-
Clinical and Translational Radiation... Jul 2024Preoperative radiosurgery (SRS) of brain metastases (BM) aims to achieve cavity local control with a reduction in leptomeningeal relapse (LMD) and without additional...
PURPOSE
Preoperative radiosurgery (SRS) of brain metastases (BM) aims to achieve cavity local control with a reduction in leptomeningeal relapse (LMD) and without additional radionecrosis compared to postoperative SRS. We present the final results of a prospective feasibility trial of linac-based stereotactic radiosurgery (SRS) prior to neurosurgical resection of a brain metastasis (PREOP-1).
METHODS
Eligibility criteria included a BM up to 4 cm in diameter for elective resection. The primary endpoint was the feasibility of delivering linac-based preoperative SRS in all patients prior to anticipated gross tumour resection. Secondary endpoints included rates of LMD, local control and overall survival. Exploratory endpoints were the level of expression of immunological and proliferative markers.
RESULTS
Thirteen patients of median age 65 years (range 41-77) were recruited. Twelve patients (92 %) received preoperative radiosurgery and metastasectomy and one patient went directly to surgery and received postoperative SRS, thus the primary endpoint was not met. The median time between referral and preoperative SRS was 6.5 working days (1-10) and from SRS to neurosurgery was 1 day (0-5). The median prescribed dose was 16 Gy (14-19) to a median planning target volume of 12.7 cm (5.9-26.1). Five patients completed 12-month follow-up after preoperative SRS without local recurrence or leptomeningeal disease. The patient who received postoperative FSRT developed LMD after six months. There was one transient toxicity (grade 2 alopecia) and nine patients have died from extracranial causes. Patients reported significant improvement in motor weakness at 6 months (P = 0.04). No pattern in changes of marker expression was observed.
CONCLUSION
In patients with large brain metastasis without raised intracranial pressure, linac-based preoperative SRS was feasible in 12/13 patients and safe in 12/12 patients without any surgical delay or intracranial complications.
PubMed: 38938931
DOI: 10.1016/j.ctro.2024.100798 -
Life (Basel, Switzerland) May 2024Pulmonary metastasectomy has become a well-established procedure for patients with certain types of solid tumors. Patients are usually scheduled for staged lung...
Pulmonary metastasectomy has become a well-established procedure for patients with certain types of solid tumors. Patients are usually scheduled for staged lung metastasectomy in case of primary tumor control, the absence of distant non-lung metastases, and when complete resection is achievable. Nodules are removed with precision resection in order to ensure radical resection with minimal margins; this technique permits good oncological results, preserving the surrounding pulmonary parenchyma and causing minimal distortion compared to staplers. When possible, anatomical resections should be avoided since they are not justified by real oncological advantages and, in the majority of cases, sacrifice too much healthy tissue, possibly leading to inoperability in the case of metachronous relapses. Thus, preserving the maximum amount of pulmonary parenchyma is crucial because repeated metastasectomies are possible and frequent, with no theoretical limits to the number of reinterventions. In our multidisciplinary board team, we support the role of pulmonary metastasectomy as a useful curative therapy, with acceptable morbidity and mortality, with indications to be discussed case-by-case.
PubMed: 38929685
DOI: 10.3390/life14060702 -
The Journal of Surgical Research Jun 2024Up to half of patients with leiomyosarcoma (LMS) present with distant metastases, most commonly in the lungs. Despite guidelines around managing metachronous...
INTRODUCTION
Up to half of patients with leiomyosarcoma (LMS) present with distant metastases, most commonly in the lungs. Despite guidelines around managing metachronous oligometastatic disease, limited evidence exists for synchronous isolated lung metastases (SILMs). Our histology-specific study describes management patterns and outcomes for patients with LMS and SILM across disease sites.
METHODS
We used the National Cancer Database to analyze patients with LMS of the retroperitoneum, extremity, trunk/chest/abdominal wall, and pelvis with SILM. Patients with extra-pulmonary metastases were excluded. We identified factors associated with primary tumor resection and receipt of metastasectomy. Outcomes included median, 1-year, and 5-year overall survival (OS) across treatment approaches using log-rank tests, Kaplan-Meier curves, and Cox proportional hazard models.
