-CPAP1 cell increased from 4.09% in untreated control sample to 36.74% after 25nM treatment for 2 days and 71.91% after 50nM treatment for 2 days. Further confirmation using FITC-conjugated Annexin V and PI assay showed that apoptotic cell increased form 8.43% in untreated cells to 47.6% and 64.82% after 25nM and 50nM treatment respectively in B-CPAP1 cells and from 12.72% in control to 48.16% and 64.02% in TPC-1 cells, indicating a dose-dependent apoptosis induced in both cell lines. Treatment of PTC cell line cells with bortezomib or expression of small interfering RNA of SKP2 caused down-regulation of SKP2 and accumulation of p27Kip1. Furthermore, treatment of PTC cells with bortezomib caused apoptosis by involving the mitochondrial pathway and activation of caspases-9 and 3, and cleavage PARP. Pretreatment with zVAD-fmk abrogated bortezomib induced apoptosis. In addition, treatment of PTC cells with bortezomib down-regulated the expression of XIAP, cIAP1, and survivin. Currently the animal study and data analysis of patient samples are still ongoing. Our preliminary results suggest that SKP2 and the ubiquitin-proteasome pathway may be potential targets for therapeutic intervention for treatment of TPC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1016. doi:10.1158/1538-7445.AM2011-1016

Abstract 2602: FoxM1 is an attractive therapeutic target in a subset of papillary thyroid cancers

The FoxM1 transcription factor promotes the pathogenesis of several malignancies. However, little is known about its expression and function in papillary thyroid cancers (PTC). In the present study we investigated the role of FoxM1 in the pathogenesis of PTC in a large series of PTC in a tissue micro array (TMA) format followed by studies using PTC cell lines and nude mice. Our data showed that expression of FoxM1 was over expressed in 28.4 % (141/496) of PTC and significantly associated with activated AKT (p&lt;0.0001) and matrix metalloproteinase-9 (MMP-9) expression (p=0.0004). FoxM1 over expression was also strongly associated with antiapoptotic markers, XIAP (p=0.0024), and Bcl-Xl (p=0.0014). In vitro data using PTC cell lines showed that inhibition of FoxM1 by thiostrepton resulted in inhibition of proliferation and induction of apoptosis in a dose dependent manner. In addition, thiostrepton treatment caused downregulation of SKP2, and consequent increase expression of p21 in PTC cell lines. We also found that down-regulation of FoxM1 reduced the expression of MMP-2, MMP-9 and vascular endothelial growth factor, resulting in the inhibition of migration, invasion, and angiogenesis in PTC cells. Furthermore, pharmacological inhibition of FoxM1 or siRNA targeted against FoxM1 triggered caspase dependent apoptosis in PTC cells. Finally, treatment of PTC cell line xenografts with thiostrepton resulted in growth inhibition of tumors in nude mice via downregulation of FoxM1 and MMP9. Altogether, our results suggest that FoxM1 and its associated signaling pathway may be a potential target for therapeutic intervention for treatment of PTC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 2602. doi:10.1158/1538-7445.AM2011-2602

Abstract 4045: c-Met inhibition synergistically enhances death receptor-induced apoptosis via upregulation of DR5 in papillary thyroid cancer

The Met receptor tyrosine kinase and its ligand, hepatocyte growth factor (HGF), are overexpressed and/or activated in variety of human malignancies. Previously we have shown that c-Met was overexpressed in Middle Eastern Papillary Thyroid Cancer (PTC) and significantly associated with poor prognoses. In this study, we investigated the functional link between c-Met/AKT signaling pathway and Dearth Receptor 5 (DR5) in a large cohort of PTC patient samples, a panel of PTC cell lines, and xenografts in a NUDE mouse model by using tissue microarray, MTT, flow cytometry and DNA fragmentation assays and western blotting. Immunohistochemistry staining showed a significant association of p-Met with DR5 in PTC patient samples. The PHA665752, an inhibitor of c-met tyrosine kinase, inhibited cell proliferation and induced apoptosis in a dose dependent manner in all cell lines studied. PHA665752 treatment resulted in dephosphorylation of c-Met, AKT and its downstream effector molecules FOXO1, GSK-3 and pBad. Additionally, treatment of PTC cell lines with PHA665752 resulted in activation of caspases-9 and 3, cleavage PARP and apoptosis. Moreover, HGF, a ligand of c-Met, stimulated the growth of all PTC cell lines via activation of c-MET and AKT. In addition, pre-treatment of PTC cell line with PHA665752 abrogated the HGF stimulated growth and activation of c-met and AKT further suggesting the critical role of c-met and AKT pathway in PTC pathogenesis. Furthermore, c-Met inhibitor PHA665752 up-regulated DR5 expression in PTC cell line cells, and synergistically potentiated death receptor-induced apoptosis with TRAIL. Finally, co-treatment with PHA665752 and TRAIL causes more pronounced effect on PTC xenograft tumor growth in NUDE mice. Our data suggest that c-Met/HGF pathway may be a potential target for therapeutic intervention for treatment of PTC with c-Met inhibitor alone or in combination of conventionally therapeutic agents.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4045. doi:10.1158/1538-7445.AM2011-4045

