Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

El destacado Dr. David Caba Molina es un especialista en Cirugía Oncológica egresado de la Universidad Anáhuac como Médico Cirujano con honores, posteriormente concluyó la especialidad en Nutrición Clínica dentro de la misma institución. Cuenta con un Postdoctorado en Inmunología realizado en la Universidad de Pittsburgh, donde al miso tiempo realiza una Maestría en Salud Pública y Epidemiología, posteriormente realizó la Especialidad en Cirugía General y Gastrointestinal en la Universidad de  Dartmouth en el  Dartmouth-Hitchcock Medical Center y la Subespecialidad en Cirugía Oncológica en la Universidad de Chicago así como fellowship en Cirugía Laparoscópica y Robótica en la Universidad de Pittsburgh.

Su amplia experiencia de más de 10 años le ha permitido pertenecer a diversas instituciones de prestigio como la Universidad de Chicago, Cleveland Clinic, Children’s Hospital Los Ángeles y el Hospital ABC Santa Fe donde actualmente se encuentra dando consulta. Es experto en Cirugía Oncológica, Cirugía Gastrointestinal y Mínimamente Invasiva/Robótica, Cáncer de Colon y Recto, Páncreas, Hígado y Vías Biliares, Mama y Piel, entre otros.

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 asi como es de los pocos mexicanos en tener 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 Board of Surgery, Society of Surgical Oncology (miembro de diversos comités) el American College of Surgeons , American Hepato-Pancreato-Biliary Association y la American Society of Breast Surgeons, entre otras.

El Dr. David Caba es fundador de V.I.D.A Contra el Cáncer, un programa destinado a ofrecer la prevención, diagnóstico y tratamiento oportuno para cada persona de acuerdo a sus necesidades; ofreciendo un seguimiento personalizado, guiado y que coordinado de la mano de un equipo de diversos expertos especializados en distintas áreas del tema, mantiene una comunicación constante para brindarle al paciente un escrutinio especializado.

Gracias a esto el Dr. Caba Molina es reconocido como uno de los mejores especialistas en Cirugía Oncológica y Cirugia Gastrointestinal de la Ciudad de México.

http://www.sociedadquirurgica.com

• Accelerated partial breast irradiation includes multiple techniques such as:
  • Interstitial brachytherapy
  • Applicator brachytherapy
  • External beam radiation therapy.
• The Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) trial:
  • Randomized 1184 patients with:
    • Low-risk invasive carcinoma or ductal carcinoma in situ (DCIS) treated with breast-conserving surgery to either whole-breast irradiation (WBI) or APBI using multicatheter brachytherapy:
      • The cumulative incidence of local recurrence at 5 years was:
        • 1.44% with APBI
        • 0.92% with WBI
• The Florence trial;
  • Randomized 520 patients to either WBI or APBI with intensity-modulated radiation therapy:
    • With a mean follow-up of 5 years:
      • The rate of local recurrence was:
        • 1.5% in both arms
• The American Society of Breast Surgeons’ MammoSite Registry found:
  • 5-year rates of local recurrence were less than 4%.
• An older randomized trial from Hungary using interstitial APBI and electrons:
  • 5-year local recurrence rate of 4.7%.

• It is important to recognize that these outcomes are likely due to:
  • The highly selected, low-risk patient populations included in many of the APBI trials as evidenced by the tables / guidelines.
    • Patients tend to be:
      • Postmenopausal
      • Tumors less than 3 cm, without DCIS
      • Node negative
      • ER-positive

Table: ASTRO Consensus Guidelines for Accelerated Partial Breast Irradiation

Table: American Brachytherapy Society Guidelinesfor Accelerated Partial Breast Irradiation

Table: GEC-ESTRO Guidelines for Accelerated Partial Breast Irradiation

Table: American Society of Breast Surgeons Accelerated Partial Breast Irradiation Position Statement

Additional follow-up is necessary and ongoing

Rodrigo Arrangoiz MS, MD, FACS a 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 of breast cancer.

  • If you have any questions about Partial Breast Irriadation  please fill free to contact Dr. Arrangoiz.

