Outcomes of Curative-Intent Treatment for Patients With Breast Cancer Presenting With Sternal or Mediastinal Involvement.
ABSTRACT: PURPOSE:Optimal treatment of patients diagnosed with de novo metastatic breast cancer limited to the mediastinum or sternum has never been delineated. Herein, we sought to determine the efficacy of multimodality treatment, including metastasis-directed radiation therapy, in curing patients with this presentation. METHODS AND MATERIALS:This is a single-institution retrospective cohort study of patients with de novo metastatic breast cancer treated from 2005 to 2014, with a 50-month median follow-up for the primary cohort. The primary patient cohort had metastasis limited to the mediastinum/sternum treated with curative intent (n = 35). We also included a cohort of patients with stage IIIC disease treated with curative intent (n = 244). Additional groups included a mediastinal/sternal palliative cohort (treatment did not include metastasis-directed radiation therapy; n = 14) and all other patients with de novo stage IV disease (palliative cohort; n = 1185). The primary study outcomes included locoregional recurrence-free survival (LRRFS), recurrence-free survival (RFS), and overall survival (OS), which were calculated using the Kaplan-Meier method. Cox multivariable models compared survival outcomes across treatment cohorts adjusted for molecular subtype, age, and race. RESULTS:For the mediastinal/sternal curative-intent cohort, 5-year LRRFS was 85%, RFS was 52%, and OS was 63%. After adjustment, there was no statistically significant difference in LRRFS (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.13-1.13; P = .08), RFS (HR, 0.87; 95% CI 0.50-1.49; P = .61), or OS (HR, 0.79; 95% CI 0.44-1.43; P = .44) between the stage IIIC cohort and the mediastinal/sternal curative-intent cohort (referent). In contrast, RFS was worse for the mediastinal/sternal palliative cohort (HR, 2.29; 95% CI 1.05-5.00; P = .04). OS was worst for the de novo stage IV palliative cohort (HR, 2.61; 95% CI 1.50-4.53; P < .001). CONCLUSIONS:For select patients presenting with breast cancer metastatic to the sternum and/or mediastinum, curative-intent treatment with chemotherapy, surgery, and radiation yields outcomes similar to those of stage IIIC disease and superior to de novo stage IV breast cancer treated with palliative intent.
Project description:We sought to determine the prognostic variables associated with overall survival (OS) and recurrence-free probability (RFP) in patients with primary and secondary sternal tumors treated with surgical resection.A retrospective analysis of patients who underwent resection of primary or secondary sternal tumors at 2 cancer institutes between 1995 and 2013 was performed. OS and RFP were estimated using the Kaplan-Meier method, and predictors of OS and RFP were analyzed using the Cox proportional hazards model.Sternal resection was performed in 78 patients with curative (67 [86%]) or palliative (6 [8%]) intent. Seventy-three patients (94%) had malignant tumors, of which 28 (36%) were primary and 45 (57%) were secondary malignancies. Sternal resections were complete in 13 patients (17%) and partial in 65 (83%). There were no perioperative deaths, and grade III/IV complications were noted in 17 patients (22%). The 5-year OS was 80% for patients with primary malignant tumors, 73% for patients with nonbreast secondary malignant tumors, and 58% for patients with breast tumors (p = 0.85). In the overall cohort, R0 resection was associated with prolonged 5-year OS (84% vs 20%) on univariate (p = 0.004) and multivariate (adjusted hazard ratio, 3.37; p = 0.029) analysis. On subgroup analysis, R0 resection was associated with improved OS and RFP only for patients with primary malignant tumors.Sternal resection can achieve favorable OS for patients with primary and secondary sternal tumors. R0 resection is associated with improved 5-year OS and RFP in patients with primary malignant tumors. We did not detect a similar effect in patients with breast or nonbreast secondary tumors.
Project description:Deep sternal wound infections (DSWI), although an infrequent complication, significantly impair postoperative outcomes after coronary artery bypass grafting (CABG) surgery. Among several preventive strategies, topical antibiotic therapy immediately before sternal closure has been strongly advocated. In this retrospective analysis, the incidence of DSWI in 517 patients undergoing isolated CABG and receiving rifampicin irrigation of mediastinum, sternum and suprasternal tissues was compared to an historical consecutive cohort of 448 patients. To account for the inherent selection bias, a 1:1 propensity matched analysis was performed. Patients receiving topical rifampicin experienced significantly less occurrence of postoperative DSWI (0.2% vs 2.5%, p?=?0.0016 in the unmatched analysis; 0.3% vs 2.1%, p?=?0.0391 in the matched analysis). Intensive care unit stay, hospital stay, and operative mortality were similar between groups. This study shows that topical rifampicin in combination with commonly prescribed preventative strategies significantly reduces the incidence of DSWI to less than 0.3% in unselected patients undergoing a full median sternotomy for CABG. Further studies, including a larger number of patients and with a randomization design, would establish the potential preventative role of topical rifampicin in reducing the occurrence of DSWI.
