Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• Whole-breast irradiation (WBI) can be administered following delivery:
  • Uterine shielding can reduce the dose but in non-life threatening situations:
    • Radiation should be held until after delivery
• Risks of radiation while pregnant can include:
  • Toxicity to the fetus
  • Increased risk of second malignancy in the child
• Although hypofractionated WBI has been studied and found to be comparable to standard WBI:
  • Few patients enrolled were younger than age 50 years
  • Current American Society for Radiation Oncology guidelines:
    • Do not recommend:
      • Hypofractionated WBI for patients younger than age 50 years
• Accelerated partial breast irradiation:
  • Has been shown to provide equivalent rates of local recurrence compared to standard WBI:
    • However, due to a paucity of young patients enrolled in such trials:
      • It is not currently recommended for patients younger age 50 years
• REFERENCES
  • Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-1241.
  • Haviland JS, Owen JR, Dewar JA, et al; START Trialists’ Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early stage breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14:1086-1094.
  • Luis SA, Christie DR, Kaminski A, Kenny L, Peres MH. Pregnancy and radiotherapy: management options for minimizing risk, case series, and comprehensive literature review. J Med Imaging Radiat Oncol. 2009;53:559-568.
  • Smith BD, Arthur DW, Buchholz TA, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys. 2009;74:987-1001.
  • Smith BD, Bentzen SM, Correa CR, et al. Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;81:59-68.
  • Strnad V, Ott OJ, Hildebrandt G, et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016;387:229-238.
  • Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513-520.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer