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

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

http://www.sociedadquirurigca.com

• Several guidelines have been published to guide decision making for treating select patients with partial breast irradiation off protocol:
  • The American Society for Radiation Oncology consensus statement (Table 1) considers patients to be “suitable” if the following characteristics are met:
    • Age 50 years and older
    • BRCA 1 / 2 wild-type
    • Tumor size 2 cm or less:
      • Multifocality is allowed:
        • Provided the total size is 2 cm or less
    • ER-positive
    • Invasive ductal (or other favorable) histology
    • Surgical margins 2 mm or greater
    • Absence of lymph-vascular invasion (LVI)
    • Pure ductal carcinoma in situ (DCIS) meeting trial criteria
    • Absence of an extensive intraductal component
    • Absence of lymph node involvement
  • “Unsuitable” characteristics included:
    • Age younger than 40 years
    • Presence of a BRCA 1 / 2 deleterious mutation
    • Tumor size greater than 3 cm (including multiple foci)
    • Multicentricity
    • Positive surgical margins
    • Extensive LVI
    • Lymph node involvement (or not assessed).
  • “Cautionary” characteristics:
    • Fall between suitable and unsuitable.

Table: ASTRO Consensus Guidelines for Accelerated Partial Breast Irradiation

• The recent American Brachytherapy Society (Table) defined acceptable criteria for partial breast irradiation as:
  • Age 50 years and older
  • Size ≤ 3 cm
  • All invasive subtypes and pure DCIS
  • ER-positive or negative
  • Negative surgical margins (“on ink”)
  • Negative lymph nodes
  • Absence of LVI.

Table: American Brachytherapy Society Guidelinesfor Accelerated Partial Breast Irradiation

• The Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) consensus statement (Table) classifies patients into “low risk” and good candidates for partial breast irradiation:
  • Patients age 50 years and older
  • ER-negative (or positive) disease
  • Tumors 3 cm

Table: GEC-ESTRO Guidelines for Accelerated Partial Breast Irradiation

• The American Society of Breast Surgeons current guidelines (Table) include:
  • Age 45 years and older for invasive tumors
  • Age 50 years and older for DCIS
  • Tumor size less than 3 cm
  • Negative margins
  • Negative lymph

Table: American Society of Breast Surgeons Accelerated Partial Breast Irradiation Position Statement

Rodrigo Arrangoiz MS, MD, FACS a 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 of breast cancer.

  • If you have any questions about Partial Breast Irriadation  please fill free to contact Dr. Arrangoiz.

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

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

http://www.sociedadquirurigca.com

• Studies continue to evaluate for a subset of patients with DCIS who may not require adjuvant radiation therapy following breast-conserving surgery:In a prospective nonrandomized trial, ECOG E5194:Evaluated two cohorts of patients:Group 1 had ≤ 2.5-cm low- and intermediate-grade DCIS
  • • • Group 2 had ≤ 1 cm high-grade DCISBoth cohorts had margins of at least 3 mm and did not receive adjuvant radiation therapyTamoxifen was given to 30% of patients:Local recurrence at 5 years was: 6.1% in group 1
        • • • 15.3% in group 2
          • The rate of local recurrence at 12 years was: 14.4% in group 124.6% in group 2. There was no plateau in the incidence of local recurrence over time.
  • The Radiation Therapy Oncology Group (RTOG) 9804 study:Randomized patients with < 2.5 cm low- and intermediate-grade DCIS and margins ≥3 mm to adjuvant radiation or no radiation therapy following partial mastectomy:Seven-year outcomes demonstrated an increase in local recurrence with the omission of radiation therapy:6.7% vs 0.9%
    • • Tamoxifen was given to 62% of patients.
  • Similar outcomes were also noted in the Dana Farber prospective trial of excision alone

Rodrigo Arrangoiz MS, MD, FACS a 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 of breast cancer.

  • If you have any questions about DCIS and radiation therapy please fill free to contact Dr. Arrangoiz.

