Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

The goals of the treatment of cancer of the oral cavity

Rodrigo Arrangoiz MS, MD, FACS, FSSO

The goals of the treatment of cancer of the oral cavity are:

  • Cure of the cancer

  • Preservation or restoration of speech, mastication, swallowing, and external appearance

  • Minimization of the sequelae of treatment such as dental decay, osteonecrosis of the mandible, and trismus

  • Awareness of the risk of subsequent primary tumors and their management.

Surgery and radiotherapy can be used as a single modality or in combination for the treatment of cancer of the oral cavity.

B9780323055895000081_f008-041-9780323055895

Treatment Approaches:

  • In general, early-stage (stage I or II) head and neck tumors may be treated using a single modality (surgery or radiotherapy), whereas advanced disease (stage III or IV) frequently benefits from multimodality therapy.

    • The best therapeutic approach for the primary tumor depends on the anatomic site.

    • Most neck disease can be treated equally well with surgery or radiation, thus the modality chosen to treat the neck is based on which modality is selected for the primary.

    • When the primary tumor is treated with irradiation, the regional lymphatics “at-risk” are incorporated into the treatment fields.

    • Neck dissections should remain standardized (ie, complete anatomic dissections, as opposed to “berry picking” or random biopsy) in these settings to avoid incomplete surgery.

Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon and is a member Center for Advanced Surgical Oncology at Palmetto General Hospital:

He is first author on some publications on oral cavity cancer:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#HeadandNeckSurgeon

#CancerSurgeon

#CASO

#CenterforAdvancedSurgicalOncology

Tongue Anatomy I

Rodrigo Arrangoiz MS, MD, FACS, FSSO

 

