Cancer Treatment

Mesothelioma Surgery Options

 

Mesothelioma is a cancer that is most often linked to asbestos exposure. Tumors usually form on the surface of the pleura (lining of the lungs) but are also found on the lining of the abdomen, heart or testicles. Pleural and abdominal mesotheliomas are the most common. Treating mesothelioma surgically remains difficult because of the growth pattern and location of the disease.

Surgery can be a viable option for some patients to treat and manage mesothelioma. For the best post-operative prognosis, accurate tumor staging is imperative since many patients in later stages of the disease are not candidates for some of the more radical surgeries.

There are generally two surgical categories for the treatment and management of mesothelioma, cytoreductive (which aims to cure) and palliative (which aims to relieve symptoms).

Cytoreductive Surgery

Cytoreductive surgeries are radical and invasive techniques that focus on removing all of the cancer. These types of surgeries are only recommended for patients who are in good health and diagnosed with stage I or stage II mesothelioma.

Extrapleural pneumonectomy (EPP) has been a standard treatment for pleural mesothelioma for many years. EPP involves the removal of the entire lung, diaphragm and pericardium. The diaphragm and pericardium are reconstructed synthetically after removal.

In studies, five-year survival rates were as high was 46 percent, though more trials are needed to get more accurate results.

Pleurectomy/Decortication (P/D) also involves surgically removing tumors. However, the lung is left mostly intact. Improved pulmonary function results in a lower mortality rate over EPP, but P/D has a slightly higher level of tumor recurrence. Postoperative radiation therapy is also limited because of the intact lung.

Both EPP and P/D are extremely invasive and the risk of morbidity and mortality are present for both procedures. Medical controversy still surrounds which procedure is more effective. More studies have yet to compare the effectiveness of these surgeries to systemic therapy and symptom control.

Palliative Surgery

Palliative surgery is a more conservative treatment. It focuses on the prevention and management of pleural effusion (fliud in the lining of the lungs) and tumor debulking to relieve chest pain and allow lung expansion. For patients in later stages of the disease, palliative treatment offers relief from symptoms and prolonged survival.

Debulking involves removing part of a tumor to delay growth, and procedures such as pleurodesis can relieve symptoms by surgically inserting a talc mixture to close the pleural space. A permanent chest drain can also be inserted to prevent the build-up of fluid.

Though surgery remains an option for the treatment of mesothelioma, more doctors advocate a multimodal approach to therapy because surgery alone typically does not prevent recurrence of tumors.

Bio: Michelle Y. Llamas is a writer for the Mesothelioma Center. She is committed to generating mesothelioma awareness and providing information regarding breakthroughs in mesothelioma treatment.

Sources:

Mott, F. E. (2012). Mesothelioma: A review. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22438785

Tannapfel, A. (Ed.). 2011. Malignant mesothelioma: Recent results in cancer research. New York: Springer.

Readmission after pancreaticodudenectomy.

The Whipple procedure is a complex and morbid up duration with significant readmission rates. In a recent review of experience at the Johns Hopkins, readmission rates have been decreasing. When early and late complications were compared, patients with early complications were likelier to be readmitted for delayed gastric emptying (12% vs. 4%; P<0.01), intra-abdominal abscess (17% vs. 4%; P<0.0001) and wound infections (6% vs.1%; P< 0.02). Conversely, the indication for those readmitted more than one year after surgery was more likely to be obstructive jaundice (17% vs. 4%; P<0.0001), metastatic disease (12% vs. 5%; P< 0.0001) or incisional hernias (12% vs. 3%; P<0.0001). Other reports show similar results.

Grewal SS, McClaine RJ, Schmulewitz N, Alzahrani MA, Hanseman DJ, Factors associated with recidivism following pancreaticoduodenectomy.HPB (Oxford). 2011 Dec;13(12):869-75.