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

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

http://www.sociedadquirurigca.com

• Introduction:
  • The Bethesda System for Reporting Thyroid Cytopathology is the most widely used classification system for the reporting of thyroid fine-needle aspiration cytology (FNAC) specimens. However, the “atypical” category (“atypia of undetermined significance” [AUS] or “follicular lesion of undetermined significance” [FLUS]) continues to cause diagnostic and therapeutic dilemmas. The objectives of this study were to describe the differential malignancy rates of FNACs diagnosed as AUS/FLUS based on nuclear or architectural atypia and to assess the significance of demographic and ultrasonographic features in predicting malignancy in this category.
• Methods:
  • A retrospective review was performed of all thyroid FNACs between 2008 and 2014 that were diagnosed as AUS/FLUS at a tertiary referral center in Singapore. Patient demographics, preoperative ultrasonographic features, and follow-up data were collected and correlated with the final histopathologic diagnosis in resected cases.
• Results:
  • In total, 309 thyroid nodules were diagnosed as AUS/FLUS, and 137 (44%) were surgically excised. Final histology yielded 37 (27%) malignancies. The malignancy rate for nodules that featured nuclear atypia was significantly higher at 36.8% than the rate for nodules that had only architectural atypia at 14.7% (P < .01). After up to 3 repeat FNACs, 67.1% of cases had a more definitive diagnosis. The only predictive sonographic finding for malignancy was irregular margins (P < .01).
• Cconclusions:
  • The disparity between malignancy risks within the Bethesda “atypical” category suggests that cytologic (nuclear) atypia is significantly more predictive of malignancy than architectural atypia. This supports the substratification of patients according to risk and a corresponding management approach within this category. A sonographic finding of irregular margins is also predictive for malignancy. Cancer Cytopathol 2017;125:245-256. © 2016 American Cancer Society.

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 thyroid cancer / 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

#Arrangoiz#Teacher

#Surgeon

#Cirujano

#ThyroidExpert

#ThyroidSurgeon

#CirujanodeTiroides

#ExpertoenTiroides

#ExpertoenParatiroides

#Paratiroides

#Hiperparatiroidismo

#CancerdeTiroides

#ThyroidCancer

#PapillaryThyroidCancer

#SurgicalOncologist

#CirujanoOncologo

#CancerSurgeon

#CirujanodeCancer

#HeadandNeckSurgeon

#CirugiaEndocrina

#EndocrineSurgery

#CirujanodeCabezayCuello

http://www.cirugiatiroides.com

http://www.sociedadquirurigca.com

http://www.hiperparatiroidismo.info

• The University of Southern California / Van Nuys Prognostic Index (USC / VNPI):
  • Estimates which patients with DCIS can be managed by:
    • Excision alone
    • Excision plus radiation
    • Versus 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:
    • Size of the DCIS
    • Margin width
  • A score from 3 to 9 was derived:
    • By assigning 1, 2, or 3 points to each of the three variables
       

• Patients who scored 3 or 4:
  • Derived little benefit from radiation
• Those who scored 5, 6, or 7:
  • Derived substantial benefit from radiation
• Those who scored 8 or 9:
  • Had a high risk of relapse despite radiation:
    • Best managed by mastectomy

• In 2003:
  • The name became the University of Southern California / Van Nuys Prognostic Index:
    • And a 4th variable was added to the score:
      • Patients who were younger than age 40 years:
        • Received a score of 3
      • Patients ages 40 to 60 years:
        • Received a 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 5 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
      • 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
    • Patients who score 9 and have margins ≥ 5 mm.
  • Mastectomy is suggested for:
    • Patients who score 8 and have margins < 3 mm
    • Patients who score 9 and have margins < 5 mm
    • All patients who score 10, 11, or 12:
      • To keep the local recurrence rate less than 20% at 12 years