Fatty acid synthase and AKT pathway signaling in a subset of papillary thyroid cancers

CONTEXT

Fatty acid synthase (FASN) is an enzyme that plays a critical role in de novo synthesis of fatty acids. FASN is overexpressed in variety of human cancers, but its role has not been elucidated in papillary thyroid carcinoma (PTC).

OBJECTIVE

Our objective was to investigate the role of FASN and its relationship with phosphatidylinositol 3-kinase/AKT activation in a large series of PTC in a tissue microarray format followed by studies using PTC cell lines and Nude mice.

DESIGN

Analysis of apoptosis and cell cycle were evaluated by flow cytometry and DNA fragmentation assays. FASN and phospho-AKT protein expression was determined by immunohistochemistry and Western blotting.

RESULTS

Our data show that expression of FASN is associated with activated AKT (phospho-AKT) in a subset of PTC. Treatment of PTC cell lines (NPA-187, ONCO-DG-1, and B-CPAP) with C-75, an inhibitor of FASN, suppresses growth and induces apoptosis in all cell lines. Treatment of PTC cells with C-75 or expression of FASN small interfering RNA causes down-regulation of FASN and inactivation of AKT activity. Furthermore, treatment of PTC cell lines with C-75 results in apoptosis via the mitochondrial pathway involving the proapoptotic factor Bad, activation of Bax, activation of caspases, and down-regulation of antiapoptotic proteins. Finally, treatment of NPA-187 xenografts with C-75 results in growth inhibition of tumors in Nude mice via down-regulation of FASN expression and inactivation of AKT.

CONCLUSIONS

Our results suggest that FASN and activated AKT pathway may be a potential target for therapeutic intervention for the treatment of PTC.

High rate of persistent/recurrent disease among patients with differentiated thyroid cancer in Saudi Arabia: factors affecting nonremission

BACKGROUND AND OBJECTIVES

A fairly high number of patients with differentiated thyroid cancer (DTC) in our center had locally advanced disease at presentation and/or persistent disease after standard treatment. Therefore, we conducted a retrospective study to find the rate of successful ablation and remission and the factors affecting these outcomes.

METHODS

The study included 100 consecutively treated patients (20 males, 80 females; median age 36 years) diagnosed with DTC. Univariate and multivariate logistic regression was used to evaluate the effect of risk factors on the persistence or recurrence of thyroid cancer. All patients underwent total thyroidectomy and had cervical lymph node dissection when indicated. All patients received sodium iodide I 131 ablation once or twice post surgery. Patients were followed clinically by neck ultrasound, (123)I whole body scan and by thyroglobulin measurements and other diagnostic tests as needed.

RESULTS

Over a median follow-up of 7.6 years (range 7-10 years), ablation occurred in 93%, remission in 50%, disease persisted without remission in 41%, and 9% had recurrence after at least 1 year of remission. Papillary thyroid cancer was found in 76%, the follicular variant in 14%, other variants (tall cell and sclerosing types) in 2%, Hurthle cell carcinoma in 4%, and pure follicular thyroid cancer in 4%. Compared with patients in remission, patients with persistent/recurrent disease were older (mean 41 versus 31 years, P=.003), had higher postoperative thyroglobulin (193 versus 29 ng/mL, P=.04) and more advanced TNM staging (P=.005). Risk factors significant for non-remission were age >40 years (odds ratio 4.1, 95% CI 1.5-10.9 years, P=.003) and TNM stage other than 1 (odds ratio 5.5, 95% CI 1.9-16.3, P=.001). Only TNM Stage 1 was significant for remission in the multivariate analysis.

