Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• The European Organisation for Research and Treatment of Cancer (EORTC) 10981 After Mapping of the Axilla, Radiation or Surgery? (AMAROS) trial:
  • Randomized 4806:
    • Clinically node-negative
    • T1 to T2 tumors:
      • To completion axillary lymph node dissection (ALND) or axillary radiation (AR):
        • If they had positive nodes
    • Of the 1425 patients with positive sentinel nodes:
      • 744 had been randomly assigned to ALND
      • 681 to AR
    • Initially:
      • Patients with tumors 3 cm or smaller were eligible:
        • But the protocol was later modified to include:
          • Tumors up to 5 cm, multifocal tumors, or both
    • In the AR arm 21% of patients had T2 lesions
    • There were no age limits for eligibility:
      • Patients ranged from age 48 to 64 years
    • In the AR arm:
      • 42% of women were premenopausal
    • Patients who had either partial or total mastectomy were enrolled in the trial:
      • 18% of women had mastectomy
    • There was no limit on the number of positive nodes for the radiation arm:
      • But the majority of patients had 1 or 2 positive nodes
    • Crossover was allowed:
      • For patients with extensive axillary disease:
        • From the radiation arm to the dissection arm
      • Patients in the dissection arm who had 4 or more positive nodes:
        • Where allowed to have axillary radiation
        • Four percent of patients who stayed in the radiation arm had 3 positive nodes, and 1% had 4 or more positive nodes.
    • Importantly:
      • In the axillary dissection arm:
        • 25% of patients had an additional 1 to 3 positive nodes (in addition to the positive sentinel nodes) at dissection
        • 8% had 4 or more additional positive nodes
      • Since it was a randomized trial:
        • We can assume the same numbers were present in the radiation arm:
          • So these patients did not necessarily have low-volume axillary disease.
    • Axillary radiotherapy (RT) included:
      • The contents of all 3 levels of the axilla and the medial part of the supraclavicular fossa
      • The prescribed dose was 25 fractions of 2 Gy each
      • For patients in the AR arm who had mastectomy:
        • Radiation to the chest wall in addition to the axilla was optional but not mandatory
    • There were no significant differences:
      • In 5-year overall survival or disease-free survival between the two arms:
        • At 6.1 years of follow-up:
          • There was no significant difference:
            • In the rate of axillary failure:
              • 0.43% ALND vs 1.19% RT
        • At 5-year follow-up there was a significant difference:
          • In clinical signs of lymphedema between the groups:
            • 23% in ALND vs. 11% in AR:
              • There was greater than a 10% difference in arm size compared to the contralateral arm:
                • In 13% of the ALND arm and 5% of the AR arm
• The AMAROS study findings would suggest that axillary RT is an appropriate alternative to ALND in patients with a positive sentinel node:
  • However, the clinical characteristics of the AMAROS cohort are remarkably similar to the American College of Surgeons Oncology Group (ACOSOG) Z0011 cohort:
    • With 80% of AMAROS patients having:
      • A tumor less than 2 cm
    • 90% patients:
      • Receiving any systemic therapy
    • 95% of patients:
      • Having only 1 to 2 positive sentinel nodes
  • Patients in ACOSOG Z0011 treated with sentinel lymph node biopsy only demonstrated:
    • Similar 5-year rates of regional recurrence as the AMAROS patients receiving axillary RT:
      • 0.9% [ACOSOG Z0011] vs 1.2% [EORTC 10981 AMAROS axillary RT]):
        • Thus, while AMAROS indicates that sentinel node biopsy and nodal RT is an alternative to ALND:
          • It does not demonstrate that RT is necessary in all patients with a positive sentinel node:
            • Particularly in those treated with breast-conserving surgery
  • The decision to include axillary RT in patients with 1 to 2 positive sentinel nodes:
    • Should be tailored to the individual:
      • Taking into account other clinical factors which may place the patient at higher risk for locoregional recurrence