  • The tongue:
    • Which is located in the oral cavity and oropharynx is a mass of muscle that is almost completely covered by a thick mucous membrane.
  • The primary function of the tongue:
    • Is taste sensation:
      • But it also assists with:
        • Mastication
        • Deglutition
        • Articulation
        • Oral cleansing
  • The complex innervation of this multifunctional organ is provided by:
    • Five cranial nerves.
  • The embryologic origins of the tongue:
    • First appear at 4 weeks’ gestation.
    • The first branchial arch is responsible for the development of the tongue derivatives:
      • It gives rise to two lateral lingual swellings and one median swelling (known as the tuberculum impar):
        • The two lateral lingual swellings grow over the tuberculum impar and merge:
          • Forming the anterior two thirds of the tongue.
    • Portions of the second, third, and fourth branchial arches:
      • Give rise to the base of the tongue.
    • The intrinsic musculature of the tongue derives from occipital somites which give rise to myoblasts.
  • Macroscopically from anterior to posterior:
    • The tongue has three surfaces:
      • Tip
      • Body
      • The base
      • The tip of the tongue is:
        • The highly mobile, pointed, anterior portion of the tongue.
      • Behind to the tip lies the body of the tongue:
        • Which has a dorsal (superior) and a ventral (inferior) surfaces.
      • The median sulcus of the tongue:
        • Separates the body into left and right halves.
      • The terminal sulcus is a V-shaped furrow:
        • That separates the body of the tongue from the base of the tongue:
          • At the tip of this sulcus is the foramen cecum:
            • A remnant of the proximal thyroglossal duct.
      • The base of tongue contains:
        • The lingual tonsils:
      • The inferior most portion of Waldeyer’s ring.
      • The body of the tongue derives its characteristic surface appearance:
        • From the presence of lingual papillae:
          • Which are projections of lamina propria covered with epithelium.
          • Four different types of lingual papillae exist:
            • Circumvallate (vallate):
              • The circumvallate papillae are flat, prominent papillae that are surrounded by troughs.
              • There are approximately eight to 12 circumvallate papillae:
                • Located directly anterior to the terminal sulcus.
                • The ducts of the lingual glands of von Ebner:
                  • Secrete lingual lipase into the surrounding troughs to begin the process of lipolysis.
            • Foliate:
              • They are located on the lateral surface of the tongue:
                • They are small folds of mucosa.
            • Filiform:
              • The filiform papillae are thin and long.
              • They are the most abundant papillae in the tongue.
              • They are located:
                • Along the entire dorsum of the tongue.
              • They are not involved in taste sensation.
            • Fungiform:
              • Are the mushroom shaped papillae.
              • They are scattered most densely along the tip and lateral surfaces of the tongue.
              • The human tongue has roughly:
                • 200 to 300 fungiform papillae.
          • Each circumvallate, foliate, and fungiform papilla:
            • Contains taste buds (250, 1000, and 1600 taste buds, respectively):
              • Innervated by multiple nerve fibers.
            • All taste buds can perceive the five different taste qualities:
              • Salt
              • Sweet
              • Bitter
              • Acid
              • Umami
            • The taste bud consists of a:
              • Taste receptor, basal cell, and edge cell.
            • When a taste molecule binds to a taste receptor:
              • The receptor cell depolarizes, causing an influx of Ca++:
                • Which results in the release of an unidentified neurotransmitter
              • Following the depolarization:
                • The afferent neural pathway depends on the location of the taste bud that was stimulated:
                  • In the anterior two thirds of the tongue:
                    • The chorda tympani branch of the facial nerve (cranial nerve VII) is stimulated
                  • The lingual-tonsillar branch of the glossopharyngeal nerve (cranial nerve IX) relays taste information from the posterior third of the tongue
  • The tongue has four intrinsic and four extrinsic muscles:
    • The muscles on each side of the tongue are separated by a fibrous lingual septum
    • The extrinsic muscles are so named because they:
      • Originate outside the tongue and insert within it 
    • The intrinsic muscles are within the substance of the organ and do not insert on bone
    • Though the muscles do not act in isolation:
      • Intrinsic muscles generally:
        • Alter the shape of the tongue
      • Whereas extrinsic muscles alter its position:
        • The extrinsic muscles of the tongue are:
          • Genioglossus
          • Hyoglossus
          • Styloglossus
          • Palatoglossus
        • The hypoglossal nerve provides the motor innervation to all muscles of the tongue except the palatoglossus:
          • Which is supplied by the pharyngeal plexus
        • The arterial supply to the tongue and floor of the mouth is derived from the:
          • Dorsal lingual, sublingual, and deep lingual branches of the lingual artery
        • The venous drainage of the tongue is into the lingual veins, which drain into the:
          • Facial and retromandibular veins:
            • Which join to form the common facial vein

#Arrangoiz #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncology #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

Surgical Approaches to the Oropharynx

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Transoral:
    • True Transoral
    • Exposure via Pull-through
    • Exposure via Mandibulotomy 
  • Transcervical:
    • Pharyngotomy:
      • Lateral pharyngotomy
      • Suprahyoid pharyngotomy
    • Laryngotomy
    • Laryngectomy
  • Transoral approach:
    • Indications:
      • Lesions of the:
        • Faucial arches
        • Tonsils
        • Upper posterior pharyngeal wall
      • Small lesions equal or less than 1.5 cm
    • Can be combined with other approaches
    • Advantages:
      • Simple
      • Mandible intact
      • Flexible
    • Disadvantage: 
      • Limited exposure
  • Pull-through approach:
    • Bilateral level I (at least) neck dissections
    • Identification of hypoglossal nerve and lingual nerve
    • Floor of mouth mucosa and extrinsic tongue muscles are divided:
      • Dropping the tongue into the neck
    • Lingual nerve and sublingual gland are kept with the mandible 
    • Advantages:
      • Better exposure than true trans oral
      • Intact lip sensation
      • Good facial cosmesis
      • Intact mandible
    • Disadvantages:
      • Exposure
      • Lingual nerve is divided
      • Bleeding
      • May need additional approach

