Early Local Therapy for the Primary Site in De Novo Stage IV Breast Cancer: Results of a Randomized Clinical Trial (EA2108)

PURPOSE Distant metastases are present in 6% or more of patients with newly diagnosed breast cancer. In this context, locoregional therapy for the intact primary tumor has been hypothesized to improve overall survival (OS), but clinical trials have reported conflicting results. METHODS Women presenting with metastatic breast cancer and an intact primary tumor received systemic therapy for 4-8 months; if no disease progression occurred, they were randomly assigned to locoregional therapy for the primary site (surgery and radiotherapy per standards for nonmetastatic disease) or continuing sysmetic therapy. The primary end point was OS; locoregional control and quality of life were secondary end points. The trial design provided 85% power to detect a 19.3% absolute difference in the 3-year OS rate in randomly assigned patients. The stratified log-rank test and Cox proportional hazards model were used to compare OS between arms. Cumulative incidence of locoregional progression was compared using Gray's test. Quality-of-life assessment used standard instruments. RESULTS Of 390 participants enrolled, 256 were randomly assigned: 131 to continued systemic therapy and 125 to early locoregional therapy. The 3-year OS was 67.9% without and 68.4% with early locoregional therapy (hazard ratio = 1.11; 90% CI, 0.82 to 1.52; P = .57). The median OS was 53.1 months (95% CI, 47.9 to not estimable) in the systemic therapy arm and 54.9 months (95% CI, 46.7 to not estimable) in the locoregional therapy arm. Locoregional progression was less frequent in those randomly assigned to locoregional therapy (3-year rate: 16.3% v 39.8%; P < .001). Quality-of-life measures were largely similar between arms. CONCLUSION Early locoregional therapy for the primary site did not improve survival in patients presenting with metastatic breast cancer. Although it was associated with improved locoregional control, this had no overall impact on quality of life.

Postoperative external beam radiotherapy for locoregional control in iodine refractory differentiated thyroid cancer

Background: The role of postoperative external beam radiotherapy (EBRT) in patients with residual iodine refractory differentiated thyroid cancer (IR-DTC) is still inconclusive. The aim of this retrospective study was to evaluate locoregional control (LRC) and overall survival (OS), and potential side effects after postoperative EBRT for both microscopic and macroscopic non-radically resected locally advanced IR-DTC. Methods: Between 1990 and 2016, 49 patients with locally advanced IR-DTC received EBRT for microscopic (R1; n=28) or macroscopic (R2; n=21) locoregional residual disease. For more insight into the added effect of EBRT we performed an intra-patient sub-analysis in 32 patients who had undergone more than one surgical intervention, comparing LRC after primary, curative-intended surgery with LRC after repeated surgery plus EBRT. To estimate LRC and OS we used Kaplan Meier curves. From 2007 onwards, we prospectively recorded toxicity data in our head and neck cancer database (n=10). Results: LRC rates five years after EBRT were higher for R1 (84.3%) than for R2 (44.9%) residual disease (p=0.016). The five-year OS rate after EBRT was 72.1% for R1 and 33.1% for R2 disease (p=0.003). In the intra-patient analysis (n=32) LRC rates were 6.3% five years after only initial surgery, and 77.9% after repeated surgery with EBRT (p=<0.001). Acute toxicity was limited to grade I and II xerostomia, mucositis, and hoarseness; only one patient developed late grade III dysphagia. Conclusions: Postoperative EBRT is associated with long-lasting locoregional control and overall survival with acceptable toxicity in patients with locally advanced IR-DTC, especially in microscopic residual disease.

An Atypical Presentation of Sinonasal Tract Alveolar Rhabdomyosarcoma in a Young Male Patient Submitted to Multimodality Treatment

Rhabdomyosarcoma (RMS), a malignant tumor derived from the neoplastic proliferation of striated skeletal muscle cells, is the most common pediatric soft tissue sarcoma. Its treatment is mainly based on neoadjuvant chemotherapy (QT+), surgical resection, and adjuvant radiotherapy (RT+). RT+ has shown satisfactory results for locoregional control of the disease, in spite of promoting local side effects. The present case report was aimed at describing the clinical and therapeutic characteristics and the management of complications resulting from multimodal therapy in a patient with an atypical presentation of RMS in the sinonasal tract. A 20-year-old Afro-descendant man complained of an expansive tumor lesion, with left eye proptosis that reduced visual acuity and caused severe regional pain. Imaging analysis showed an extensive and infiltrative lesion in the periorbital region, sinonasal tract, left maxilla, and orbital roof. According to the histopathological analysis, the diagnosis was established corresponding to parameningeal alveolar RMS that was unresectable. Treatment was initiated with three cycles of QT+ which showed partial response and later RT+. After completing half of the RT+ sessions, the patient showed a complete response with reduction in tumor volume and improvement in pain and local conditions. Side effects such as alopecia and dermatological changes induced by radiation were observed. Moreover, painful erythematous areas were observed in the region of the hard and soft palate, uvula, and oropharynx, compatible with Grade 2 mucositis lesions. After the cytological swab test, some of them were diagnosed as herpes simplex lesions; thickening and decrease in salivary flow were also found. A local drug therapy approach was instituted, and photobiomodulation was performed to manage oral complications. RT+ was shown to be effective in locoregional control of the disease; however, the early management of its undesirable effects on the surrounding tissues was required.

Adjuvant Radiation Does Not Affect Locoregional Control Following Resection of Melanoma Satellitosis or In-Transit Disease

Background This study evaluates the association of adjuvant radiation therapy (RT) with improved locoregional (LR) recurrence for resected melanoma satellitosis and in-transit disease (ITD). Materials and Methods Data were collected retrospectively for resected melanoma satellitosis/ITD from 1996 to 2017. Results 99 patients were identified. 20 patients (20.2%) received adjuvant RT while 79 (79.8%) did not. Mean follow-up in the RT group was 4.3 years and 4.7 years in the non-RT group. 80% of patients who underwent RT suffered a complication, most commonly dermatitis. Locoregional recurrence occurred in 9 patients (45%) treated with adjuvant RT and 30 patients (38%) in the non-RT group ( P = 0.805). Median LR-DFS was 5.8 years in the RT group and 9.5 years in the non-RT group ( P = 0.604). On multivariable analysis, having a close or positive margin was the only independent predictor of LR-DFS (HR 3.8 95% CI 1.7-8.7). In-transit disease was associated with improved overall survival when compared to satellitosis (HR 0.260, 95% CI 0.08-0.82). Discussion The use of adjuvant RT is not associated with improved locoregional control in resected melanoma satellitosis or ITD. Close or positive margin was the only treatment-related factor associated with decreased LR-DFS after surgical resection of satellitosis/ITD.

THYROID CARCINOSARCOMA: A CASE REPORT

Thyroid carcinosarcoma is a rare and aggressive neoplasm of the thyroid gland, with a recurrent character and a bad prognosis, despite the introduction of a multimodal treatment that is not yet codied. We present a case of thyroid carcinosarcoma, number 32 described in the literature, in a 64-year-old man complicating a multinodular goiter that had been evolving for 10 years and which relapsed 6 months after total thyroidectomy. On the anatomopathological level, thyroid sarcoma was mentioned before the microscopic aspect of the tumor and conrmed by the immune histochemical study. The recurrence was massive requiring the use of tumor reduction surgery that allowed the avoidance of a tracheotomy and a good locoregional control of the tumor. And yet the patient died of lung metastases 4 months later.