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• Multiple groups have attempted to define a favorable subgroup of women in whom the omission of adjuvant irradiation following a partial mastectomy is reasonable:The CALGB 9343 trial:Randomized women:Ages 70 years and older
  • • • With clinical stage I (T1,N0,M0) disease:To tamoxifen for 5 years versus tamoxifen plus whole-breast irradiationPatients with estrogen receptor-negative tumors were excluded
        • Most tumors were 2 cm or less
        • Surgical margins were required to be negative:Defined as the absence of tumor at the inked margin
    • Adjuvant whole-breast irradiation:Significantly reduced the risk of local or regional failure:From 10% to 2% at 10 yearsThere were no significant differences in:Distant disease-free survival or overall survival between the groups
  • The PRIME II trial:Enrolled 1326 patients:Ages 65 years and older
    • • T1 to T2
      • Node-negative tumors
      • Clear margins
    • Following breast-conserving surgery:Patients received endocrine therapyAnd were randomized to adjuvant radiation therapy or no further treatment
    • At 5 years:Those undergoing radiation:Demonstrated a reduction in local recurrence:4.1% vs 1.3%
      • • With no difference in survival
• Typical breast tangents:Without targeted nodal irradiation:Would be appropriate for a patient with pN0 disease
• Adjuvant irradiation reduces the risk of ipsilateral breast tumor recurrence regardless of whether the margins are positive:A positive margin:Significantly increases the risk of local failure despite irradiation

