Tsuyoshi Takanaka

The role of axillary lymph node dissection in breast cancer management

Although it is generally accepted that axillary dissection provides no survival advantage in patients with breast cancer, it is commonly regarded as a reliable method of assessing nodal status and treating regional disease. However, it is time to consider eliminating routine axillary dissection in patients who are clinically node-negative. A sentinel lymph node biopsy may assess axillary nodal status while obviating a full axillary dissection. At present, axillary dissection remains the standard approach for the surgical management of all patients with invasive carcinoma of the breast, regardless of tumor size or patient age, though it is unnecessary for patients with small intraductal carcinomas.

Pathologic Assessment of Surgical Margins on Frozen and Permanent Sections in Breast Conserving Surgery

The diagnostic value of frozen section was evaluated in the histologic assessment of surgical margins obtained by wide excision of breast tumors. There were 87 patients with unilateral breast cancer, and 5 with bilateral breast cancers. The periphery of the excised breast tissue was peeled like an orange and histologically examined by frozen and permanent section. If eitherin situ or infiltrating microscopic tumor was found at the margin, it was considered positive. Using frozen sections, the margin was judged histologically positive or suspicious in 30 tumors (31%) and negative in 67 (69%) tumors. Positive surgical margins were histologically confirmed by permanent section in 20 (67%) of the 30 tumors diagnosed as positive or suspicious on frozen section. Another 10 tumors had negative margins. In 4 tumors, however, while the initial or re-excised margin was negative on frozen section, the margins were positive by permanent section. These surgical margins were positive due exclusively to the presence of ductal carcinomain situ (DCIS). Evaluation of surgical margins in breast cancer by frozen section, thus exhibited a diagnostic accuracy of 86%, a sensitivity of 83%, and a specificity of 86%. It is concluded that frozen sections are useful in the determination of involvement of surgical margins after the wide excision of breast cancer. It must be pointed out that frozen sections will often overestimate involvement of the surgical margins.

Oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle, and axillary dissection followed by radiotherapy

We evaluated the oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle (LDM), and axillary dissection followed by radiotherapy. In this study, a wide excision of breast tissue was performed to obtain tumor-free margins. The subsequent breast deformity was not corrected in six patients in the early phase of the study (Group 1), and in 16 patients in the late phase (Group 2) in which the breast deformity was not remarkable at the time of operation. Breast deformity was corrected by transposing adipose tissue with LDM on a vascular pedicle in the remaining 51 patients (Group 3). Five year survival was 100%. Two patients developed distant metastases. None were found to have local recurrence. Fifty percent of the Group 1 patients, 69% of the Group 2 patients, and 67% of the Group 3 patients had an excellent or good cosmetic result. However, when the cosmetic results were evaluated in patients who underwent transposition and had small breasts, the results were excellent or good in 76%, compared to 38% in the patients who had reconstructions who had large breasts. The difference was statistically significant (p = 0.0309). Therefore, it was confirmed that wide excision and axillary dissection followed by breast radiation could provide adequate local control, but frequently resulted in breast deformity. However, transposition of adipose tissue may be useful to correct the breast deformity, especially in women with small breasts.

Feeding artery of laryngeal and hypopharyngeal cancers: role of the superior thyroid artery in superselective intraarterial chemotherapy.

The purpose of this study was to elucidate the role of the superior thyroid artery in intra-arterial infusion chemotherapy for laryngeal and hypopharyngeal cancers. Thirty-nine patients with laryngeal cancer and 29 patients with hypopharyngeal cancer underwent intra-arterial infusion chemotherapy. We performed a retrospective analysis of the feeding arteries confirmed by computed tomography during selective arteriography and compared the results with the extent of the tumors. In 14 of 39 laryngeal and 15 of 29 hypopharyngeal cancers, the tumor did not cross the midline (group 1). In the remaining 25 and 14 cancers, respectively, the tumor crossed the midline or located in the center (group 2). For 13 of 14 laryngeal and 7 of 15 hypopharyngeal cancers in group 1 and for 6 of 25 laryngeal cancers in group 2, the entire tumor was contrast enhanced by the ipsilateral superior thyroid and/or superior laryngeal artery. For 12 of 25 laryngeal and 1 of 14 hypopharyngeal cancers in group 2, the entire tumor was contrast enhanced by the bilateral superior thyroid artery. For the other patients, infusion via the other arterial branches such as the inferior thyroid and the lingual arteries were needed to achieve contrast enhancement of the entire tumor. Superselective intra-arterial chemotherapy for laryngeal cancer from the superior thyroid artery is appropriate, whereas that for hypopharyngeal cancer is less sufficient. To accomplish contrast enhancement of the entire tumor, additional intra-arterial infusion from other arteries such as the inferior thyroid artery is often necessary.