BRCA and Variant of Uncertain Clinical Significance

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • When patients are told they have a variant of unknown significance (VUS):
    • It can often lead to anxiety and overtreatment
  • It is important to counsel patients that a VUS:
    • Is not clinically actionable and the majority of VUS are reclassified as benign
  • Patients should be counseled to update their genetic counselors:
    • As their family history changes and keep contact information up to date as variant reclassification does occur
  • The American College of Medical Genetics has recommended that genetic testing classify genetic variants using the following classification schema: 
    • Deleterious (pathogenic)
    • Suspected deleterious (likely pathogenic)
    • Variant of Uncertain Clinical Significance
    • Genetic variant, favor polymorphism (likely benign)
    • Polymorphism (benign)
  • While deleterious and suspected deleterious BRCA mutations:
    • Are known to be associated with an increased risk of breast and ovarian cancer:
      • Among breast cancer patients:
        • It is estimated that 2% to 6% carry a BRCA 1 / 2 mutation
      • Among epithelial ovarian cancer patients:
        • It is estimated that 10% to 15% carry a BRCA 1 / 2 mutation
      • The lifetime risk of breast cancer for BRCA 1 / BRCA 2 mutation carriers:
        • Is approximately 45% to 80%
      • The lifetime ovarian cancer risk is:
        • 45% to 60% for BRCA 1 mutation carriers
        • 11% to 35% for BRCA 2 mutation carriers
  • It is unknown whether a BRCA VUS mutation:
    • Is associated with an increased risk due to limited available data
  • As the use of genetic testing increases and as more of the population is tested:
    • The knowledge base regarding variant pathogenicity constantly grows
  • Given the amount of data available from many years of BRCA 1 / 2 testing:
    • The prevalence of VUS among this population has declined to 2% to 5%:
      • However, among moderate and low penetrance genes:
        • The number of VUS continues to rise
  • As the data expand and knowledge regarding a variant evolves:
    • A variant may be reclassified:
      • In a recent study reported in the Journal of the American Medical Association:
        • 25.4% of patients initially diagnosed with a VUS were reclassified over a 12-year period:
          • Of these patients, 97% were downgraded to benign or likely benign
          • Three percent of patients were upgraded to pathogenic or likely pathogenic variants
          • Given this low risk of reclassification to pathogenic mutation:
            • Risk-reducing mastectomy, salpingo-oophorectomy, or genetic testing of family members are not indicated for this patient
    • There is currently no established effective screening protocol for pancreatic cancer, even among patients with a deleterious BRCA 2 mutation
  • References
    • Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, et al. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med. 2015;17(5):405-424.
    • Hall MJ, Reid JE, Burbidge LA, Pruss D, Deffenbaugh AM, Frye C, et al. BRCA1 and BRCA2 mutations in women of different ethnicities undergoing testing for hereditary breast-ovarian cancer. Cancer. 2009;115(10):2222-2233.
    • Mersch J, Brown N, Pirzadeh-Miller S, Mundt E, Cox HC, Brown K, et al. Prevalence of variant reclassification following hereditary cancer genetic testing. JAMA. 2018;320(12):1266-1274.

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #BreastCancer #BRCAMutation #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

American College of Radiology (ACR) Appropriateness Criteria – ADJUVANT THERAPY FOR RESECTED SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK

Rodrigo Arrangoiz MS, MD, FACS, FSSO

👉Expert Panel on Radiation Oncology – Head & Neck Cancer: Joseph K. Salama, MD; Nabil Saba, MD; Harry Quon, MD, MS; Jonathan J. Beitler, MD; Madhur Kumar Garg, MD; Joshua Lawson, MD; Mark W. McDonald, MD7; John A. Ridge, MD, PhD; Richard V. Smith, MD; Anamaria Reyna Yeung, MD1; Sue S. Yom, MD.

👉Introduction


1. The standard definitive treatment of locoregionally advanced squamous cell cancer of the head and neck (SCCHN) is either concurrent chemoradiotherapy (CRT) or appropriate surgical resection followed by adjuvant therapy directed by pathologic risk factors.

2. However, local or regional recurrences and distant metastases remain frequent after surgical treatment of stage III or IV disease.