Dawn M. Emick, Taylor S. Riall, John L. Cameron, Jordan M. Winter, Keith D. Lillemoe, JoAnn
Hospital readmission after pancreaticoduodenectomy Journal of Gastrointestinal Surgery
Volume 10, Number 9, 1243-1253, 2006

ZHU Zi-yi, HE Ji-kai, WANG Yi-fan, LIANG Xiao, YU Hong, WANG Xian-fa and CAI Xiu-junChin MedMultivariable analysis of factors associated with hospital readmission following pancreaticoduodenectomy
for malignant diseases  J 2011;124(7):1022-1025

 

MRI to screen preoperatively for DCIS

Most guidelines recommend breast MRI for screening in women with high-risk of developing breast cancer and to clarify diagnostic uncertainties after mammography and ultrasound. As use of MRI has increased, many other situations for which, MRI might be helpful came to the fore. Unfortunately, literature support for most of them, is lacking.

Currently, guidelines indicate MRI for screening of women at high risk based on family history or for clarifying diagnostic dilemmas that are unable to be clarified by mammography and ultrasound. Some physicians adopt the strategy of using MRI to decide between a mastectomy and lumpectomy, when DCIS is present. The reasoning is that if widespread DCIS is found, a mastectomy would be performed rather than a lumpectomy. This strategy has not been formally evaluated and is not recommended by guidelines. A clinical trial is ongoing: Breast MRI as a Preoperative Tool for DCIS, NCT00605982. The purpose of this study is to see how often MRI can find other areas of cancer in women with one area of breast cancer, and to determine how having the MRI test affects their treatment.  The study also aims to follow women who enter the study over a 10-year period to determine how often the breast cancer comes back.

ACR says: " Invasive carcinoma and ductal cardinoma in situ (DCIS) – Breast MRI may be useful to determine the extent of disease and the presence of multifocality and multicentricity in patients with invasive carcinoma and ductal carcinoma in situ (DCIS). MRI can detect occult disease up to 15% to 30% of the time in the breast containing the index malignancy. MRI determines the extent of disease more accurately than standard mammography and physical examination in many patients. It remains to be conclusively shown that this alters recurrence rates relative to modern surgery, radiation, and systemic therapy."

 REFERENCES:

Kuhl CK, Schrading S, Bieling HB, et al. MRI for diagnosis of pure ductal carcinoma in situ: A prospective observational study. Lancet. 2007;370(9586):485-492.

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/breast/MRI_Breast.pdf - 2008

 nccn.org, screening 2012

Laparascopic liver resection for benign lesions.

It is a fairly rare for benign liver lesions causing pain and there are no specific guidelines for thist. However, the literature contains many reports of this procedure being performed for non-cancer diagnosis(2,4). In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection  appear to be comparable to those after open resections.

1.http://www.hpblondon.com/assets/Laparoscopic%20liver%20re%20EC5A1.pdf

2.Simillis C, Constantinides V, Tekkis P, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms- a meta-analysis. Surgery. 2007;141:203–211.

3.Vibert E, Perniceni T, Levard C, et al. Laparoscopic liver resection. Br J Surg. 2006;93:67–72.

4.Laparoscopic Liver Resection for Malignant and Benign Lesions Ten-Year Norwegian Single-Center Experience Airazat M. Kazaryan,Arch Surg. 2010;145(1):34-40

Autologous hematopoietic tissue graft

Autologous hematopoietic tissue graft is a collection of stem cells, paltelets and tissue factors that are placed into an operative site to promote healing and prevent infections. Much of the aplication has been in plastic and cardiac surgery as well as in wound healing. There are no guideliens that I could locate, cosnesnsus statemetns or large prospective studies and there are studies that show that this treatment is not effective as well as many reports of effectiveness.

Khalafi, Reza S., Bradford, Darien W., Wilson, Michael G.
Topical application of autologous blood products during surgical closure following a coronary artery bypass graft
Eur J Cardiothorac Surg 2008 34: 360-364

S Gunaydin, K McCusker, T Sari, M. Onur, A Gurpinar, H Sevim, P Atasoy, C Yorgancioglu, and Y Zorlutuna
Clinical impact and biomaterial evaluation of autologous platelet gel in cardiac surgery
Perfusion, May 1, 2008; 23(3): 179 - 186.