• A combination of the North Central Cancer Treatment Group (NCCTG) N9831 trial and the National Adjuvant Breast and Bowel Project (NSABP) B-31 clinical trials:
  • Showed a:
    • 40% improvement in disease-free survival
    • 37% improvement in overall survival:
      • With the addition of a year of trastuzumab to doxorubicin, cyclophosphamide, and paclitaxel chemotherapy.
        • Improvements in disease-free survival and overall survival were observed in all patients:
          • Independent of hormone receptor status and extent of nodal involvement.
• The duration of trastuzumab therapy has been debated:
  • The Herceptin Adjuvant (HERA) trial:
    • Evaluated 1 year of therapy versus 2 years of therapy:
      • It did not show a significant difference in disease-free survival and overall survival between the two groups.
  • The Protocol of Herceptin Adjuvant with Reduced Exposure (PHARE) trial:
    • A Randomized Comparison of 6 Months vs 12 Months in All Women Receiving Adjuvant Herceptin (PHARE) trial:
      • Evaluated 6 months of trastuzumab compared to 12 months:
        • At 3.5-year follow-up:
          • The shorter trastuzumab course did not have a worse survival outcome compared to the 12-month course.
  • A Cochrane meta-analysis of eight trials:
    • Including more than 11,900 patients with early and locally advanced HER2-positive breast cancer:
      • Found improvements in disease-free survival (HR 0.66) and overall survival (HR 0.60) with chemotherapy plus trastuzumab versus chemotherapy alone or trastuzumab alone regimens.
  • Two small trials administering trastuzumab for less than six months:
    • Did not differ from trials with longer treatment duration and had less trastuzumab-associated toxicities:
      • However, given these studies’ small cohort size and short follow-up:
        • 12 months of trastuzumab treatment remains standard therapy.
• References:
  • Perez EA, Romond EH, Suman VJ, et al. Trastuzumab plus adjuvant chemotherapy for human epidermal growth factor receptor 2-positive breast cancer: planned joint analysis of overall survival from NSABP B-31 and NCCTG N9831. J Clin Oncol. 2014;32(33):3744-3752.
  • Goldhirsch A, Gelber RD, Piccart-Gebhart MJ, et al. 2 years versus 1 year of adjuvant trastuzumab for HER2-positive breast cancer (HERA): an open-label, randomised controlled trial. Lancet. 2013;382(9897):1021-1028.
  • Pivot X, Romieu G, Debled M, et al. 6 months versus 12 months of adjuvant trastuzumab for patients with HER2-positive early breast cancer (PHARE): a randomised phase 3 trial. Lancet Oncol. 2013;14(8):741-748.
  • Moja L, Tagliabue L, Balduzzi S, et al. Trastuzumab containing regimens for early breast cancer. Cochrane Database Syst Rev. 2012;4:CD006243.

• Data from the Early Breast Cancer Trialists’ Collaborative Group meta-analysis of adjuvant systemic therapy trials begun in or before 1995 show:
  • A 30% relative reduction in breast cancer-related mortality associated with adjuvant hormonal therapy and with adjuvant chemotherapy.
  • Reduced rates of:
    • Ipsilateral local recurrence
    • Contralateral cancers
    • Distant metastases
      • These suggests there is eradication of occult residual disease in many patients.
  • The absolute survival benefit of adjuvant therapy is greater in node-positive than in node-negative patients.
  • The absolute survival benefit of chemotherapy is greater for younger (<50 years of age) than for older women (50 to 69 years of age).

• The definition of menopause is defined as the permanent cessation of menses.
  • The use of the term in breast cancer clinical trials has resulted in a variety of definitions:
    • Including a profound and permanent decrease in ovarian estrogen synthesis.
• According to the NCCN guidelines, reasonable criteria for determining menopause includes the following:
  • History of bilateral oophorectomy
  • Age greater than or equal to 60
  • Age less than 60 and:
    • Amenorrheic for 12 or more months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression and follicle-stimulating hormone (FSH) and estradiol in the postmenopausal range
  • If taking tamoxifen or toremifene, and age less than 60:
    • Then FSH and plasma estradiol level in postmenopausal ranges
• It is not possible to assign menopausal status to women who are receiving an LHRH agonist or antagonist.
• In women premenopausal at the beginning of adjuvant chemotherapy, amenorrhea is not a reliable indicator of menopausal status, as ovarian function may still be intact or resume despite anovulation / amenorrhea after chemotherapy:
  • For these women with therapy-induced amenorrhea:
    • Oophorectomy or serial measurement of FSH and / or estradiol are needed to ensure postmenopausal status if the use of  is being considered as endocrine therapy.