Jose A. Lejarcegui

Exeresis and Brachytherapy as Salvage Treatment for Local Recurrence After Conservative Treatment for Breast Cancer: Results of a Ten-Year Pilot Study

PURPOSE To analyze the long-term results of a pilot study assessing excision and brachytherapy as salvage treatment for local recurrence after conservative treatment of breast cancer. METHODS AND MATERIALS Between December 1990 and March 2001, 36 patients with breast-only recurrence less than 3 cm in diameter after conservative treatment for Stage I or II breast carcinoma were treated with local excision followed by high-dose rate brachytherapy implants (30 Gy in 12 fractions over a period of 5 days). No patient was lost to follow-up. Special attention was paid to local, regional, or distant recurrences; survival; cosmesis; and early and late side effects. RESULTS All patients completed treatment. During follow-up (range, 1-13 years), 8 patients presented metastases (2 regional and 6 distant) as their first site of failure, 1 had a differed local recurrence, and 1 died of the disease. Actuarial results at 10 years were as follows: local control, 89.4%; disease-free survival, 64.4%; and survival, 96.7%. Cosmetic results were satisfactory in 90.4%. No patient had Grade 3 or 4 early or late complications. Of the 11 patients followed up for at least 10 years, all but 1 still had their breast in place at the 10-year stage. CONCLUSIONS High-dose rate brachytherapy is a safe, effective treatment for small-size, low-risk local recurrence after local excision in conservatively treated patients. The dose of 30 Gy of high-dose rate brachytherapy (12 fractions over a period of 5 days twice daily) was well tolerated. The excellent results support the use of breast preservation as salvage treatment in selected patients with local recurrence after conservative treatment for breast cancer.

Prospective evaluation of squamous cell carcinoma and carcinoembryonic antigen as prognostic factors in patients with cervical cancer.

Carcinoembryonic antigen (CEA) and squamous cell carcinoma(SCC) serum levels were prospectively determined in 159 untreated patients diagnosed with carcinoma of the uterine cervix from 1991 to 2001. The histological analysis showed epidermoid cancer in 117 patients, adenocarcinoma in 26 patients, adenosquamous carcinoma in 12 patients and other histological types in the remaining 4 patients. Tumor marker sensitivity was related to the histological type with abnormal SCC (>2 ng/ml) in 51.3% of squamous tumors in contrast to the 7.1% found in other histologies. By contrast, CEA sensitivity was not related to histology with abnormal values (>5 ng/ml) in 25% of squamous tumors, 19% of adenocarcinomas, 33% of adenosquamous carcinomas and 25% of other histologies. CEA and SCC serum levels were clearly related to tumor stage, parametrial invasion, tumor size and nodal involvement. Elevated pretreatment CEA indicates parametrial invasion with a probability of 82%. Likewise, pretreatment CEA and SCC serum levels were of prognostic value, with a shorter disease-free survival and overall survival in patients with abnormal levels. All patients with adenocarcinomas and abnormal CEA had relapse during follow-up. Multivariate analysis indicated that parametrial invasion, age, tumor size and SCC were independent prognostic factors. In conclusion, CEA and SCC are useful tumor markers in carcinomas of the uterine cervix, with a clear relationship with well-known prognostic factors (parametrial invasion, nodal involvement), and are of prognostic value.

Comparative study of laparoscopically assisted radical vaginal hysterectomy and open Wertheim-Meigs in patients with early-stage cervical cancer: eleven years of experience.

Introduction: The aim of this study was to compare the feasibility, safety, and survival outcomes of Coelio-Schauta (CS) procedure versus open Wertheim-Meigs (WM) as primary surgical treatment of early-stage cervical cancer. Methods: Observational study on the consecutive cases of cervical cancer undergoing CS during the last 11 years at our institution was performed. Data on clinical characteristics of patients, surgical performance, long-term morbidity, and survival were prospectively analyzed and compared with a historical series of 23 consecutive WM performed at the same hospital in the immediate previous period. Results: Sixty-seven patients were included in the study group (CS). Cases and controls were comparable in age, body mass index, stage, tumor size, and histological diagnosis. The number of pelvic nodes, disease-free margin, and complications rate were similar in both groups, but blood loss and blood transfusion rate were marginally less in the CS group. Operating time was longer in the first 20 CS patients, but it became comparable to WM once the learning curve was overcome. Hospital stay was significantly shorter in the CS group as well as the bladder function recovery time. However, no differences were seen regarding long-term urinary and bowel function between groups. Four patients (5.9%) from the CS group and 3 (13%) in the WM group had recurrence. Mortality rates were 3% and 8.7%, respectively (P = not significant). Conclusions: The CS procedure is a suitable alternative to WM for small-volume, early-stage cervical cancer, showing a good safety profile, shorter postoperative recovery time, and similar survival outcomes.