Gunaydin S, McCusker K, Sari T, Onur M, Gurpinar A, Sevim H, Atasoy P, Yorgancioglu C, Zorlutuna  Clinical impact and biomaterial evaluation of autologous platelet gel in cardiac surgery.
Perfusion. 2008 May;23(3):179-86.

Bhanot S, Alex JC.Current applications of platelet gels in facial plastic surgery.
Facial Plast Surg. 2002 Feb;18(1):27-33.

Electrical stimulation for bone fusion

Data from uncontrolled studies of patients with failed spinal fusion suggests that noninvasive electrical stimulation results in a significantly higher fusion rate. The lack of controlled clinical trials is balanced by the fact that these patients served as their own control. The most common bone stimulators include low-intensity pulsed ultrasound (LIPUS) and pulsed electromagnetic field therapy. Data from a randomized controlled clinical trial of patients meeting the criteria for high risk for development of failed fusion suggests that invasive or noninvasive electrical bone stimulation as an adjunct to spinal fusion surgery is associated with a significantly higher spinal fusion success rate in the treated group compared with the control group. 
 The Food and Drug Administration, in 1994, approved the use of LIPUS for use in accelerating fresh fracture healing, and in 2000, for treatment of established nonunions.  Similarly, electrical stimulation has been approved for the treatment of nonunions in the United States. Basic science research supports the use of LIPUS in signal transduction, gene expression, blood flow, and tissue modeling and remodeling.  Multiple, small randomized trials have also supported the use of LIPUS.

This modality may also be useful in patients at high risk of nonunion. These include: Fusion to be performed at more than one level
Current smoking habit
Diabetes or other metabolic diseases where bone growth is poor
Renal disease
Documented history of alcoholism
Obese patients who are at greater than 50% over their ideal body weight

Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M. The use of low-intensity ultrasound to accelerate the healing of fractures. J Bone Joint Surg Am 2001;83:259-70.   

5. Khan Y, Laurencin CT. Fracture repair with ultrasound: Clinical and cell-based evaluation. J Bone Joint Surg Am 2008;90:138-44.  

Prophylactic and reconstructive bilateral mastectomy

Prophylactic mastectomy is the surgical removal of both breasts to help prevent breast cancer. Prophylactic mastectomy is a controversial procedure among members of the medical community. Based on recent scientific findings that show prophylactic mastectomy to be effective at preventing breast cancer, some physicians think that it is sometimes defensible. According to the American Cancer Society Board of Directors, "only very strong clinical and/or pathological indications warrant doing this type of ‘preventive operation."

A contralateral mastectomy is a little different becasue it is removal of the non-diseased breast at the time of cancer surgery for the other breast. A recent study study examined 56,400 women with breast cancer diagnosed between 1979 and 1999, of whom 1.9% underwent a contralateral prophylactic mastectomy.The observed impact of contralateral mastectomy on the occurrence of breast cancer was profound. The risk was reduced by 97%, adjusting for primary and adjuvant therapy, characteristics of the tumor, and family history.2 Five women (0.5%) in the contralateral prophylactic mastectomy group developed a contralateral breast cancer despite this procedure. From these data, women may be counseled that their risk will be dramatically reduced but not completely eliminated.

This remains an area of disagreement and controversy. A survey of national policies for coverage, including various medicare policies, revealed that 24% had a formal policy on non-coverage for prophylactic mastectomy even with BRCA positivity. 45% had no policy. Some 30% covered for either BRCA or a strong family history.

Helzlsouer, Kathy J.
Contralateral Prophylactic Mastectomy: Quantifying Benefits and Weighing the Harms
J Clin Oncol 2005 23: 4251-4253

http://www.annalssurgicaloncology.org/cgi/reprint/7/5/325.pdf

Bilateral breast cancer

Lay Summary: Bilateral mastectomies followed by standard adjuvant chemotherapy is the prevailing approach for bilateral breast cancer.