RESULTS
We identified 629 LMS patients with SILM from 2004 to 2017. Patients were more likely to have resection of their primary tumor or lung metastases if treated at an academic center compared to a community cancer center. Five year OS for patients undergoing both primary tumor resection and metastasectomy was 20.9% versus 9.2% for primary tumor resection alone, and 2.6% for nonsurgical patients. Median OS for all-comers was 15.5 mo. Community treatment site, comorbidity score, and larger primary tumors were associated with worse survival. Chemotherapy, primary resection, and curative intent surgery predicted improved survival on multivariate Cox regression.
CONCLUSIONS
An aggressive surgical approach to primary LMS with SILM was undertaken for select patients in our population and found to be associated with improved OS. This approach should be considered for suitable patients at high-volume centers.
PubMed: 38925091
DOI: 10.1016/j.jss.2024.03.020 -
South Asian Journal of Cancer Apr 2024Purnima Thakur This study aimed to identify the prognostic factors affecting the survival of patients suffering from Krukenberg tumor (KT) and also to determine the...
Purnima Thakur This study aimed to identify the prognostic factors affecting the survival of patients suffering from Krukenberg tumor (KT) and also to determine the survival in these patients. A retrospective review of patients diagnosed with KT between January 2015 and December 2021 was conducted at a tertiary cancer center. Clinicopathological variables were scrutinized, and survival analysis was performed. Thirty-six patients were enrolled in this study. The median age at diagnosis was 48 years (ranging from 22 to 71 years). The median overall survival (OS) was 9.9 months (95% confidence interval [CI]: 6.6 to 13 months). The mean OS for tumors originating in the colorectal region was longer compared to that for tumors of other sites (15.4 vs. 9 months, respectively; = 0.048). In univariate analysis, patients who received chemotherapy had better survival, while those presenting with ascites had a poor prognosis. No correlation was observed between age, menstrual status, bilaterality, size of ovarian metastases, extent of metastatic disease, metastasectomy, and survival. Multivariate Cox regression analysis showed that chemotherapy predicted a favorable survival outcome (hazard ratio [HR] = 0.200, 95% CI: 0.046-0.877, -value = 0.033). KT is an aggressive tumor with a median OS of less than a year. Chemotherapy may improve survival. Patients with a primary tumor in the colorectal region have a better outcome, while those presenting with ascites indicate a poor prognosis.
PubMed: 38919659
DOI: 10.1055/s-0043-1776789 -
Endocrine, Metabolic & Immune Disorders... Jun 2024Neuroendocrine tumors [NETs] exhibit a wide range of clinical presentations, including the production of various hormones. Calcitonin, a sensitive marker for medullary...
INTRODUCTION
Neuroendocrine tumors [NETs] exhibit a wide range of clinical presentations, including the production of various hormones. Calcitonin, a sensitive marker for medullary thyroid cancer [MTC], is nonspecific and may be elevated in extra-thyroidal NETs.
CASE REPORT
We present the case of a 64-year-old female patient who underwent total thyroidectomy due to a nodule in the isthmus, with a fine-needle aspiration biopsy indicating follicular neoplasia. Pathological examination revealed macro- and micro-nodular thyroid hyperplasia, along with a parathyroid adenoma. During postoperative follow-up, a progressive elevation of calcitonin was observed, reaching 64.2 pg/ml, while carcinoembryonic antigen levels remained normal. Since no MTC foci were found upon reviewing the thyroidectomy specimen, an investigation into the origin of the elevated calcitonin was initiated. Serum chromogranin A and specific neuronal enolase levels were within normal ranges. Tc-99m HYNIC-TOC scintigraphy yielded negative results. Additionally, an upper gastrointestinal endoscopy revealed a submucosal lesion in the second portion of the duodenum, with a biopsy confirming a grade 1 NET. The patient underwent Whipple surgery and hepatic metastasectomy. Postoperatively, a decrease in baseline serum calcitonin levels was observed. Seven years after surgery, she continues specialized monitoring with no biochemical or imaging evidence of disease.
CONCLUSION
Serum calcitonin contributes to the diagnosis and monitoring of anterior intestine NETs.
PubMed: 38918999
DOI: 10.2174/0118715303309948240524054836 -
Frontiers in Oncology 2024Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide with limited therapeutic options. The aim of this study was to analyze the value of...