3. Radiation therapy (RT) is added to surgery to decrease locoregional failure.

4. Adjuvant RT has been shown to improve locoregional control compared to neoadjuvant RT in a multi-institutional randomized trial.
5. Postoperative RT (PORT) has traditionally been given for most patients with potentially resectable stages III, IVa, and IVb SCCHN with the goal of maximizing cure and maintaining organ function.
6. Following PORT, locoregional control is 69% to 72%, and 5-year survival rates approach 30% to 40%.
7. This has prompted interest in adding chemotherapy to surgery and RT to improve outcome.
8. The addition of concurrent chemotherapy to adjuvant RT has been shown to result in improved locoregional control, disease-free survival (DFS), and/or overall survival (OS) rates for selected SCCHN patients.
B. Role of Postoperative Radiation Therapy
1. The addition of PORT became an accepted treatment following the publication of results from the MD Anderson Cancer Center (MDACC) which demonstrated that adjuvant RT decreased recurrence.
2. The Radiation Therapy Oncology Group (RTOG) 73-03 trial randomized 320 (T2 to T4, N any) head and neck cancer patients to 50 Gy preoperatively versus 60 Gy postoperatively.
– The 10-year locoregional control was significantly improved in the postoperatively treated patients (70% vs 58%).
– OS was not different between the groups due to deaths from distant metastases and second primary cancers.
3. Further evidence supporting the role of adjuvant RT includes an analysis by the Surveillance, Epidemiology and End Results (SEER) program of node-positive head and neck cancer patients reporting an absolute 10% overall and cause-specific survival benefit at 5 years.
– All nodal stages and primary sites (except oral cavity) had improved 5-year OS rates following PORT compared to patients who did not receive PORT.
– Additionally, within a randomized study of postoperative patients, a prospective cohort of nonrandomized low-pathologic-risk postoperative patients was observed.
= Compared to patients with intermediate pathologic risk treated with PORT, the low-risk group had comparable, if not worse locoregional control.
= Finally, a small randomized study of buccal mucosa patients demonstrated a DFS benefit to PORT compared to surgical resection alone.
C. High-risk pathologic features were initially defined by two large analyses.
1. A post-hoc analysis of a randomized study of SCCHN patients treated at the MDACC demonstrated that extranodal extension was an independent predictor of recurrence, and that two or more involved lymph nodes trended toward worse locoregional recurrence.
2. These factors (ENE and two or more positive lymph nodes) were validated in a combined analysis of postoperative RTOG studies:
– RTOG 85-03 testing the addition of cisplatin prior to PORT and RTOG 88-24 testing the addition of concurrent cisplatin to PORT were reanalyzed to determine the importance of different pathologic features on risk of recurrence.
= Patients treated on the RTOG 85-03 were stratified into three post-hoc groups:
= Group 1 included those with no more than two pathologically involved lymph nodes, no extracapsular spread (ECS), and uninvolved surgical margins
= Group 2 included patients with two or more pathologically involved lymph nodes or extranodal extension and surgically uninvolved margins
= Group 3 included patients with microscopically involved surgical margins.
= These risk stratifications resulted in significant differences in 5-year locoregional recurrence rates: 17%, 27%, and 67% in groups 1, 2, and 3, respectively.
= Furthermore, median survival times were different among the three groups, being 5.6 years in group 1, 2.6 years in group 2, and 1.5 years in group 3.
D. Timing of PORT:
1. When PORT is delivered without chemotherapy, the combination of surgical resection and PORT should be considered as a treatment package.
2. Completion of the treatment package in as short a time as possible has been associated with improved locoregional control and survival rates, which are likely related to tumor repopulation effects.
3. The strongest evidence favoring completion of surgery and PORT within a tight schedule comes from a trial at the MDACC randomizing 213 patients to a tailored therapy based on their respective risk factors:
– Patients with no pathologic risk features received no PORT
– Those in the intermediate-risk group (n = 31) received 57.6 Gy over 6.5 weeks
– Those in the high-risk group were randomized to receive either 63 Gy over 5 weeks (n = 76) or 7 weeks (n = 75).
– For high-risk patients, completion of the entire treatment package in less than 11 weeks was associated with improved actuarial 5-year locoregional control (76%) compared to packages of 11 to 13 weeks duration (62%) and greater than 13 weeks duration (38%) (P=0.002).
– Although a statistically significant OS benefit defined as a P value < 0.05 was not seen, patients receiving accelerated PORT over 5 weeks trended towards improved survival (P=0.08) and locoregional control (P=0.11).
= Some single institution retrospective analyses support this finding while others do not.
= Confounding these analyses is the fact that potentially larger tumors with high-risk features required larger more complex operations with potentially longer recovery times, which may influence the initiation of PORT.
4. When PORT is delivered with concurrent chemotherapy, the impact of time to completion of treatment is presently unknown.
– In general, the treatment should be completed in as short a time frame as possible when patients have adequately healed from their surgical wounds.
– However, when the RTOG examined the addition of postoperative paclitaxel followed by radiation concurrent with paclitaxel and cisplatin, there was a noted improvement in locoregional control rates and survival when compared to historical controls.
= Therefore, whether the timing of PORT affects outcomes in the setting of concurrent chemotherapy is not clear.