CONCLUSION

The low remission rate in our DTC patients is probably due to more advanced disease at time of presentation. Early detection may, therefore, be essential in improving outcome.

Laparoscopic vs. open adrenalectomy: experience at King Faisal Specialist Hospital and Research Centre, Riyadh

BACKGROUND

The laparoscopic approach for adrenalectomy is now widely accepted and preferred over the conventional open approach. We describe our experience of adreanalectomy and compare the results of open and laparoscopic approach.

PATIENTS AND METHODS

From March 1999 to March 2002, we performed 23 adrenalectomies. An anterior transabdominal approach was used for the open procedure, and a lateral transperitoneal approach for the laparoscopic procedure. Data from both groups were analyzed and compared.

RESULTS

There was no difference in tumor size or pathology between two groups. The tumor size was smaller, operative time was longer and estimated blood loss was less in the laparoscopic procedure group, however these differences were statistically insignificant. The mean length of hospital stay was shorter (5.1 vs. 9.2 days, P<0.01), the mean use of postoperative narcotic analgesia was less (4.2 vs. 8.1 injections, P<0.05), and the mean time for resumption of oral intake was faster (1.17 vs. 2 days, P<0.01) in the laparoscopic procedure group compared to the open adrenalectomy group.

CONCLUSION

Laparoscopic adrenalectomy is a safe procedure that can be performed for most adrenal pathology. It is associated with faster recovery, less postoperative pain, and shorter hospital stay.

Obstructive endotracheal lesions of thyroid cancer

Airway invasion is a life-threatening complication of thyroid cancer. An important issue that deserves better attention is the differentiation between the clinical features of tracheal wall invasion versus those of an obstructive endotracheal lesion. We present information on the clinical course, diagnostic modalities utilized, management instituted, along with the prognosis, and follow-up data on a group of patients presenting with obstructive endotracheal lesions of thyroid cancer. Two thousand four hundred and eighty-nine thyroid cancer patients were seen at our institution from December 1975 to May 2000. Thirteen patients presented with symptoms of respiratory distress related to obstructive endotracheal lesions. At presentation, 11 patients underwent endoscopic examination. Imaging studies consisting of I123 whole body scan (WBS), computed tomography/magnetic resonance imaging (CT/MRI) of neck and chest, whole body positron emission tomography using 18-fluoro-2-deoxy-D-glucose ((FDG)PET) were done, as also was determination of the tumour markers, serum thyroglobulin (TG) and calcitonin. Patients were followed for one to 108 months after the initial presentation. Intraluminal tracheal obstruction was severe in eight patients; five had near-total-occlusion. Paralysis of the vocal folds was present in five. Evidence of metastatic disease was present in most patients. Dissociation between iodine uptake and TG synthesis was evident in five patients during follow-up. Four patients died of cancer. Of the nine living patients; cancer persisted in six, recurred in two patients, and remitted in one. This study has identified obstructive endotracheal lesion of thyroid cancer as a distinct entity apart from tracheal wall disease. These data provide evidence that intraluminal tracheal invasion of thyroid cancer is an ominous sign and a frequent cause of morbidity.

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma after open partial adrenalectomy in von Hippel-Lindau disease

BACKGROUND AND PURPOSE

Unilateral total adrenalectomy is the standard treatment for benign unilateral adrenal tumors. Partial adrenalectomy has to be considered for bilateral adrenal tumors. Recently, our group has reported the feasibility of unilateral and bilateral partial adrenalectomy by means of laparoscopy. Now, we present a case of recurrent pheochromocytoma after open bilateral adrenalectomy and demonstrate that laparoscopic cortex-sparing surgery is feasible for a recurrence after open surgery.

CASE REPORT

At the age of 10 years, a boy was found to have bilateral adrenal pheochromocytoma and was treated by open bilateral partial adrenalectomy. Eight years later, the patient presented with palpitation, sweating, and severe hypertension. Investigations biochemically and radiologically demonstrated functional recurrent pheochromocytoma in the left adrenal gland. Genetic studies confirmed mutation of the von Hippel-Lindau (VHL) gene. The patient was prepared for surgery preoperatively by phenoxybenzamine and metropolol. The surgery was performed as planned, and the normal adrenal tissue was spared. The patient had an uneventful postoperative course. His blood pressure was normal on the day of discharge.