• Angiosarcomas are rare, aggressive tumors arising in either blood or lymphatic vessels:
  • The scalp and face are the most common sites
• Complete surgical resection with wide margins:
  • Is preferred for local and locoregional disease:
    • Due to the propensity for insidious local infiltration:
      • Preoperative or postoperative radiation (RT) for almost all patients is recommended
• The role of adjuvant chemotherapy is unclear
• Neoadjuvant chemotherapy and / or RT:
  • May allow some patients with locally advanced lesions:
    • To undergo potentially less mutilating surgery
• Angiosarcomas are tumors:
  • Arising in either blood or lymphatic vessels:
    • They account for about:
      • 15% of all head and neck sarcomas:
        • 1% of all soft tissue sarcomas
  • The scalp and face are the most common sites of origin:
    • In a SEER database series:
      • 434 cases of cutaneous angiosarcomas
      • Reported between 1973 and 2007
      • 270 (72%) arose in the region of the head and neck:
        • Head and neck angiosarcomas tend to be a disease of:
          • Older Caucasian men
          • With a median age of incidence:
            • Of 65 to 70
          • A male to female ratio of 2:1
        • The relative Caucasian male predominance, age of incidence, and localization to the face and scalp:
          • Has led some to propose that sun exposure contributes to the etiology, but this has not been clearly demonstrated
        • A prior history of radiotherapy to the face or scalp:
          • Is elicited in 5% to 20% of patients
• Clinical presentation:
  • Patients typically present with a blue or purple lesion on the scalp or face:
    • That has been present for several months
  • These lesions may appear:
    • Macular, nodular, or plaque-like
      • Diffuse, clinically undetectable intra-dermal spread:
        • Leads to indistinct borders and a high incidence of multicentricity
  • Advanced lesions:
    • Can show hemorrhage or ulceration
  • Cervical lymphadenopathy:
    • Is found in approximately 10% of patients at the time of presentation
• Natural history and prognosis:
  • The outlook for these tumors is poor:
    • With five-year survival:
      • Generally less than 40%:
  • As an example:
    • In a series of 133 angiosarcomas of the scalp and neck reported to the SEER database between 1973 and 2007:
      • Five and 10-year survival rates were:
        • 34% and 14%, respectively:
          • Local recurrence is a major problem
  • But distant metastases are also frequent
• The most important prognostic factor for survival in patients with head and neck angiosarcoma:
  • Is size and the ability to completely resect the tumor:
    • Patients with tumors less than 5 cm in diameter:
      • Have better overall survival and a lower risk of regional recurrence:
• In addition:
  • Cellular epithelioid morphology:
    • Is emerging as a potentially adverse prognostic factor:
      • As is age 70 and older
• Treatment:
  • There is limited evidence, other than case series:
    • Upon which to base treatment recommendations for angiosarcoma of the head and neck
  • Complete surgical resection with wide margins:
    • Is preferred for local and locoregional disease:
  • Although the risk of lymph node spread is higher with angiosarcomas than with other head and neck sarcomas:
    • The overall risk remains lower than what is generally considered an indication for elective lymph node dissection:
      • As a result, most surgeons reserve neck treatment for gross nodal disease only
  • Reconstruction is performed immediately following resection; even sizable deficits can be reconstructed using current techniques:
    • Radial forearm and rectus abdominis microvascular free flaps can cover large surface defects with minimal donor site morbidity
    • Smaller defects can be reconstructed using skin grafts, or local or regional flaps
  • Some surgeons perform small mapping biopsies along the proposed margins preoperatively:
    • So that disease with subclinical microscopic spread can be identified and appropriate ablative and reconstructive planning undertaken prior to definitive resection
  • Due to the propensity for insidious local infiltration:
    • Resection should be combined in nearly all cases by preoperative or postoperative RT:
      • Although randomized trials are not available, the benefits of RT are supported by several small reports
        • As examples:
          • In one series of 28 patients with angiosarcoma of the head and neck treated at the University of California, Los Angeles (UCLA):
            • Only 1 of 12 patients treated with surgery alone remained disease free compared with four of six who received postoperative RT, with or without chemotherapy
          • In a second report of 70 patients with non- metastatic angiosarcoma of the face and scalp:
            • Combined therapy with surgery plus RT (versus surgery alone or RT alone) was associated with:
              • Improved overall survival (68% versus 32%)
              • Disease-specific survival (76% versus 33%)
              • As well as better local control
  • The role of adjuvant chemotherapy, either alone or concurrent with RT, is unclear:
    • In the above cited series of 70 patients with non-metastatic angiosarcoma, outcomes were not significantly better in those who received any chemotherapy in addition to local therapy:
      • Five-year overall survival 45% versus 39%, p = 0.54)
    • However, interest is increasing in neoadjuvant chemotherapy and / or RT as a component of combined modality therapy, which may allow some patients to undergo potentially less mutilating surgery
  • For patients with unresectable tumors or those who refuse surgery, definitive RT or chemoradiation is an option
  • Systemic treatment for metastatic angiosarcoma generally follows the same principles as for other anthracycline-sensitive adult-type advanced soft tissue sarcomas:
    • However, in contrast to other soft-tissue sarcomas:
      • Angiosarcomas appear to be particularly responsive to taxanes
    • In addition, promising responses, occasionally dramatic, have been demonstrated in very limited number of angiosarcoma patients with various biologic molecules, including:
      • Bevacizumab, sunitinib, and sorafenib, either as single agents or in combination with chemotherapy
• References:
• Albores-Saavedra J, Schwartz AM, Henson DE, et al. Cutaneous angiosarcoma. Analysis of 434 cases from the Surveillance, Epidemiology, and End Results Program, 1973-2007. Ann Diagn Pathol 2011; 15:93.
• Lydiatt WM, Shaha AR, Shah JP. Angiosarcoma of the head and neck. Am J Surg 1994; 168:451.
• Mark RJ, Tran LM, Sercarz J, et al. Angiosarcoma of the head and neck. The UCLA experience 1955 through 1990. Arch Otolaryngol Head Neck Surg 1993; 119:973.
• Panje WR, Moran WJ, Bostwick DG, Kitt VV. Angiosarcoma of the head and neck: review of 11 cases. Laryngoscope 1986; 96:1381.
• Holden CA, Spittle MF, Jones EW. Angiosarcoma of the face and scalp, prognosis and treatment. Cancer 1987; 59:1046.
• Fury MG, Antonescu CR, Van Zee KJ, et al. A 14-year retrospective review of angiosarcoma: clinical characteristics, prognostic factors, and treatment outcomes with surgery and chemotherapy. Cancer J 2005; 11:241.
• Maddox JC, Evans HL. Angiosarcoma of skin and soft tissue: a study of forty-four cases. Cancer 1981; 48:1907.
• Morrison WH, Byers RM, Garden AS, et al. Cutaneous angiosarcoma of the head and neck. A therapeutic dilemma. Cancer 1995; 76:319.
• Willers H, Hug EB, Spiro IJ, et al. Adult soft tissue sarcomas of the head and neck treated by radiation and surgery or radiation alone: patterns of failure and prognostic factors. Int J Radiat Oncol Biol Phys 1995; 33:585.
• Lahat G, Dhuka AR, Hallevi H, et al. Angiosarcoma: clinical and molecular insights. Ann Surg 2010; 251:1098.
• Köhler HF, Neves RI, Brechtbühl ER, et al. Cutaneous angiosarcoma of the head and neck: report of 23 cases from a single institution. Otolaryngol Head Neck Surg 2008; 139:519.
• Patel SH, Hayden RE, Hinni ML, et al. Angiosarcoma of the scalp and face: the Mayo Clinic experience. JAMA Otolaryngol Head Neck Surg 2015; 141:335.
• Aust MR, Olsen KD, Lewis JE, et al. Angiosarcomas of the head and neck: clinical and pathologic characteristics. Ann Otol Rhinol Laryngol 1997; 106:943.
• Guadagnolo BA, Zagars GK, Araujo D, et al. Outcomes after definitive treatment for cutaneous angiosarcoma of the face and scalp. Head Neck 2011; 33:661.
• Amato L, Moretti S, Palleschi GM, et al. A case of angiosarcoma of the face successfully treated with combined chemotherapy and radiotherapy. Br J Dermatol 2000; 142:822.
• Lankester KJ, Brown RS, Spittle MF. Complete resolution of angiosarcoma of the scalp with liposomal daunorubicin and radiotherapy. Clin Oncol (R Coll Radiol) 1999; 11:208.
• Young RJ, Brown NJ, Reed MW, et al. Angiosarcoma. Lancet Oncol 2010; 11:983.
• DeMartelaere SL, Roberts D, Burgess MA, et al. Neoadjuvant chemotherapy-specific and overall treatment outcomes in patients with cutaneous angiosarcoma of the face with periorbital involvement. Head Neck 2008; 30:639.