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• Following breast-conserving surgery (partial mastectomy, lumpectomy):
  • Adjuvant radiotherapy is recommended due to benefits in:
    • Local control
    • Potentially breast cancer mortality.
• The Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) meta-analysis:
  • Found that for patients undergoing breast-conserving surgery that are N0:
    • Radiation reduced:
      • The risk of any recurrence:
        • From 31% to 16%
      • Reduced breast cancer mortality:
        • From 21% to 17%
  • The EBCTCG also found that for patients undergoing mastectomy with 1 to 3 positive nodes:
    • Radiotherapy was associated with a:
      • Reduction in locoregional recurrence (LRR):
        • From 20% to 4%
      • Reduction in breast cancer mortality:
        • From 50% to 42%
  • Although many have interpreted the EBCTCG findings to mean:
    • All postmastectomy patients with 1 to 3 positive nodes should have postmastectomy radiation therapy (PMRT):
      • The patients enrolled in the trials in that meta-analysis were from a different era:
        • Making it difficult to know how relevant the findings are to patients who are diagnosed and treated by current standards:
          • The patients were enrolled between 1964 and 1986
          • Many of them did not receive systemic therapy:
            • The 64% who received chemotherapy were treated with:
              • Cyclophosphamide, methotrexate, and fluorouracil:
                • Which is inferior to modern regimens
          • Only 24% of patients were treated with tamoxifen
          • No patients received an aromatase inhibitor.
    • The benefit of PMRT diminishes:
      • As the risk of LRR diminishes
    • Patients with 1 to 3 positive nodes in the meta-analysis who were not treated with PMRT:
      • Had a 20% rate of LRR (vs. 4%):
        • But recurrence is significantly lower with modern systemic treatment:
          • Sharma et al. retrospectively reviewed patients:
            • Who had mastectomies between 1997 and 2002 and did not receive PMRT:
              • The 10-year rate of LRR in patients with 1 to 3 positive nodes:
                • Was only 4.3%:
                  • Compared to 20% in the EBCTCG meta-analysis
          • Another study of patients with 1 to 3 positive nodes:
            • Compared the risk of LRR:
              • Between two different eras, before and after the routine use of sentinel node biopsy, taxane therapy, and aromatase inhibitors:
                • Use of PMRT reduced the 15-year rate of LRR in the first era:
                  • From 14.5% to 6.1%
                • PMRT did not appear to benefit patients treated in the second era:
                  • With 5-year LRR rates of:
                    • 2.8% without PMRT
                    • 4.2% with PMRT
          • The NSABP B-28 study:
            • Randomized node-positive patients to:
              • Doxorubicin and cyclophosphamide versus doxorubicin and cyclophosphamide plus paclitaxel
            • Use of PMRT was not allowed in patients who were treated with mastectomy:
              • So the trial gives a good view of the risk of LRR for node-positive patients who are treated with mastectomy and relatively modern systemic therapy.
            • For patients with 1 to 3 positive nodes:
              • LRR at 10 years was:
                • 6% for patients with high-risk oncotype DX recurrence scores
                • 4.1% with intermediate-risk oncotype DX recurrence scores
                • 2.4% with low-risk oncotype DX recurrence scores
          • Lai et al. recently reviewed 293 mastectomy patients with T1 to T2 breast cancer and 1 to 3 positive lymph nodes:
            • All received anthracycline or taxane based chemotherapy and none received PMRT.
            • After stratifying patients according to:
              • Luminal A and B, luminal HER2, HER2, and triple-negative subtypes:
                • They found patients with triple-negative breast cancer to have the highest 5-year LRR when compared to all other subtypes:
                  • 10.6% vs 4.2%:
                    • P=0.05
              • Multivariate analysis found that the following factors significantly increased the risk of LRR:
                • Patients younger than age 40 years
                • Tumors larger than 3 cm
                • The presence of extensive intraductal components .
              • The authors concluded that:
                • Administering modern systemic therapy to early breast cancer patients not receiving PMRT:
                  • Significantly reduces the rate of LRR.
        • In view of the fact that PMRT significantly increased overall mortality in node-negative patients in the EBCTCG (47.6% vs 41.6%; rate ratio 1.23):
          • Caution should be taken in extrapolating the results to all patients with 1 to 3 positive nodes in the modern era.
    • The American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Surgical Oncology:
      • Recently released an updated consensus statement regarding the role of PMRT in women with 1 to 3 positive lymph nodes:
        • The consensus panel unanimously agreed that PMRT in this subset of patients (with T1 to T2 breast cancer with 1 to 3 positive lymph nodes):
          • Reduces local-regional failure
          • Any recurrence
          • Breast cancer mortality in patients.
        • They agreed that the decision for PMRT:
          • Should be made in a multidisciplinary setting
          • With the involvement of the patient and her wishes after she is presented with all available data.
        • The panel went on to acknowledge that in some subsets of patients:
          • The risk of local-regional failure may be so low that the:
            • Absolute benefit of PMRT is outweighed by its toxicities.
        • Further, even if axillary lymph node dissection is omitted in the setting of a positive lymph node:
          • PMRT should only be used if there is already significant evidence justifying the benefit of PMRT without knowing the status of any additional axillary nodes.
        • When given:
          • PMRT should include the:
            • Internal mammary, supraclavicular, and apical axillary nodes and the chest wall or reconstructed breast.
        • All patients with a positive axillary node after receipt of neoadjuvant chemotherapy should receive PMRT

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Retrospective Application of the 2015 American Thyroid Association Guidelines for Ultrasound Classification, Biopsy Indications, and Follow-up Imaging of Thyroid Nodules- Can Improved Reporting Decrease Testing?

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En Sociedad Quirúrgica S.C. nos hemos dado a la tarea de satisfacer las demandas de salud de la población de Ciudad de México y sus alrededores ofreciendo servicios integrales de prevención y tratamiento contra las enfermedades:

• Para lograr esto, contamos con la tecnología más avanzada en instalaciones y equipos, así como médicos profesionales especializados en diversas áreas de la medicina.

https://wordpress.com/view/rodrigoarrangoizmd.wordpress.com

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• Hyperthyroidism is approximately 10 times less common than hypothyroidism:
  • Symptoms and signs of thyrotoxicosis are listed in the Table.
• Hyperthyroid elderly patients often have more cardiac symptoms but less systemic manifestations of thyrotoxicosis.
• Patients with suspected hyperthyroid syndrome should be evaluated for signs or symptoms of:
  • Weight loss, heat intolerance, tremor, palpitations, anxiety, menstrual abnormalities, and new onset atrial fibrillation.
  • Evaluation should be considered, especially in patients with increased risk of hyperthyroidism, including:
    • A strong family history of thyroid dysfunction (hypothyroidism and hyperthyroidism)
    • Other autoimmune conditions
    • Long-standing goiter:
      • Especially after contrast or amiodarone administration.
• Routine screening of asymptomatic patients for hyperthyroidism is not recommended.