Project description:Solitary fibrous tumors are uncommon soft tissue tumors initially reported only in the pleura but, in recent years, they have been described at many extra pleural sites, such as mediastinum. The treatment of choice is the extensive surgical resection that is curative for most benign lesions.We present the case of solitary fibrous tumor of the anterior mediastinum in obese patient (BMI: 34.3) undergoing complete surgical resection by robotic-assisted thoracoscopic surgery with da Vinci® Surgical System.Robotic-assisted thoracoscopic surgery with da Vinci® Surgical System is an interesting option for obese patient, at higher risk for deep sternal wound infection.
Project description:OBJECTIVES: Osteosynthetic closure of the chest after median sternotomy is usually performed with steel wires. We describe, for the first time, a case series in which titanium hooks were implanted from the sternal surface in patients who required secondary or additional stabilization. In comparison to the classic wires, the diameters of the hooks are approximately three times bigger and therefore reduce the risk of cutting through the bones. Additionally, there is no need to dissect retrosternal adhesions, which may reduce the risk of injuring mediastinal tissues. METHODS: The hooks are shaped like fishing hooks and can be inserted parasternally into the intercostal spaces. They can be pulled to the contralateral side of the sternum by the attached wires and then intertwined with a second hook. RESULTS: In 13 patients, the system was used to provide additional stabilization, while in two patients the hooks were implanted for exclusive stabilization of sternal fractures. In all cases but one, the implantation was able to eliminate the sternal problems. No infections, necrosis or bleeding of neighbouring tissues occurred. One patient developed chronic sternal infection, which necessitated explantation of the hooks. CONCLUSIONS: This sternal closure system using titanium hooks inserted parasternally is an effective alternative to conventional techniques and may increase stability of the breastbone and reduce the risk of injury to retrosternal tissues.
Project description:OBJECTIVES: We examined the impact of the bioresorbable osteosynthesis sternal pin (Super Fixsorb 30) on sternal healing after median sternotomy. METHODS: Sixty-three patients who underwent aortic surgery through median sternotomy between January 2006 and March 2009 were analysed. Sternal pins were utilized in 36 patients in addition to the standard closure of the sternum with Ethibond sutures (Group A), and 27 patients received no pins with the standard Ethibond sternal closure (Group B). The occurrence of transverse sternal dehiscence, anterior-posterior displacement and complete fusion of the sternum were evaluated by a computed tomography scan. The cross-sectional cortical bone density area (CBDA) of the sternum was examined to evaluate the osteoconductivity of the sternal pin over a 12-month period. RESULTS: There was no sternal displacement (0%) observed in Group A at discharge. Meanwhile, five displacements (18.5%) were observed in Group B (P = 0.007). The complete sternal fusion rates at 12 months postoperatively were 100% in Group A, and 21.6% in Group B (P < 0.001). A significant increase in the CBDA was observed in Group A (P < 0.001; between CBDA at discharge and 12 months postoperatively). CONCLUSIONS: The Super Fixsorb 30 sternal pin reduced an anterior-posterior sternal displacement and facilitated an earlier sternal fusion. The pin may have the potential to promote osteogenesis.
Project description:OBJECTIVES:Invasive mediastinal nodal staging is recommended before curative-intent resection in patients with non-small cell lung cancer deemed at risk for mediastinal lymph node involvement. We evaluated the use and survival effect of preoperative invasive mediastinal nodal staging in a population-based non-small cell lung cancer cohort. METHODS:We analyzed all curative-intent resections for non-small cell lung cancer from 2009 to 2018 in 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions, comparing patients who did not have invasive mediastinal nodal staging with those who did. RESULTS:Preoperative invasive nodal staging was used in 22% of 2916 patients, including mediastinoscopy only in 13%, minimally invasive procedures only in 6%, and both approaches in 3%. Sixty-three percent of patients at risk for nodal disease (tumor size ?3.0 cm/T2-T4; N1-N3 by computed tomography or positron-emission tomography-computerized tomography criterion) did not undergo invasive staging; among those who did not have invasive testing, 47% had at least 1 of the 3 clinical indications. Mediastinoscopy yielded a median of 3 lymph nodes and 2 nodal stations; 17% of mediastinoscopies and 31% of endobronchial ultrasound procedures yielded no lymph node material. Patients not invasively staged were more likely to have no nodes (6% vs 2%; P < .0001) and no mediastinal nodes (20% vs 11%; P < .0001) examined at surgery. Invasive staging was associated with significantly better survival (P = .0157). CONCLUSIONS:More than a decade after the 2001 American College of Surgeons Patient Care Evaluation report, preoperative invasive nodal staging remains underused and of variable quality, but was associated with survival benefit in high-risk patients.