INTRODUCTION
Gastric cancer (GC) is the fourth leading cause of cancer-related death worldwide with limited therapeutic options. The aim of this study was to analyze the value of adding surgery to the first-line treatment in patients with oligometastatic GC (OGC).
METHODS
This retrospective study included patients with OGC who underwent induction chemotherapy followed by surgery of both primary tumor and synchronous metastasis between April 2012 and April 2022. Endpoints were overall survival (OS) and relapse-free survival (RFS) analyzed by the Kaplan-Meier method. Prognostic factors were assessed with the Cox model.
RESULTS
Data from 39 patients were collected. All cases were referred to our multidisciplinary tumor board (MTB) to evaluate the feasibility of radical surgery. After a median follow-up of 33.6 months (mo.), median OS was 26.6 mo. (95% CI 23.8-29.4) and median RFS was 10.6 mo. (95% CI 6.3-14.8). Pathologic response according to the Mandard criteria (TRG 1-3, not reached versus 20.5 mo. for TRG 4-5; HR 0.23, p=0.019), PS ECOG ≤ 1 (26.7 mo. for PS ≤ 1 versus 11.2 mo. for PS >1; HR 0.3, p=0.022) and a low metastatic burden (26.7 mo. for single site versus 12.9 mo. for ≥2 sites; HR 0.34, p=0.039) were related to good prognosis. No major intraoperative complications nor surgery-related deaths occurred in our series.
DISCUSSION
A sequential strategy of preoperative chemotherapy and radical surgical excision of both primary tumor and metastases was demonstrated to significantly improve OS and RFS. Multidisciplinary evaluation is mandatory to identify patients who could benefit from this strategy.
PubMed: 38912067
DOI: 10.3389/fonc.2024.1343596 -
Journal of Clinical Medicine May 2024: The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national...
: The surgical resection of pulmonary metastases is considered a therapeutic option in selected cases. In light of this, we present the results from a national multicenter prospective registry of lung metastasectomy. : This retrospective analysis involves data collected prospectively and consecutively in a national multicentric Italian database, including patients who underwent lung metastasectomy. The primary endpoints were the analysis of morbidity and overall survival (OS), with secondary endpoints focusing on the analysis of potential risk factors affecting both morbidity and OS. : A total 470 lung procedures were performed (4 pneumonectomies, 46 lobectomies/bilobectomies, 13 segmentectomies and 407 wedge resections) on 461 patients (258 men and 203 women, mean age of 63.1 years). The majority of patients had metastases from colorectal cancer (45.8%). In most cases (63.6%), patients had only one lung metastasis. A minimally invasive approach was chosen in 143 cases (30.4%). The mean operative time was 118 min, with no reported deaths. Morbidity most frequently consisted of prolonged air leaking and bleeding, but no re-intervention was required. Statistical analysis revealed that morbidity was significantly affected by operative time and pulmonary comorbidities, while OS was significantly affected by disease-free interval (DFI) > 24 months ( = 0.005), epithelial histology ( = 0.001) and colorectal histology ( = 0.004) during univariate analysis. No significant correlation was found between OS and age, gender, surgical approach, surgical extent, surgical device, the number of resected metastases, lesion diameter, the site of lesions and nodal involvement. Multivariate analysis of OS confirmed that only epithelial histology and DFI were risk-factors, with -values of 0.041 and 0.031, respectively. : Lung metastasectomy appears to be a safe procedure, with acceptable morbidity, even with a minimally invasive approach. However, it remains a local treatment of a systemic disease. Therefore, careful attention should be paid to selecting patients who could truly benefit from surgical intervention.
PubMed: 38892816
DOI: 10.3390/jcm13113106 -
Cells Jun 2024The treatment landscape for metastatic renal cell carcinoma (mRCC) has undergone significant transformations in recent years. The introduction of novel combination...