Clinical outcome of percutaneous osteoplasty for pain caused by metastatic bone tumors in the pelvis and femur

We examined the pain-relieving effects in five patients who underwent percutaneous osteoplasty (POP) for pain caused by metastatic bone tumors in the pelvis and femur. Pain intensity, improvement of walking, and complications associated with POP were evaluated. Pain was measured using a numerical rating scale (NRS), with scores ranging from 0 (no pain) to 10 (worst pain imaginable). The patients were four men and one woman (mean age, 65 years). POP was performed in the pelvis in three patients and in the femur in two patients. Three of the subjects had already received radiation therapy at the lesion. The scores on the NRS on moving in the five patients before POP were 5, 8, 5, 4, and 7. After POP, the NRS scores decreased to 0, 0, 2, 0, and 1, respectively, within 72 hs. Three of the patients showed improvements in walking. There were no complications associated with POP. However, pathological fracture occurred, while walking, 4 days after POP in one patient. Percutaneous osteoplasty is a safe and effective treatment for pain caused by metastatic bone tumors in the pelvis and femur. However, care and attention should be paid to the risk of pathological fracture after POP of the femur.

Intra-arterial chemotherapy less intensive than RADPLAT with concurrent radiotherapy for resectable advanced head and neck squamous cell carcinoma : A prospective study

Objectives: This study was designed to evaluate the efficacy and feasibility of our intra-arterial chemotherapy protocol with a lower amount and frequency of cisplatin delivery than in RADPLAT for the treatment of resectable advanced head and neck cancer. Methods: Fifty-one patients with advanced squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx were included in this prospective study. The patients were treated with 3 courses of cisplatin (100 mg at 1 treatment, intra-arterial) and sodium thiosulfate (28 g at 1 treatment, intravenous) once every 2 weeks during concurrent radiotherapy (66 to 70 Gy, 2 Gy per fraction, daily for 5 days over 7 weeks). Nodal metastases larger than 3 cm in diameter were treated with an additional 50 mg of cisplatin. The patients with less than 50% tumor reduction after 40 Gy and 2 courses of chemotherapy were treated with surgery. Results: The protocol was completed for 49 patients. All living patients had a minimum follow-up period of 2 years. Including the 3 patients with salvage surgery, local disease-free control was achieved in 39 patients (80%). For 36 patients (73.5%), disease-free primary organs were preserved at 2 years after treatment. Locoregional disease-free control for 2 years was obtained for 38 patients (77.6%), in 30 of them without salvage surgery. The patients treated with surgery had an overall survival rate similar to that of the patients with a complete response (80% and 84.6%, respectively). The patients with a partial response had a worse prognosis (40%; p = 0069). Conclusions: This treatment regimen is feasible and effective for advanced resectable head and neck cancer.

The management of tumor motions in the stereotactic irradiation to lung cancer under the use of Abches to control active breathing

PURPOSE Breathing control is crucial to ensuring the accuracy of stereotactic irradiation for lung cancer. This study monitored respiration in patients with inoperable nonsmall-cell lung cancer using a respiration-monitoring apparatus, Abches, and investigated the reproducibility of tumor position in these patients. METHODS Subjects comprised 32 patients with nonsmall-cell lung cancer who were administered stereotactic radiotherapy under breath-holding conditions monitored by Abches. Computed tomography (CT) was performed under breath-holding conditions using Abches (Abches scan) for treatment planning. A free-breathing scan was performed to determine the range of tumor motions in a given position. After the free-breathing scan, Abches scan was repeated and the tumor position thus defined was taken as the intrafraction tumor position. Abches scan was also performed just before treatment, and the tumor position thus defined was taken as the interfraction tumor position. To calculate the errors, tumor positions were compared based on Abches scan for the initial treatment plan. The error in tumor position was measured using the BrainSCAN treatment-planning device, then compared for each lung lobe. RESULTS Displacements in tumor position were calculated in three dimensions (i.e., superior-inferior (S-I), left-right (L-R), and anterior-posterior (A-P) dimensions) and recorded as absolute values. For the whole lung, average intrafraction tumor displacement was 1.1 mm (L-R), 1.9 mm (A-P), and 2.0 mm (S-I); the average interfraction tumor displacement was 1.1 mm (L-R), 2.1 mm (A-P), and 2.0 mm (S-I); and the average free-breathing tumor displacement was 2.3 mm (L-R), 3.5 mm (A-P), and 7.9 mm (S-I). The difference between using Abches and free breathing could be reduced from approximately 20 mm at the maximum to approximately 3 mm in the S-I direction for both intrafraction and interfraction positions in the lower lobe. In addition, maximum intrafraction tumor displacement with the use of Abches was 4.5 mm (S-I) in the lingular segment. These results suggest that use of the Abches system can reduce deviations in tumor position to levels below those achieved under free breathing, irrespective of the tumor location. CONCLUSIONS Respiratory control with high accuracy and reproducibility is required for high-precision radiotherapy of inoperable nonsmall-cell lung cancer and was achieved using Abches in this study.

