John S. Bolton

Recurrence and Outcomes Following Hepatic Resection, Radiofrequency Ablation, and Combined Resection/Ablation for Colorectal Liver Metastases

Objective:To examine recurrence and survival rates for patients treated with hepatic resection only, radiofrequency ablation (RFA) plus resection or RFA only for colorectal liver metastases. Summary Background Data:Thermal destruction techniques, particularly RFA, have been rapidly accepted into surgical practice in the last 5 years. Long-term survival data following treatment of colorectal liver metastasis using RFA with or without hepatic resection are lacking. Methods:Data from 358 consecutive patients with colorectal liver metastases treated for cure with hepatic resection ± RFA and 70 patients found at laparotomy to have liver-only disease but not to be candidates for potentially curative treatment were compared (1992–2002). Results:Of 418 patients treated, 190 (45%) underwent resection only, 101 RFA + resection (24%), 57 RFA only (14%), and 70 laparotomy with biopsy only or arterial infusion pump placement (“chemotherapy only,” 17%). RFA was used in operative candidates who could not undergo complete resection of disease. Overall recurrence was most common after RFA (84% vs. 64% RFA + resection vs. 52% resection only, P < 0.001). Liver-only recurrence after RFA was fourfold the rate after resection (44% vs. 11% of patients, P < 0.001), and true local recurrence was most common after RFA (9% of patients vs. 5% RFA + resection vs. 2% resection only, P = 0.02). Overall survival rate was highest after resection (58% at 5 years); 4-year survival after resection, RFA + resection and RFA only were 65%, 36%, and 22%, respectively (P < 0.0001). Survival for “unresectable” patients treated with RFA + resection or RFA only was greater than chemotherapy only (P = 0.0017). Conclusions:Hepatic resection is the treatment of choice for colorectal liver metastases. RFA alone or in combination with resection for unresectable patients does not provide survival comparable to resection, and provides survival only slightly superior to nonsurgical treatment.

Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for Tis,1,2 breast cancer

BACKGROUND We hypothesized that wide-field brachytherapy (BRT) after margin negative excision would result in complication rates, local recurrence rates, and cosmesis scores equivalent to external beam radiotherapy (ERT). METHODS Patients with T(is,1,2) tumors less than or equal to 4 cm, 0 to 3 positive axillary nodes, and negative inked surgical margins were entered prospectively into BRT phase I/II trial. Patients who met the eligibility criteria for BRT but were treated with ERT during the same time period were retrospectively identified as controls. A blinded panel of healthcare professionals graded cosmetic outcome. RESULTS Fifty patients with 51 breast cancers received BRT from January 1992 to October 1993. We identified 94 patients eligible for BRT but concurrently treated with ERT. At a median follow-up of 75 months, the two groups were similar for grade III treatment toxicities, local/regional recurrence rates, and cosmesis scores. CONCLUSIONS For selected breast cancer patients undergoing breast-conserving therapy, BRT is an attractive alternative to ERT.

Survival After Resection of Multiple Bilobar Hepatic Metastases From Colorectal Carcinoma

OBJECTIVE To define the long-term outcome and treatment complications for patients undergoing liver resection for multiple, bilobar hepatic metastases from colorectal cancer. METHODS A retrospective analysis of 165 consecutive patients undergoing liver resection for metastatic colorectal cancer was performed. Patients were divided into a simple hepatic metastasis group, consisting of patients with three or fewer metastases in a unilobar distribution, and a complex hepatic metastases group, consisting of patients with four or more unilobar metastases or at least two bilobar metastases. RESULTS The 5-year survival rate was 36% for the simple group and 37% for the complex group. Multivariate analysis revealed that the number of hepatic segments involved by tumor and the maximum diameter of the largest metastasis correlated significantly with the 5-year survival rate. The surgical death rate was 4.9% for the simple group and 9.1% for the complex group; this difference was not significant. Multivariate analysis revealed that extended lobar resection and concomitant colon and hepatic resection were significant and independent predictors of surgical death. The combination of extended lobar resection and concomitant colon resection was used significantly more frequently in the complex group than in the simple group. CONCLUSIONS Resection of complex hepatic metastases, as defined in this study, results in a 5-year survival rate of 37% and confers the same survival benefit as does resection of limited hepatic metastases. The surgical death rate for this aggressive approach is significantly higher if extended lobar resections are necessary and if concomitant colorectal resection is performed. Patients who have complex hepatic metastases at the time of diagnosis of the primary colorectal cancer and who would require extended hepatic lobectomy should have hepatic resection delayed for at least 3 months after colon resection.