• Thyroid Tests in the Evaluation of Thyrotoxicosis
  • Measurement of serum TSH:
    • Is the most sensitive way to diagnose hyperthyroidism:
      • As it is always suppressed in primary hyperthyroidism.
    • Patients with hyperthyroidism will almost always have a serum TSH concentration of:
      • Less than 0.1 mIU/L and often under 0.05 mIU/L:
        • The use of a second-generation TSH assay with a functional sensitivity of < 0.2 mIU/L is sufficient for the diagnosis and management of hyperthyroidism.
    • Secondary hyperthyroidism from a:
      • Is extremely rare but should be suspected when the patient has symptoms suggestive of hyperthyroidism with an inappropriately “normal” TSH:
        • This rare clinical condition should be referred to an endocrinologist for further diagnosis and management.
  • Certain medical conditions (severe non-thyroidal illness, acute starvation, first-trimester pregnancy) and medications (glucocorticoids, dopamine), in addition to hypothalamic or pituitary disease:
    • Can result in low TSH:
      • If any of these conditions are suspected:
        • The help of a specialist is invaluable for determining the thyroid status of the patient.
  • An algorithm for ambulatory thyroid function testing for hyperthyroidism is shown:

• If the TSH is within normal limits:
  • The patient does not have hyperthyroidism:
    • No further workup is indicated:
      • Thyroid function tests should be repeated as clinically indicated.
• If the TSH is less than 0.3:
  • Thyroid hormone levels should be determined in addition to repeat measurement of TSH:
    • Small increases of the thyroid hormone level will cause:
      • A disproportionate suppression of TSH because of their inverse log-linear relationship.
    • The degree of hyperthyroidism cannot be assessed by second-generation assay TSH:
      • Because even very mild thyrotoxicosis will suppress the TSH to very low levels.
    • Although a third-generation assay can better differentiate between the degrees of hyperthyroidism:
      • Routine laboratory measurements of:
        • Total T4, THBR, FT4I, and total T3 can easily and accurately assess the degree of hyperthyroidism.
        • Measurement of total T3 is needed in the evaluation of hyperthyroidism:
          • Graves’ disease excretes a relatively high ratio of T3 / T4.
        • If serum TSH is less than 0.3 and FT4I and total T3 is low:
          • Hypothalamic or pituitary disease needs to be considered.

Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon / endocrine surgeon / surgical oncologist and is a member of Sociedad Quirúrgica S.C at the America British Cowdray Medical Center in Mexico City:

• He is an expert in the surgical management of thyroid diseases.

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

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• Merkel cell carcinoma (MCC) is the eponym for :
  • Primary cutaneous neuroendocrine carcinoma:
    • A dermal neoplasm with cytoplasmic, dense-core neuroendocrine granules and keratin filaments. 
    • MCC is a rare primary cutaneous neuroendocrine malignancy
• The incidence of MCC in the United States has recently been reported to have increased by an estimated annual percentage change of 8% from 1986 to 2001:
  • Approximately 1500 new cases were predicted by the American Cancer Society in the United States alone in 2008. 
• MCC is one of the few cancers found to be:
  • Associated with immune suppression
  • Polyomavirus has been shown to be integrated within the genome
• Merkel cell carcinoma (MCC) is an uncommon and aggressive cutaneous neoplasm that lacks distinguishing clinical features. 
• More than half of Merkel cell carcinomas (MCCs) occur in the head and neck of elderly people in areas of actinically damaged skin:
  • The most common site of occurrence is the periorbital region. 
• Merkel cell carcinoma (MCC) has a propensity to recur and to cause:
  • Local (25% to 30% of the cases) and distant metastases (30% to 35% of the cases). 
• Distant metastases indicate a condition that is nearly always fatal.
• Merkel cell carcinoma (MCC) is a deadly disease with a poor likelihood for survival:
  • Local recurrence occurs in:
    • 44% of patients:
      • Multiple local recurrences occur in 15% of patients. 
• These tumors appear as:
  • Rapidly growing, painless nodules in elderly caucasian individuals or in young adults with ectodermal dysplasia syndromes. 
  • Merkel cell carcinomas (MCCs) usually appear as:
    • Indurated plaques or violaceous (red or deep purple) solitary and dome-shaped nodules. 
    • The surface is typically shiny, with telangiectasias and possibly ulceration. 
    • Most tumors measure 0.7 cm to 1.2 cm in diameter.
    • Merkel cell carcinomas (MCCs) usually occur in sun-damaged skin. 
    • They are often found near other lesions of actinically damaged skin, including skin involved with:
      