American College of Radiology ACR Appropriateness Criteria ADJUVANT THERAPY FOR RESECTED SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK
Expert Panel on Radiation Oncology – Head & Neck Cancer: Joseph K. Salama, MD; Nabil Saba, MD; Harry Quon, MD, MS; Jonathan J. Beitler, MD; Madhur Kumar Garg, MD; Joshua Lawson, MD; Mark W. McDonald, MD7; John A. Ridge, MD, PhD; Richard V. Smith, MD; Anamaria Reyna Yeung, MD1; Sue S. Yom, MD.
A. Introduction:
1. The standard definitive treatment of locoregionally advanced squamous cell cancer of the head and neck (SCCHN) is either concurrent chemoradiotherapy (CRT) or appropriate surgical resection followed by adjuvant therapy directed by pathologic risk factors.
2. However, local or regional recurrences and distant metastases remain frequent after surgical treatment of stage III or IV disease.
3. Radiation therapy (RT) is added to surgery to decrease locoregional failure.
4. Adjuvant RT has been shown to improve locoregional control compared to neoadjuvant RT in a multi-institutional randomized trial.
5. Postoperative RT (PORT) has traditionally been given for most patients with potentially resectable stages III, IVa, and IVb SCCHN with the goal of maximizing cure and maintaining organ function.
6. Following PORT, locoregional control is 69% to 72%, and 5-year survival rates approach 30% to 40%.
7. This has prompted interest in adding chemotherapy to surgery and RT to improve outcome.
8. The addition of concurrent chemotherapy to adjuvant RT has been shown to result in improved locoregional control, disease-free survival (DFS), and/or overall survival (OS) rates for selected SCCHN patients.
B. Role of Postoperative Radiation Therapy
1. The addition of PORT became an accepted treatment following the publication of results from the MD Anderson Cancer Center (MDACC) which demonstrated that adjuvant RT decreased recurrence.
2. The Radiation Therapy Oncology Group (RTOG) 73-03 trial randomized 320 (T2 to T4, N any) head and neck cancer patients to 50 Gy preoperatively versus 60 Gy postoperatively.
– The 10-year locoregional control was significantly improved in the postoperatively treated patients (70% vs 58%).
– OS was not different between the groups due to deaths from distant metastases and second primary cancers.
3. Further evidence supporting the role of adjuvant RT includes an analysis by the Surveillance, Epidemiology and End Results (SEER) program of node-positive head and neck cancer patients reporting an absolute 10% overall and cause-specific survival benefit at 5 years.
– All nodal stages and primary sites (except oral cavity) had improved 5-year OS rates following PORT compared to patients who did not receive PORT.
– Additionally, within a randomized study of postoperative patients, a prospective cohort of nonrandomized low-pathologic-risk postoperative patients was observed.
= Compared to patients with intermediate pathologic risk treated with PORT, the low-risk group had comparable, if not worse locoregional control.
= Finally, a small randomized study of buccal mucosa patients demonstrated a DFS benefit to PORT compared to surgical resection alone.
C. High-risk pathologic features were initially defined by two large analyses.
1. A post-hoc analysis of a randomized study of SCCHN patients treated at the MDACC demonstrated that extranodal extension was an independent predictor of recurrence, and that two or more involved lymph nodes trended toward worse locoregional recurrence.