#Arrangoiz #Surgeon #CancerSurgeon #HeadandNeckSurgeon #HeadandNeckCancer #SurgicalOncologist #CASO #PalmettoGeneralHospital

• The USC / VNPI:
  • Estimates which patients with DCIS can be managed by:
  • Excision alone vs
  • Excision plus radiation vs
  • Those who require mastectomy
• There are three groups of patients in the index:
  • Group 1 patients have:
    • Non-high nuclear grade DCIS without necrosis
  • Group 2 patients have:
    • Non-high nuclear grade DCIS with necrosis
  • Group 3 patients have:
    • High nuclear grade DCIS with or without necrosis
• The original Van Nuys Prognostic Index:
  • Introduced in 1996, had two additional variables:
    • They were:
      • Size of DCIS and margin width
  • A score from 3 to 9 was derived by:
    • Assigning 1, 2, or 3 points to each of the 3 variables as shown below in the Table 1:

• Patients who scored 3 or 4:
  • Derived little benefit from radiation
• Patients who scored 5, 6, or 7:
  • Derived substantial benefit from radiation
• Patients who scored 8 or 9:
  • Had a high risk of relapse despite radiation and are best managed:
    • By mastectomy
• In 2003:
  • The name became the University of Southern California / Van Nuys Prognostic Index
  • A 4th variable was added to the score:
    • Patients who were younger than age 40 years:
      • Received a score of 3
    • Patients from ages 40 to 60 years:
      • Received score of 2
    • Patients older than age 60 years:
      • Received a score of 1
  • The range of possible scores then became 4 to 12:
    • Patients with a score of 4, 5, or 6:
      • Did not receive a statistically significant benefit from radiation
    • Patients with scores of 7, 8, and 9:
      • Who were treated with radiation:
        • Received a significant reduction in local disease-free recurrence:
          • Of 12% to 15%
    • Patients with scores of 10, 11, and 12:
      • Had a local recurrence rate of almost:
        • 50% at five-years despite radiation
• By 2010 the number of patients was large enough to allow analysis by individual scores as opposed to groups of scores, and the following was reported:
  • To achieve a local recurrence rate of less than 20% at 12 years:
    • These data support excision alone:
      • For all patients scoring 4, 5, or 6 and patients who score 7 but have margin widths ≥ 3 mm
    • Excision plus radiation therapy achieves the less than 20% local recurrence requirement at 12 years for patients:
      • Who score 7 and have margins < 3 mm, patients who score 8 and have margins ≥ 3 mm, and for patients who score 9 and have margins ≥ 5 mm
    • Mastectomy is suggested for patients:
      • Who score 8 and have margins < 3 mm, who score 9 and have margins < 5 mm, and for all patients who score 10, 11, or 12 to keep the local recurrence rate less than 20% at 12 years
• REFERENCES
  • Silverstein MJ. The University of Southern California/Van Nuys Prognostic Index for ductal carcinoma in situ of the breast. Am J Surg. 2003;186:337-343.
  • Silverstein MJ, Lagios MD. Choosing treatment for patients with ductal carcinoma in situ: fine tuning the University of Southern California/Van Nuys Prognostic Index. J Natl Cancer Inst Monogr. 2010;2010:193-196.
  • Silverstein MJ, Lagios MD. Treatment selection for patients with ductal carcinoma in situ (DCIS) of the breast using the University of Southern California/Van Nuys (USC/VNPI) Prognostic Index. Breast J. 2015;21:127-132.
  • Silverstein MJ, Lagios MD, Craig PH, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77:2267-2274.