      • Bowen disease, squamous cell carcinoma, basal cell carcinoma, solar keratoses, or lentigo maligna. 

• The mean age at presentation is 68 years:
  • No gender bias is observed. 
• Merkel cell carcinoma (MCC) has also been linked to:
  • Previous radiation exposure and B-cell lymphoma.
• The nonspecific characteristics of Merkel cell carcinoma (MCC) lead to a lengthy differential diagnosis that includes:
  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Keratoacanthoma
  • Amelanotic melanoma
  • Epidermal cysts
  • Lymphoma
  • Metastatic carcinoma of the skin
    • As a result:
      • Merkel cell carcinoma (MCC) is rarely diagnosed until biopsy is performed
  • Approximately 53% of Merkel cell carcinomas (MCCs) occur in the head and neck:

    • 35% occur in the extremities. 
    • In the head and neck:
      • 46% of tumors occur in the periorbital region
      • 29%, on the cheek
      • 18%, on the eyelid
      • 17%, on the forehead. 
      • Other sites in the head and neck include:
        • The lips (9%)
        • Ears (7%)
        • Nose and neck (5.4%)
        • Scalp (4%)
    • Tumors have also been reported in areas not exposed to sun, such as the:
      • Nasal cavity
      • Buccal mucosa
      • Gingiva
      • Hard palate
      • Postauricular skin

• Approximately 3% of patients with Merkel cell carcinoma (MCC) have tumors at several sites. 
• MCC is an aggressive tumor:
  • With an overall five-year survival of 40%
• Reported five year survival rates of local, nodal and metastatic disease are:
  • 64%, 39% and 18%, respectively
• Reported rates of regional lymph node involvement at the time of presentation vary from 10% to 45%:
  • Around 50% of patients with lymph node metastases harbor concurrent distant metastases:
    • Most often in the:
      • Liver, lung, brain, bone or skin
• MCC has high rates of local recurrence:
  • 25% to 30% of patients.
• MCC has high rates of distant metastasis:
  • 30% to 35% of patients.

Rodrigo Arrangoiz MS, MD, FACS a head and neck surgeon / endocrine surgeon / surgical oncologist and is a member of Sociedad Quirúrgica S.C at the America British Cowdray Medical Center in Mexico City:

• He is an expert in the management Merkel Cell Carcinoma.

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#Teacher

#Surgeon

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#ExpertoenTiroides

#ExpertoenParatiroides

#Paratiroides

#Hiperparatiroidismo

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#PapillaryThyroidCancer

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#CirugiaEndocrina

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http://www.cirugiatiroides.com

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http://www.hiperparatiroidismo.info

Rodrigo Arrangoiz MS, MD, FACS es especialista en Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina y Cirugía Oncológica compleja. Fue egresado como Médico General de la Universidad Anahuac Suma Cum Laude. Es miembro de Sociedad Quirúrgica S.C. que es el único grupo quirúrgico en México en donde todos los socios se entrenaron en las mejores instituciones académicas de los Estados Unidos de América. El Doctor Arrangoiz es experto en el manejo del Cáncer de Tiroides, Patología Quirúrgica de Tiroides, Hiperparatiroidismo Primario, Tumores de Cabeza y Cuello y Cáncer de Mama. 