2. These factors (ENE and two or more positive lymph nodes) were validated in a combined analysis of postoperative RTOG studies:
– RTOG 85-03 testing the addition of cisplatin prior to PORT and RTOG 88-24 testing the addition of concurrent cisplatin to PORT were reanalyzed to determine the importance of different pathologic features on risk of recurrence.
= Patients treated on the RTOG 85-03 were stratified into three post-hoc groups:
= Group 1 included those with no more than two pathologically involved lymph nodes, no extracapsular spread (ECS), and uninvolved surgical margins
= Group 2 included patients with two or more pathologically involved lymph nodes or extranodal extension and surgically uninvolved margins
= Group 3 included patients with microscopically involved surgical margins.
= These risk stratifications resulted in significant differences in 5-year locoregional recurrence rates: 17%, 27%, and 67% in groups 1, 2, and 3, respectively.
= Furthermore, median survival times were different among the three groups, being 5.6 years in group 1, 2.6 years in group 2, and 1.5 years in group 3.
D. Timing of PORT:
1. When PORT is delivered without chemotherapy, the combination of surgical resection and PORT should be considered as a treatment package.
2. Completion of the treatment package in as short a time as possible has been associated with improved locoregional control and survival rates, which are likely related to tumor repopulation effects.
3. The strongest evidence favoring completion of surgery and PORT within a tight schedule comes from a trial at the MDACC randomizing 213 patients to a tailored therapy based on their respective risk factors:
– Patients with no pathologic risk features received no PORT
– Those in the intermediate-risk group (n = 31) received 57.6 Gy over 6.5 weeks
– Those in the high-risk group were randomized to receive either 63 Gy over 5 weeks (n = 76) or 7 weeks (n = 75).
– For high-risk patients, completion of the entire treatment package in less than 11 weeks was associated with improved actuarial 5-year locoregional control (76%) compared to packages of 11 to 13 weeks duration (62%) and greater than 13 weeks duration (38%) (P=0.002).
– Although a statistically significant OS benefit defined as a P value < 0.05 was not seen, patients receiving accelerated PORT over 5 weeks trended towards improved survival (P=0.08) and locoregional control (P=0.11).
= Some single institution retrospective analyses support this finding while others do not.
= Confounding these analyses is the fact that potentially larger tumors with high-risk features required larger more complex operations with potentially longer recovery times, which may influence the initiation of PORT.
4. When PORT is delivered with concurrent chemotherapy, the impact of time to completion of treatment is presently unknown.
– In general, the treatment should be completed in as short a time frame as possible when patients have adequately healed from their surgical wounds.
– However, when the RTOG examined the addition of postoperative paclitaxel followed by radiation concurrent with paclitaxel and cisplatin, there was a noted improvement in locoregional control rates and survival when compared to historical controls.
= Therefore, whether the timing of PORT affects outcomes in the setting of concurrent chemotherapy is not clear.