About 3% or breast cancers present with synchronous bilateral disease IBBC) and 11% are bilateral over the course of a patient's lifetiime.Unlike unilateral breast cancer there are no clear treatment guidelines for BBC.In a recent retrospective review, thirty out of 1100 (2.7%) patients with breast cancer treated between 1993 and 2003 had BBC, of whom 20 patients had metachronous and 10 patients had synchronous BBC. Family history of breast cancer was present in five patients (16%) only. Contralateral breast cancer (CBC) was detected mammographically in three and by clinical examination in 27 patients. Most CBC patients had early-stage disease compared with the index side (73% versus 27%). Fifty-six out of 60 tumors were found to be invasive ductal carcinoma, and none of the patients had lobular carcinoma. Twenty-three patients had bilateral mastectomy, three had unilateral mastectomy and four had a combination of breast conservation and mastectomy. Sixteen patients had unilateral and six had bilateral adjuvant radiotherapy. All patients received adjuvant chemotherapy and/or hormonal therapy both for index and CBC based on the stage and hormone receptor status. At a median follow up of 31.5 months (3–142 months), 23 (76%) patients were disease free and seven (24%) patients had disease relapse. Mean overall survival of patients with MBBC was significantly longer than those with SBBC (30.4 months versus 19.2 months; P = 0.045).

Bilateral mastectomies, as opposed to breast conserving surgey is supported by a supposition that bilateral breast cancer is more agressive, but this is not universally accepted. however, in the absence of guidelines, there is sufficient literature support for bilateral mastectomies to consider it to be a standard of care approach. Bilateral mastectomies followed by adjuvant standard chemotherapy is the most common approach.

MA Chaudary, RR Millis, EO Hoskins et al., Bilateral primary breast cancer: a prospective study of disease incidence. Br J Surg 71 (1984), pp. 711–714.

AD Rochefordiere, B Asselain, S Scholl et al., Simultaneousbilateral breast carcinomas: a retrospective review of 149 cases. Int J Radiat Oncol Biol Phys 30 (1994), pp. 35–41.

J. J. Jobsen, J. van der Palen, F. Ong and J. H. Meerwaldt
Synchronous, bilateral breast cancer: prognostic value and incidence
The Breast, Volume 12, Issue 2, April 2003, Pages 83-88

Treatment of brain metastases

Lay Summary: We overview treatment options for brain metastases.

Surgical resection should be considered in patients with single brain metastasis in an accessible location, especially when the size is large, the mass effect is considerable and an obstructive hydrocephalus is present. Surgery is recommended when the systemic disease is absent/controlled and the Karnofsky Performance score is 70 or more (level A recommendation). When the combined resection of a solitary brain metastasis and a non-small cell lung carcinoma (stage I and II) is feasible, surgery for the brain lesion should come first, with a maximum delay between the two surgeries not exceeding 3 weeks. Patients with disseminated but controllable systemic disease (i.e. bone metastases from breast cancer) or with a radioresistant primary tumor (melanoma, renal cell carcinoma, and colon cancer) may benefit from surgery. Surgery at recurrence is useful in selected patients.

Stereotactic radiosurgery (SRS) should be considered in patients with metastases of a diameter of <3–3.5 cm and/or located in eloquent cortical areas, basal ganglia, brain stem or with comorbidities precluding surgery. Gamma-knife or linear accelerator (Linac) are equally effective. SRS may be effective at recurrence after prior radiation treatment.

The role of adjuvant whole-brain radiotherapy (WBRT) after surgery or radiosurgery remains to be clarified. In case of absent/controlled systemic disease and Karnofsky Performance score of 70 or more, one can either withhold initial WBRT if close follow-up with MRI (every 3 to 4 months) is performed or deliver early WBRT with fractions of 1.8–2 Gy to a total dose of 40–55 Gy to avoid late neurotoxicity. Whole-brain radiotherapy alone is the therapy of choice for patients with active systemic disease and/or poor performance status and should employ hypofractionated regimens such as 30 Gy in 10 fractions or 20 Gy in five fractions. For elderly patients with poor performance status WBRT can be withheld and supportive care only employed .