#Arrangoiz #BreastSurgeon #CancerSurgeon #BreastCancer #SurgicalOncologist

• The National Surgical Adjuvant Bowel and Breast Project B-18:
  • Was designed to determine whether preoperative chemotherapy:
    • Would result in improved survival:
      • Compared to postoperative chemotherapy
  • Secondary aims included:
    • Evaluation of pCR rates
    • Comparison of breast conservation rates and ipsilateral recurrence rates between the two groups
• Between 1988 and 1993:
  • 1523 patients with:
    • Clinical T1 to T3, N0 to N1 operable breast cancer were enrolled in the trial
  • 763 were randomized to preoperative therapy while
  • 760 were randomized to postoperative therapy
• At 16-years of follow-up:
  • There was no difference in:
    • Disease-free survival:
      • HR = 0.93, 95% CI, 0.81 to 1.06
        • p = 0.27 or
    • Overall survival:
      • HR = 0.99, 95% CI, 0.85 to 1.16
        • p = 0.90
          • Between the postoperative and preoperative chemotherapy groups
• In the preoperative group:
  • A pCR was documented in:
    • 13% of patients
• Preoperative chemotherapy patients had a:
  • Significantly increased incidence of having:
    • Pathologically negative nodes compared to postoperative chemotherapy patients:
      • 58% vs. 42%, respectively
        • p<0.0001
• The rate of breast conservation was higher:
  • Among women who received neoadjuvant chemotherapy compared to women who received postoperative chemotherapy:
    • 68% versus 60%, respectively
      • p = 0.001
        • The significant downstaging of tumors greater than 5 cm in the preoperative chemotherapy arm:
          • Primarily drove this breast conservation trend
• There was a trend toward a higher rate of:
  • Ipsilateral breast tumor recurrence with preoperative vs postoperative chemotherapy:
    • 13% of 506 patients vs 10% of 450 patients, respectively:
      • Although this difference was not statistically significant (p = 0.21)
• Retrospective series later found:
  • No difference in surgical complications:
    • Between women who received preoperative or postoperative chemotherapy

• REFERENCES
  • Fisher B, Bryant J, Wolmark N, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol. 1998;16(8):2672-2685.
  • Boughey JC, Peitinger F, Meric-Bernstam F, et al. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 2006;244(3):464–470.
  • Rastogi P, Anderson SJ, Bear HD, et al. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol. 2008;26(5):778-785.

#ARRANGOIZ #BreastSurgeon #CancerSurgeon #SurgicalOncologist

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #SalivaryGlandSurgery

👉In patients with failure to localize on traditional imaging studies, PET choline may be an option and is offered at select centers around the country.