A Phase II trial of brachytherapy alone after lumpectomy for select breast cancer: Tumor control and survival outcomes of RTOG 95-17

PURPOSE Radiation Therapy Oncology Group 95-17 is a prospective Phase II cooperative group trial of accelerated partial breast irradiation (APBI) alone using multicatheter brachytherapy after lumpectomy in select early-stage breast cancers. Tumor control and survival outcomes are reported. METHODS AND MATERIALS Eligibility criteria included Stage I/II breast carcinoma confirmed to be <3 cm, unifocal, invasive nonlobular histology with zero to three positive axillary nodes without extracapsular extension. APBI treatment was delivered with either low-dose-rate (LDR) (45 Gy in 3.5-5 days) or high-dose-rate (HDR) brachytherapy (34 Gy in 10 twice-daily fractions over 5 days). End points evaluated included in-breast control, regional control, mastectomy-free rate, mastectomy-free survival, disease-free survival, and overall survival. The study was designed to analyze the HDR and LDR groups separately and without comparison. RESULTS Between 1997 and 2000, 100 patients were accrued and 99 were eligible; 66 treated with HDR brachytherapy and 33 treated with LDR brachytherapy. Eighty-seven patients had T1 lesions and 12 had T2 lesions. Seventy-nine were pathologically N0 and 20 were N1. Median follow-up in the HDR group is 6.14 years with the 5-year estimates of in-breast, regional, and contralateral failure rates of 3%, 5%, and 2%, respectively. The LDR group experienced similar results with a median follow-up of 6.22 years. The 5-year estimates of in-breast, regional, and contralateral failure rates of 6%, 0%, and 6%, respectively. CONCLUSION Patients treated with multicatheter partial breast brachytherapy in this trial experienced excellent in-breast control rates and overall outcome that compare with reports from APBI studies with similar extended follow-up.

A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping

BACKGROUND When lymphazurin became unavailable to our institution, we elected to employ methylene blue to perform sentinel node mapping for patients with breast cancer. The purpose of this study was to compare methylene blue and lymphazurin for performing sentinel node mapping for breast cancer. METHODS We evaluated our sentinel node mapping experience from April 1, 2001 to March 31, 2002. Patients were divided into two groups based on the dye used for lymphatic mapping. The two groups were compared to evaluate the results of the sentinel node mapping procedure. RESULTS During the study period a total of 199 patients were evaluated with sentinel node mapping, 87 with lymphazurin and 112 with methylene blue. The two groups were similar in demonstrating the success of the sentinel node procedure, nodes identified per case, and technique used for node identification (colloid or dye, or both). CONCLUSIONS In our initial experience, methylene blue appears to be equivalent to lymphazurin for sentinel node mapping in breast cancer.

Initial experience with surgical treatment planning in the newly diagnosed breast cancer patient at high risk for BRCA-1 or BRCA-2 mutation.

Abstract:  Despite an abundance of information available for dealing with patients with BRCA‐1 and BRCA‐2 mutations, little guidance is available to assist the surgeon in dealing with the genetically high‐risk patient recently diagnosed with breast cancer. A retrospective review was undertaken of 170 patients who underwent genetic counseling and testing over a 3‐year period from March 2000 to March 2003. Forty‐three of the 170 patients tested were diagnosed with breast cancer prior to genetic testing. Nine patients (20.9%) tested positive for a deleterious mutation. Fifty‐eight percent underwent genetic counseling prior to definitive cancer surgery. Five of the 25 patients who underwent lumpectomy tested positive for a deleterious mutation. Testing results became available during systemic therapy or radiation was delayed until results were known. After counseling, all five patients testing positive went on to bilateral prophylactic mastectomy and reconstruction. None had radiation therapy. Because of a strong family history, eight patients elected to undergo prophylactic mastectomy and reconstruction prior to obtaining genetic test results; and despite compelling histories, all eight tested negative for a mutation. Treatment algorithms are developed to manage patients that are first discovered to be at high risk for a BRCA‐1 or BRCA‐2 mutation at the time they are diagnosed with breast cancer. Patients diagnosed with breast cancer who are discovered to be at high risk for a genetic mutation should undergo counseling prior to definitive surgery. This maximizes the time that patients have to consider options for prophylaxis and monitoring should their test be positive. It also prevents women who would otherwise be candidates for breast preservation from undergoing unnecessary radiation therapy should they chose prophylactic mastectomy in the face of a positive test. 