Types of Calcifications of the Breast

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Screening mammography:
    • Is important in identifying breast cancer at an early stage:
  • Calcifications have many forms:
    • The characteristics of the calcifications help identify whether they are associated with a benign or malignant process:
      • Smooth, round, large and layering calcium:
        • Are generally associated with benign findings
      • Fine, irregular, punctate, linear and branching, and pleomorphic calcifications:
        • Are characteristics generally associated with malignant findings
  • Magnification views of the calcifications:
    • Are essential in helping to evaluate the calcifications to determine the appearance and to be able to accurately interpret the findings
  • References:
    • Brant W, Helms C. Fundamentals of Diagnostic Radiology, 5th Edition. Lippincott, Williams & Wilkins; 2019
    • Baldwin P. Breast calcification imaging. Radiol Technol. 2013;84(4):383M-404M.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncology #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

Predictors of Distant Recurrence Using Gene Expression Profiles

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The benefit of chemotherapy among women with early-stage, hormone-receptor positive breast cancers has become largely determinant on the use of gene expression profiles, including Oncotype DX, MammaPrint, and PAM50. Oncotype DX score is a 21-gene assay that uses RT-PCR to calculate recurrence risk using a scoring system from 0 to 100, and categorizes women into low, intermediate, and high risk of recurrence based on pre-specified cut points. MammaPrint is a 70-gene assay performed with microarray, and classifies tumors as having good vs poor prognostic signatures. PAM50 tests 50 classifier genes and categorizes women by intrinsic subtypes including luminal A, luminal B, HER2-enriched, basal-like and normal-like. Adjuvant! Online is an online program that uses standard clinicopathologic variables to estimate survival for breast cancer patients treated by local therapy alone and the survival and disease-free survival benefit gained by the addition of systemic adjuvant therapy.

REFERENCES

  1. Paik S. Is gene array testing considered to be routine now? Breast. 2011;20 Suppl 3:S87-S91.
  2. Paik S, Shak S, Tang G, et al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351(27):2817-2826.
  3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines for Oncology: Breast Cancer. https://www.nccn.org/professionals/physician_gls/f_guidelines.asp Published January 2016. Accessed January 31, 2017.

Facts About Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • In 2020, an estimated 276,480 new cases of invasive breast cancer will be diagnosed in women in the U.S. as well as 48,530 new cases of non-invasive (in situ) breast cancer.
  • 64% of breast cancer cases are diagnosed at a localized stage (there is no sign that the cancer has spread outside of the breast), for which the 5-year survival rate is 99%.
  • This year, an estimated 42,170 women will die from breast cancer in the U.S.
  • Although rare, men get breast cancer too. In 2020, an estimated 2,620 men will be diagnosed with breast cancer this year in the U.S. and approximately 520 will die.
  • 1 in 8 women in the United States will be diagnosed with breast cancer in her lifetime
  • Breast cancer is the most common cancer in American women, except for skin cancers. It is estimated that in 2020, approximately 30% of all new women cancer diagnoses will be breast cancer.
  • There are over 3.5 million breast cancer survivors in the United States.
  • On average, every 2 minutes a woman is diagnosed with breast cancer in the United States.

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncology #PalmettoGeneralHospital

CALGB 9343 Trial

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The Cancer and Leukemia Group B (CALGB) 9343 trial:
    • Enrolled 647 patients:
      • From 1994 until 1999
    • Long-term follow-up data:
    • Were published in 2013:
      • With a median follow-up of:
        • 12.6 years
      • Women age 70 years or older:
        • With clinical stage I:
          • cT1, cN0, cM0
          • ER-positive breast cancer
          • Treated by lumpectomy 
    • Were randomly assigned to receive:
      • Tamoxifen plus radiation therapy (TamRT) or
      • Tamoxifen alone (Tam)
    • At 10 years:
      • 98% of women:
        • Receiving TamRT were free from local and regional recurrences
      • Compared to 91% of those receiving Tam
      • The 10-year estimates of overall survival (OS) were: o 67% (95% confidence interval [CI], 62–72%) in the TamRT group versus o 66% (95% CI, 61%–71%) in the Tam group:  But the difference was not statistically significant  In addition to concluding that: • While RT (in addition to Tam): o Reduces locoregional recurrence:  The authors noted that “the impact of breast cancer in this select group of older women is much smaller than that of comorbid conditions”: • Only 3% of women in study have died as a result of breast cancer whereas 49% have died as a result of other causes • References: o Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31:2382-2389.