CONCLUSIONS

In a specialized center with experienced laparoscopic surgeons, laparoscopic partial adrenalectomy for recurrent pheochromocytoma is feasible even after previous open surgery on the ipsilateral adrenal gland. Adrenal-sparing surgery is indicated in hereditary syndromes such as VHL and MEN II to avoid the problems of life-long steroid replacement. Recurrences have to be expected, but further surgery may be less difficult by the previous laparoscopic approach.

Partial laparoscopic adrenalectomy for aldosterone-producing adenoma: short-and long-term results

BACKGROUND AND PURPOSE

Laparoscopic surgery for adrenal gland tumors is the gold standard operative approach now. Adrenal-sparing surgery has special indications. We demonstrated the safety and feasibility of performing adrenal-sparing surgery by means of laparoscopy for aldosterone-producing adenoma (Conn's syndrome).

PATIENTS AND METHODS

Between 1995 and 1999, seven patients with Conn's syndrome had laparoscopic adrenal-sparing resection of their tumors. These patients were followed up by means of radiology and biochemistry.

RESULTS

All seven patients had successful laparoscopic surgery without complications. Most patients were discharged in 2 to 6 days (mean 3 days). At follow-up, the six patients investigated had normal blood pressure. No recurrences have been encountered with a median follow-up of 12 months in these six patients.

CONCLUSIONS

Adrenal-sparing resection of tumors causing primary hyperaldosteronism is technically feasible by means of laparoscopy. This procedure has the advantage of keeping a greater reserve of normal adrenal tissue and of rapid postoperative recovery.

Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population

In the Kingdom of Saudi Arabia (KSA), breast cancer constitutes 18% of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA. The relative frequency of locally advanced disease among our breast cancer population and the lack of a uniform consensus in the literature about its optimal management have prompted this retrospective analysis of the medical records of patients with Stage III breast cancer patients seen at King Faisal Specialist Hospital and Research Center between 1981 and 1991. In all, 315 patients were identified. Their median age +/- SD was 46 +/- 11.6 years which is distinctly different from the 60-65 years median age in industrial Western nations. Most patients were younger than 50 years (64%) and premenopausal (62%). Patients were approximately equally divided between Stage IIIA and Stage III B. Patients received multimodality treatment, including surgery, adjuvant chemotherapy, tamoxifen, and adjuvant radiotherapy. Sixty-one patients were excluded from survival analysis as they were considered lost to follow-up. Of the remaining 254 patients, 73 (29%) were alive and disease free, and 18 patients (7%) were alive but with evidence of the disease. The remaining 163 (64%) had died from breast cancer or its related complications. Their median overall survival (OS) was 54 months, (95% CI, 27 to 121 months) and the median progression-free survival (PFS) was 28.8 months (95% CI, 14.2 to 113 months). Cox proportional hazard model identified Stage III B and the number of positive axillary lymph nodes as poor predictors of OS and PFS. Radiotherapy was the only adjuvant modality that affected survival favourably. The prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach. The overall young age of our patients may have contributed to the poor outcome. Moreover, the adverse effect of Stage III B disease (as compared with Stage III A) and axillary nodal status was evident. Whilst the favourable effect of radiotherapy on survival was demonstrated, the lack of independent efficacy of other modalities (adjuvant chemotherapy and tamoxifen) or the apparent deleterious effect of neoadjuvant chemotherapy should be addressed with discretion in such retrospective analysis. Optimal management of patients with locally advanced breast cancer disease should be appraised in well designed, prospective, randomised studies.

Detection of metastatic parathyroid carcinoma with Tc-99m sestamibi imaging

PURPOSE

To assess the use of Tc-99m sestamibi to localize recurrent and metastatic parathyroid carcinoma.

METHODS

A patient with a history of parathyroid carcinoma that was resected 6 months before had high serum calcium and high serum parathyroid hormone levels. Tc-99m sestamibi imaging was performed to localize the recurrence.

RESULTS

Tc-99 sestamibi imaging detected the recurrence and the metastatic lymph nodes. These findings were confirmed surgically and pathologically.

CONCLUSION

Tc-99m sestamibi can be useful in diagnosing and localizing metastatic parathyroid carcinoma.