The treatment landscape for metastatic renal cell carcinoma (mRCC) has undergone significant transformations in recent years. The introduction of novel combination therapies involving tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors has resulted in improved oncological outcomes compared to traditional TKI monotherapy. In this evolving paradigm, the pivotal role of the multidisciplinary tumor board is underscored, particularly in shaping the therapeutic trajectory for patients eligible for locoregional interventions like cytoreductive nephrectomy and metastasectomy. In cases where systemic treatment is deemed appropriate, the absence of direct comparisons among the various combination therapies complicates the selection of a first-line approach. The clinician is faced with the challenge of making decisions based on patient-specific factors such as performance status, risk classification according to the International Metastatic Renal Cell Carcinoma Database Consortium, comorbidities, and disease characteristics, including the number and location of metastases and tumor histology. Considering these concerns, we propose, as a member of a Tuscany Interdisciplinary Uro-Oncologic Group, an algorithm to streamline the decision-making process for mRCC patients, offering guidance to clinicians in their day-to-day clinical practice.
Topics: Humans; Algorithms; Carcinoma, Renal Cell; Italy; Kidney Neoplasms; Neoplasm Metastasis
PubMed: 38891093
DOI: 10.3390/cells13110961 -
Clinics in Colon and Rectal Surgery Jul 2024Liver metastases are seen in at least 60% of patients with colorectal cancer at some point during the course of their disease. The management of both primary and liver... (Review)
Review
Liver metastases are seen in at least 60% of patients with colorectal cancer at some point during the course of their disease. The management of both primary and liver disease is uniquely challenging in rectal cancer due to competing treatments and complex sequence of treatments depending on the clinical presentation of disease. Recently, several novel concepts are shaping new treatment paradigms, including changes in timing, sequence, and duration of therapies combined with potential deescalation of treatment components. Overall, the treatment of this clinical scenario mandates multidisciplinary evaluation and personalization of care; however, there is still considerable debate regarding the timing of liver metastasectomy in the context of the overall treatment plan. Herein, we will discuss the current literature on management of rectal cancer with synchronous liver metastasis, current treatment approaches with respect to chemotherapy, and role of hepatic artery infusion therapy.
PubMed: 38882938
DOI: 10.1055/s-0043-1770719 -
Translational Cancer Research May 2024Patients with distant metastases have an unfavourable prognosis, but patients with isolated pulmonary metastases should generally not be considered hopeless. Complete...
The impact of the location, incidence and distribution of lung metastases in primary colorectal and renal cell cancer patients on prognosis: a retrospective observational study.
BACKGROUND
Patients with distant metastases have an unfavourable prognosis, but patients with isolated pulmonary metastases should generally not be considered hopeless. Complete resection of metachronous and solitary metastases leads to prolonged survival; however, the influence of the location, distribution and bilaterality of pulmonary metastases needs to be investigated further. This article aimed to investigate the role of the distribution of lung metastases in primary colorectal and renal cell cancer patients on prognosis.
METHODS
We retrospectively investigated the prognosis of patients with pulmonary metastases and colorectal or renal cell carcinoma, defined as the survival time of patients with different metastases. The types of metastases were unilobar, multilobar, unilateral, bilateral, diffuse, synchronous, or metachronous. The secondary outcome of this study was differences in prognosis according to additional criteria.
RESULTS
Patients with metachronous metastases had significantly greater median survival than patients with synchronous metastases. There was a statistically significant difference in median survival between patients with unilateral (better survival) and patients with bilateral (worse survival) lung metastases. In patients with renal cell carcinoma, a statistically significant difference in median survival time was detected for patients with unilateral metastases. A significantly longer median survival time was observed in patients without diffuse metastases. A significantly greater median survival time was detected in patients with no thoracic nodal involvement. Moreover, there was no statistically significant difference in the median survival time for patients with colorectal versus renal cell carcinoma in general or for those with lung metastases. No statistically significant difference in median survival time was detected for patients according to single or multiple lung metastases, additional tumours or metastases during disease, the distance of residence from a specialized clinic in Coburg, sex, smoking or adipocytes, multimorbidity, immunosuppression or different cancer treatments.
CONCLUSIONS
For a minority of patients, pulmonary resection is a chance for prolonged survival. The perioperative mortality rate after metastasectomy is less than five percent. Patients with metachronous and unilateral lung metastases should be evaluated for surgery. Patients with diffuse metastases or lymph node involvement have a significantly shorter median survival time. Decision-making should be interdisciplinary.
PubMed: 38881932
DOI: 10.21037/tcr-23-1961