A better understanding of the term radial scar

BACKGROUND Radial scar is a breast lesion with mammographic and histologic features similar to carcinoma. We reviewed the characteristics of patients with radial scars to better understand these lesions and to determine the incidence of associated carcinoma. METHODS Records for all patients undergoing diagnostic wire localized excisional breast biopsy from January 1993 to September 1999 were reviewed to identify those with histologic or mammographic evidence of radial scar. Clinical records, mammograms, and pathologic slides of these patients were reviewed. RESULTS We identified 45 cases of radial scar: 10 patients had mammographic and histologic evidence of radial scar (group I), 29 only mammographic evidence (group II), and 6 only histologic evidence (group III). Breast cancer risk was similar in the three patient groups. Carcinoma was identified in 18 patients with mammographic radial scars. CONCLUSION Mammographically detected radial scars were associated with carcinoma in 18 of 39 (46%) cases. Histologically identified radial scars are not associated with malignancy and should not be confused with mammographically identified lesions.

Esophageal resection for cancer.

Currently, relatively safe, reliable resection techniques are available for most patients with esophageal carcinoma who present with nonmetastatic disease. For optimal results, the surgeon must be familiar with both transhiatal and transthoracic approaches and must individualize the approach depending on the tumor size and location and the patients functional status. Whereas post-resection survival rates are good for patients with early-stage disease (Stage I or IIa), most patients present with locally advanced, Stage III disease. Although some progress has been made in the past decade in regard to early diagnosis among patients with Barretts metaplasia undergoing endoscopic surveillance and additional progress has been made in adapting multimodality treatment programs successfully to patients with locally advanced disease, the overall cure rate for patients with esophageal carcinoma remains low.

Laparoscopic repair of congenital diaphragmatic hernias.

Most Morgagni and Bochdalek hernias are found and repaired in children, but 5% are found in adults. Symptoms of these hernias are attributable to the involved viscera. Both hernias require repair on presentation because of the risk of incarceration. We describe a laparoscopic method of repairing these hernias that allows shorter recovery than open surgery.

Hepatic Arterial Infusion and Systemic Chemotherapy after Multiple Metastasectomy in Patients with Colorectal Carcinoma Metastatic to the Liver: A North Central Cancer Treatment Group (NCCTG) Phase II Study, 92-46-52

BACKGROUND Patients with multiple liver metastases from colorectal cancer are at high risk of recurrence after resection. Hepatic artery infusion (HAI) alternating with systemic therapy after surgical resection may improve survival after surgery. METHODS Patients with liver-only metastases from colorectal cancer amenable to resection/cryoablation were eligible. Previous adjuvant chemotherapy for a completely resected primary tumor was allowed. Alternating courses of HAI and systemic therapy included floxuridine (FUDR) by HAI. Systemic chemotherapy consisted of bolus leucovorin (LV) plus 5-fluorouracil (5-FU). RESULTS Forty-nine patients had complete resection of their liver metastases, with 44% having more than 4 hepatic metastases and 78% having bilobar disease. Thirty-six patients had HAI FUDR alternating with systemic therapy. Patients received a median of 3.5 cycles (range, 1-4) and 3 cycles (range, 0-6) of therapy with HAI FUDR and systemic therapy, respectively. At the time of final analysis the estimated median disease-free survival and hepatic disease-free survival was 1.2 years (95% confidence interval [CI], 0.9-2.1) and 1.8 years (95% CI, 1.8-not available), respectively. Eleven patients (31%) were alive at this writing. All surviving patients had a minimum of 5.5 years of follow-up. CONCLUSION This trial of adjuvant chemotherapy in patients who underwent complete resection with unfavorable characteristics demonstrates apparent improvement in outcome compared with historical series treated with surgery alone. However the results of this trial and other randomized trials of HAI do not appear to support its use at this time because of the development of more effective systemic options.