Fue entrenado en las mejores instituciones académicas de los Estados Unidos y mantiene certificaciones por los Consejos de Cirugía General y Cirugía Oncológica en México y en los Estados Unidos de América. Su entrenamiento incluyó:

Cirugía General y Gastrointestinal – Michigan State University (2004 – 2010)

Cirugía Oncológica / Tumores de Cabeza y Cuello / Cirugía Endocrina – Fox Chase Cancer Center en Filadelfia (2010 al 2012)

Maestría en Ciencias (Clinical Research for Health Professionals) – Drexel University (Filadelfia) (2010 – 2012)

Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina (2014 al 2016) – IFHNOS / Memorial Sloan Kettering Cancer Center

Ha participado en múltiples cursos y congresos como Conferencista y Profesor Invitado, así mismo ha realizado diversas publicaciones y artículos sobre temas relacionados con su especialidad. Se encuentra certificado por el Consejo Mexicano de Cirugía General y el Consejo Mexicano de Oncología así como es de los pocos mexicanos certificado por, el AMERICAN BOARD OF SURGERY,  el cuál le faculta como cirujano con licencia en los EU. Es miembro de diversas asociaciones médicas como el American College of Surgeons, American Thyroid Association, American Society of Endocrine Surgeons, American Medical Association, American Society of Clinical Oncology, Association of Academic Surgeons, Society of Surgical Oncology,  The Society of Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons, y la American Society of Breast Surgeons, entre otras.

Es pionero en México de la cirugía minimamente invasiva radioguiada de paratiroides, técnica inventada por el Dr. James Norman, para el tratamiento del hiperparatiroidismo primario. Tiene múltiples publicaciones en revista internacionales sobre la patología del hiperparatiroidismo primario.

Gracias a esto el Dr. Rodrigo Arrangoiz es reconocido como uno de los mejores especialistas en Cirugía de Tumores de Cabeza y Cuello / Cirugía Endocrina / Cirugía Oncológica en México, además de ser galardonado como uno de los 50 mejores médicos de México en los Top Doctors Awards 2018.

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El Dr. Fernando Cordera González de Cosío es un experimentado Cirujano Oncólogo con formación en instituciones de alto prestigio como la Clínica Mayo Rochester, Fox Chase Cancer Center de Filadelfia, EITS en Francia y Memorial Sloan Kettering de Nueva York.

Su trayectoria se ha desarrollado principalmente en USA y México. Actualmente ejerce como Cirujano Oncólogo en el Centro Médico ABC y en el Hospital Ángeles Lomas.

Cuenta con más de 20 años de experiencia siendo experto en el tratamiento y diagnóstico del Cáncer de mama, Cáncer de Tiroides, Cirugía Oncológica cabeza y cuello, Melanoma, Sarcoma, entre otros.

Asimismo, es Presidente de la Práctica Médica Grupal de Cirugía Oncológica del Centro Médico ABC en la Ciudad de México.
Está Certificado por el American Board of Surgery, el Consejo Mexicano de Cirugía General y el Consejo Mexicano de Oncología.

Su aportación a la investigación y formación de acuerdo a su especialidad es extensa; cuenta con más de 10 años de experiencia en intervenciones como profesor y ponente en cursos, congresos y simposios a nivel nacional e internacional.

Ha publicado más de 45 artículos médicos a nivel nacional e internacional. En el 2004 fue galardonado con el Kaare K. Nygaard Award de la Clínica Mayo para Outstanding Surgical Research Achievement y en el 2009 recibió otro premio, el Prize to the Medical Achievement for a Better Life por la Organización Internacional para la Capacitación e Investigación Médica.

Gracias a esto el Dr. González de Cosío es reconocido como uno de los mejores especialistas en Cirugía Oncológica de la Ciudad de México.

http://www.sociedadquirurgica.com