In patients with up to three brain metastases, good performance status (KPS of 70 or more) and controlled systemic disease, SRS is an alternative to WBRT (level B recommendation), whilst surgical resection is an option when the lesions are in an accessible location (level C recommendation). In patients with more than three brain metastases WBRT with hypofractionated regimens is the treatment of choice (level B recommendation). In bedridden patients it should be considered to withhold active radiation treatment and restrict therapy to supportive care.

There appears to not be a role for IMRT since it is neither a good therapy for overall brain like WBRT not specific enought for the tumor alone, like radiosurgery.

The Role of Chemotherapy

Chemotherapy may be the initial treatment for patients with brain metastases from chemosensitive tumors, like small cell lung cancers, lymphomas, germ cell tumors and breast cancers, especially for chemonaive patients or if an effective chemotherapy schedule for the primary is still available. Radiation therapy, with or without chemotherapy, is still the treatment of choice for patients needing a palliation of neurological symptoms

In two phase II trials of temozolomide in heavily pretreated patients with various solid tumor brain metastases, temozolomide was safe and generally well tolerated and showed clinical activity, with three partial responses and 19 disease stabilizations. Results of a third randomized phase II trial of concurrent administration of temozolomide and radiation therapy followed by adjuvant temozolomide therapy compared with radiation alone showed a higher rate of complete and partial responses (objective response of 96% v 67%) and significantly more complete responses (38% v 33%, P =.017), primarily in patients with newly diagnosed brain and lung metastases.

Mintz AP, Perry J, Laperriere N, Cairncross G, Chambers A, Spithoff K, Neuro-oncology Disease Site Group. Management of single brain metastases: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Aug 15. 26 p. (Evidence-based series; no. 9-1). [29 references]

Soffietti R, Cornu P, Delattre JY, Grant R, Graus F, Grisold W, Heimans J, Hildebrand J, Hoskin P, Kalljo M, Krauseneck P, Marosi C, Siegal T, Vecht C. EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force. Eur J Neurol 2006 Jul;13(7):674-81. [44 references]

Abrey LE, Christodoulou C. Temozolomide for treating brain metastases.Semin Oncol. 2001 Aug;28(4 Suppl 13):34-42.

Gastric bypass

As weight loss begins to slow down after gastric bypass, the risk of nutritional problems increases. This is due to dysfunctional or bypassed small bowel. B12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation.

Iron deficiency after gastric bypass is usually only seen in menstruating women or in patients who are actively and chronically bleeding. Ferritin or iron levels and erythrocyte counts need to be monitored after a bypass, as iron deficiency can develop early after surgery or years later; one study found that iron stores continuously declined up to 7 years after bypass surgery. Due to bypass of the lower stomach, in which iron is absorbed, it is very difficult for iron-deficient patients to absorb sufficient oral iron. Many cannot tolerate read meat. Intramuscular iron can be impractical over the long run. Usually, intravenous iron dextran or iron sucrose is used regularly; many patients require intravenous iron several times a year. This is done as an outpatient procedure and is well tolerated by patients.

Brolin RE et al. Prophylactic iron supplementation after Roux-en Y gastric bypass: a prospective, double blind, randomized study. Arch Surg. 1998;133(7):740-744.

Dimitrios V Avgerinos, Omar H Llaguna, Matthew Seigerman, Amanda J Lefkowitz, and I Michael Leitman
Incidence and risk factors for the development of anemia following gastric bypass surgery, World J Gastroenterol. 2010 April 21; 16(15): 1867–1870.

Love AL, Billett HH. Obesity, bariatric surgery, and iron deficiency: true, true, true and related.Am J Hematol. 2008 May;83(5):403-9.