#CheckYourCalcium #Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #HeadandNeckSurgeon

• I went to medical school at the Anahuac University in Mexico City, which is one of the most prestigious medical schools in Mexico:
  • I graduated Suma Cum Laude from this medical school and was the president of the student medical council.
• I trained in general surgery at Michigan State University where I was named chief resident during my fifth year of residency which was a great honor.
• My complex surgical oncology fellowship which included a head and neck training was performed at the Fox Chase Cancer Center in Philadelphia, Pennsylvania.
• At the same time, I undertook a Masters in Science (Clinical Research for Health Care Professionals) at Drexel University in Philadelphia, Pennsylvania.
• I also performed a two-year global online fellowship in Head and Neck Surgery and Oncology with the International Federations of Head and Neck Societies / Memorial Sloan Kettering Cancer Center.
  • I encountered patients with very complex problems, and the greatest lesson I learned was there are always treatment options, utilizing all different types of techniques including radiation, chemotherapy and surgery.
    • This comprehensive training has provided me with an extensive understanding of the multidisciplinary approach to treating patients with cancer.
• I have developed a particularly strong interest in the surgical and multimodal treatment of patients with breast cancer, head and neck cancer (including thyroid and parathyroid cancer), and endocrine diseases (benign and malignant thyroid and parathyroid diseases), using traditional surgery, regional therapies, and minimally invasive techniques.
  • I am an expert in the treatment of thyroid cancer including; active surveillance for early, small papillary thyroid cancers, minimally invasive thyroid surgery, selective and comprehensive neck dissections.
  • For the management of parathyroid disease, I offer a minimally invasive radio-guided technique called MIRP (minimally invasive radio-guided parathyroidectomy) through a 2 cm incision which will allow the patient to have a great cosmetic result and quick return to normal life after the operation.
  • I am extremely aware of the impact that a breast cancer diagnosis has on a patient. I do my best to promote a positive atmosphere in which to start my patients’ course of treatment and take the time to explain the pros and cons of each treatment option, so that they can make an informed decision.
    • My management philosophy also includes, not just an emphasis on successful treatment, but also preserving a good cosmetic outcome. I feel fortunate to be a fellowship trained, very highly specialized clinician, because this combination of factors allows me, and our treatment team to focus on one thing all day, every day, and do it well: curing cancer. I think there is nothing more rewarding that I could do as a clinician.
• I hold my patients as my number one priority. I will spend as much time as necessary educating, answering questions and providing guidance for each individual patient to help them throughout each stage of their management. I believe in honest discussions, where both the patients and family’s goals and expectations are openly communicated. We will work together as a team to put together an evidence based personalized treatment plan. My personal goal is to treat and care for every patient with the same compassion and honesty as if they were a friend or family member.

👉Will join the Center for Advanced Surgical Oncology at Palmetto General Hospital as a breast / thyroid / parathyroid / head and neck surgeon in July, 2020

#Arrangoiz #Surgeon #CancerSurgeon #HeadandNeckSurgeon #BreastSurgeon #SurgicalOncologist #PalmettoGeneralHospital #CenterforAdvancedSurgicalOncology

• Killian’s dehiscence:
  • Also known as:
    • Killian’s triangle
    • Laimer triangle
    • Laimer-Killian triangle
    • Laimer-Haeckermann area
  • Is a triangular area in the wall of the pharynx:
    • Between the thyropharyngeal and cricopharyngeus muscle of the inferior constrictor of the pharynx:
      • It represents a potentially weak spot:
        • Where a pharyngoesophageal diverticulum (Zenker’s diverticulum) is more likely to occur

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #Surgeon #Teahcer

• Zenker diverticulum:
  • Is a pulsion-pseudodiverticulum:
    • Results from herniation of mucosa and submucosa:
      • Through the Killian triangle (or Killian dehiscence):
        • A focal weakness in the hypopharynx:
          • At the normal cleavage plane between the fibres of the inferior pharyngeal constrictor (thyropharyngeus muscle) and the cricopharyngeus muscles

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• In more than 80% of patients:
  • Tumors spread to involve the local lymph nodes are detected on physical examination or by imaging at first presentation
• The lymphatics fluid flows mostly via collectors into the lymph nodes of :
  • Levels II and III:
    • A direct relationship to level I has not been detected
  • Drainage to involve level IV occurs frequently
• The lymphatic drainage of the posterior pharyngeal wall occurs:
  • Mainly first into:
    • The retropharyngeal lymph nodes:
      • Accounts for over 40% cases
• In hypopharyngeal cancers:
  • Because of its advanced stage at presentation and its involvement or extension to cross the midline:
    • The risk of contralateral metastases is high, with histological identification of tumor in:
      • More than 20% of cases treated surgically, and supports the therapeutic decision:
        • To treat both sides of the neck, either by surgery or by radiotherapy in the N0 neck

#Arrangoiz #Teacher #Surgeon #CancerSurgeon #HeadandNeckSurgeon #NasopharyngealCancer