Project description:BACKGROUND:Few large studies describe initial disease trajectories and subsequent mortality in people with head and neck cancer. This is a necessary first step to identify the need for palliative care and associated services. AIM:To analyse data from the Head and Neck 5000 study to present mortality, place and mode of death within 12?months of diagnosis. DESIGN:Prospective cohort study. PARTICIPANTS:In total, 5402 people with a new diagnosis of head and neck cancer were recruited from 76 cancer centres in the United Kingdom between April 2011 and December 2014. RESULTS:Initially, 161/5402 (3%) and 5241/5402 (97%) of participants were treated with 'non-curative' and 'curative' intent, respectively. Within 12?months, 109/161 (68%) in the 'non-curative' group died compared with 482/5241 (9%) in the 'curative' group. Catastrophic bleed was the terminal event for 10.4% and 9.8% of people in 'non-curative' and 'curative' groups, respectively; terminal airway obstruction was recorded for 7.5% and 6.3% of people in the same corresponding groups. Similar proportions of people in both groups died in a hospice (22.9% 'non-curative'; 23.5% 'curative') and 45.7% of the 'curative' group died in hospital. CONCLUSION:In addition to those with incurable head and neck cancer, there is a small but significant 'curative' subgroup of people who may have palliative needs shortly following diagnosis. Given the high mortality, risk of acute catastrophic event and frequent hospital death, clarifying the level and timing of palliative care services engagement would help provide assurance as to whether palliative care needs are being met.
Project description:Abstract An 82?year?old man with untreated diabetes mellitus (DM) had anterior chest wall swelling and ulcers 2 years following blunt chest trauma. Contrast?enhanced computed tomography revealed sternal fracture with osteolytic change and subcutaneous abscess. Blood and sternal cultures were positive for methicillin?susceptible Staphylococcus aureus (MSSA). Transesophageal echocardiogram showed vegetation on the right coronary cusp and moderate aortic regurgitation. The patient received a diagnosis of infective endocarditis associated with chronic sternal osteomyelitis complicated by subcutaneous abscess because of MSSA. This case report showed that trivial trauma in patients with uncontrolled DM can cause chronic sternal osteomyelitis resulting in infective endocarditis. Trivial trauma of the sternum in patients with uncontrolled DM may cause late?onset sternal osteomyelitis resulting in infective endocarditis. Physicians should consider a history of trivial trauma in the sternum in patients with uncontrolled DM because it can lead to late?onset sternal osteomyelitis, which subsequently causes infective endocarditis.
Project description:BACKGROUND: The aim of this study is to provide data on long term results of gastric cancer surgery and in particular the D1 gastric resection. METHODS: In the period 1992-2004, 235 male and female patients with a median age of 69 and 70 years respectively, were included with a stage I through IV gastric carcinoma, of which 37% was stage IV disease. Whenever possible a gastric resection was performed. In case of obstructive tumour growth palliation was provided by means of a gastro-enterostomy. RESULTS: Gastrectomy with curative intent was achieved in 50%, palliative resection in 22%, palliative surgery (gastro-enterostomy) in 10% and in 18% irresectability led to surgical exploration only. Patients in the curative intent group demonstrated a 47% survival after 5 years and up to 34% after 10 years. However metastases where seen in 32% of the patients after gastrectomy with curative intent. After palliative resection one year survival was 57%, whereas 19% survived more than 3 years. Overall postoperative morbidity and mortality rates were 40% and 13% respectively. CONCLUSION: Long term survival after surgery for gastric cancer is poor and is improved by early detection and radical resection. However, palliative resection showed improved survival compared to gastro-enterostomy alone or no resection at all which may be an effect of adjuvant therapy.
Project description:BACKGROUND:Curative-intent treatment for localized hilar cholangiocarcinoma (HC) requires surgical resection. However, the effect of adjuvant therapy (AT) on survival is unclear. We analyzed the impact of AT on overall (OS) and recurrence free survival (RFS) in patients undergoing curative resection. METHODS:We reviewed patients with resected HC between 2000 and 2015 from the ten institutions participating in the U.S. Extrahepatic Biliary Malignancy Consortium. We analyzed the impact of AT on RFS and OS. The probability of RFS and OS were calculated in the method of Kaplan and Meier and analyzed using multivariate Cox regression analysis. RESULTS:A total of 249 patients underwent curative resection for HC. Patients who received AT and those who did not had similar demographic and preoperative features. In a multivariate Cox regression analysis, AT conferred a significant protective effect on OS (HR 0.58, P?=?0.013), and this was maintained in a propensity matched analysis (HR 0.66, P?=?0.033). The protective effect of AT remained significant when node negative patients were excluded (HR 0.28, P?=?0.001), while it disappeared (HR 0.76, P?=?0.260) when node positive patients were excluded. CONCLUSIONS:AT should be strongly considered after curative-intent resection for HC, particularly in patients with node positive disease.