Three or Four Fractions of 4–5 Gy per Week in Postoperative High-Dose-Rate Brachytherapy for Endometrial Carcinoma

PURPOSE To evaluate the results of high-dose-rate brachytherapy (HDRBT) using a schedule of three or four fractions per week, when possible, in 89 patients on local control and toxicity in postoperative treatment of endometrial carcinoma. The effect of the overall HDRBT treatment time (OTT) on toxicity was also evaluated. PATIENTS AND METHODS Fédération Internationale de Gynécologie Obstétrique Stage: 24 IB, 45 IC, 4 IIA, 6 IIB, 4 IIIA, 2 IIIB, and 4 IIIC. Radiotherapy: Group 1-67 of 89 patients received external beam irradiation (EBI; 44-50 Gy) plus HDRBT (3 fractions of 4-6 Gy); Group 2-22 of 89 patients received HDRBT alone (6 fractions of 4-5 Gy). OTT: Group 1-HDRBT was completed in a median of 5 days in 32 patients and in >5 days in 35; Group 2-HDRBT was completed in <15 days in 11 patients and in ≥16 days in 11. Toxicity was evaluated using Radiation Therapy Oncology Group scores and the bioequivalent dose (BED) study was performed in vaginal mucosa surface. Statistics included Students t test, chi-square test, and receiving operator curves. RESULTS With a mean follow-up of 31 months (range, 6-70), 1 of 89 patients had vaginal relapse. Early toxicity appeared in 8 of 89 (9%) patients and was resolved. Late toxicity appeared in 13/89 (14%): vaginal nine Grade 1, three Grade 2, one Grade 4; bladder two Grade 2; rectal three Grade 1, one Grade 2. No differences were found in relation to OTT in Groups 1 and 2. Mean BED was 88.48 Gy in Group 1 and 165.28 Gy in Group 2. Cases with Grade 2 late vaginal toxicity received >75 Gy after EBI and >165 Gy in Group 2. CONCLUSIONS Three fractions of 4-5 Gy in 3-5 days after EBI or 6 fractions in <15 days in patients receiving HDRBT alone was a safe treatment in relation to toxicity and local control. Vaginal surface BED less than 75 Gy after EBI and less than 160 Gy in HDRBT alone may be safe to avoid G2 toxicity.

Keloids and Hypertrophie Scars

Abnormal skin scarring was first described in the Smith papyrus between 2500 and 3000 BC [7]. In 1817, Alibert proposed the word “cheloide” (keloid) to differentiate these lesions from malignant neoplasms [2]. Today, keloids and hypertrophie scars are recognized as uncontrolled proliferations of fibrous tissue after injury or trauma to the skin [15]. However, meanwhile hypertrophie scars are confined to the extent of the original wound; in contrast, keloids invade the surrounding skin [15].

Partial Breast Brachytherapy after Lumpectomy as Salvage Treatment of Local Recurrences after Conservative Treatment of Breast Cancer: Eighteen-year Results of a Non-randomized Comparison with Mastectomy

Purpose/Objective(s): To report the long term results obtained in a prospective group of patients (pts) treated for local recurrence after conservative treatment of breast cancer treated by a second conservative surgery or by total mastectomy. Materials/Methods: Between 12/1990 and 10/2004, 85 patients with <3cm, low-risk local recurrence after conservative treatment for breast cancer were offered total mastectomy. 48 of them refused it and were treated by a second lumpectomy followed by HDR brachytherapy implant to the tumor bed plus a 3 cm margin. 30 Gy in 12 fractions in 5 days were given. Patients treated by mastectomy had no further radiotherapy treatment. Postmenopausal patients with negative receptors had no systemic treatment. The rest of the patients had chemo or hormonal treatment. No patient was lost for follow-up. Results: All patients completed treatment. During the 17-year, 1-year minimum follow-up, in the 2nd conservative group there were 8 pts who had regional (2 pts) or distant metastases (6 pts) as their first site of failure. 3 of them experienced a differed local recurrence and 1 died from the disease. In the total mastectomy group, there were 2 local recurrences, 1 regional recurrence and 5 distant metastases as first site of failure. One patient died from the disease. Actuarial results at 17-year for 2nd conservative and total mastectomy were respectively: local control 84.2% 71.7%; disease free survival 65.4%-63.8%; and survival 90.7% and 88.2%. Cosmetic results were satisfactory in 89.4 % treated conservatively. No patient experienced arm edema or grade 3-4 early or late complications. Between the 14 pts that were followed-up for at least 10-years, 13 of them were with their breast still in place. Conclusions: Second conservative treatment by HDR brachytherapy was a safe and effective method of treatment for small-size, lowrisk, local recurrence after local excision in conservatively treated patients. Partial breast irradiation with wide margins probed to be enough treatment, without significant side-effects in previously intesively irradiated patients. Lumpectomy and partial breast brachytherapy can be conidered the treatment of choice in selected patients with low-risk recurrent breast tumors.