Long-term pain relief effects in four patients undergoing percutaneous vertebroplasty for metastatic vertebral tumor.

We reviewed long-term pain relief in four patients undergoing percutaneous vertebroplasty (PVP) for lumbar or back pain due to metastatic vertebral tumors. The patients received anesthesiological palliative care with analgesics until their death after PVP. Pain intensity, the presence or absence of recurrence of pain, changes in dosage of analgesics given before and after PVP, and complications associated with PVP were evaluated. A numerical rating scale (NRS) from 0 (no pain) to 10 (worst pain imaginable) was used to measure pain. The patients were three men and one woman (mean age, 58 years). PVP was performed in five vertebrae (one thoracic and four lumbar). The NRS scores on moving before PVP were 10, 8, 10, and 10. After PVP, NRS decreased to 0, 3, 5, and 0, respectively, within 72 h. No recurrence of pain in the treated area occurred until death in any of these patients. The dosages of analgesics given were decreased in two cases, but no changes were made in the other two cases. There were no complications associated with PVP. Percutaneous vertebro-plasty is a safe and effective treatment for long-time pain relief in patients with metastatic vertebral tumors.

Results of Recent Therapy for Non–small-cell Lung Cancer With Brain Metastasis as the Initial Relapse

The results of radiosurgery for treatment of patients with non–small-cell lung cancer with brain metastasis as the initial relapse were evaluated. Twenty-three patients were included in the study. The dominant pathologic type was adenocarcinoma (56.5%). In the mean interval of 13.7 months (range, 3–52 months) between the lung operation and treatment of brain metastasis, a solitary lesion developed in 9 patients and multiple lesions developed in 14 patients. The modalities used for brain metastasis were gamma-knife radiation therapy (GKS) in nine patients, GKS plus operation in six, GKS plus whole brain radiation therapy (WBR) in two, operation plus WBR in two, operation only in one, WBR only in two, and no treatment in one. The 1- and 3-year survival rates after treatment of brain were 47.3% and 7.4%, respectively. The prognostic impact of stage and number of brain metastases was not clear. Primary tumor size and adjuvant chemotherapy after the lung operation significantly affected survival after the management of brain metastasis. The low invasive radiosurgery is beneficial in terms of improving the quality of life of patients.

Basaloid squamous cell carcinoma in the nasal cavity treated with proton beam therapy concurrent with cisplatin: a case report.

IntroductionBasaloid squamous cell carcinoma is a rare and aggressive variant of squamous cell carcinoma. Basaloid squamous cell carcinoma is mostly seen in the upper aerodigestive tract and has a propensity for lymph node spread and systemic metastases. Various treatment modalities have been reported, including surgical excision supplemented with radiotherapy/adjuvant chemotherapy. To the best of our knowledge, treatment of nasal basaloid squamous cell carcinoma with proton beam therapy and cisplatin has not been described in the literature.Case presentationWe report the case of a 56-year-old Japanese man with locally invasive basaloid squamous cell carcinoma in his right nasal cavity with invasion of the orbit, paranasal sinus, and buccal subcutaneous tissue. He underwent proton beam therapy concurrent with cisplatin. Acute and late side effects did not exceed grade 3. At 24-month follow up, he remains in complete remission.ConclusionProton beam therapy concurrent with cisplatin may be one choice for locally invasive basaloid squamous cell carcinoma.