A recent Cochrane review of somatostatin analogues (SSAs) for pancreatic surgery concluded that SSAs reduce perioperative complications but do not reduce perioperative mortality. They do shorten hospital stay.  Based on the current available evidence, somatostatin and its analogues are recommended for routine use in patients undergoing pancreatic resection for malignancy. There is currently no evidence to support their routine use in pancreatic surgeries performed for other indications.

In a meta-analysis by Zeng et al., the conclusion was that the use of somatostatin and its analogues does not significantly reduce postoperative complications after pancreaticoduodenectomy.

A recent review on surgicalcriticalcare.net concluded that : “There is insufficient evidence to conclude that octreotide reduces fistula closure rates or time to closure. Octreotide therapy
may be useful when there is reason to believe that a reduction in fistula output would facilitate patient management. However, its use for the purpose of fistula closure or the use of doses greater than those evaluated in clinical trails cannot be recommended.”

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The impact of CT-based follow-up for the detection of resectable disease recurrence was addressed in a review of 705 patients who underwent resection of isolated colorectal cancer liver metastases at a single institution over a 14-year period. All were followed with a similar surveillance protocol, which included outpatient clinical examinations at 3, 6, 12, 18, and 24 months, and annually thereafter, with measurement of CEA and CA 19-9 levels at each visit. In addition, all patients had CT of the thorax, abdomen and pelvis every three months for the first two years, at six monthly intervals for three more years, then annually from year six to ten.

Of the 444 patients with a recurrence diagnosed on a surveillance CT, 404 were detected within two years. The site of recurrent disease was liver only in 36 percent, outside of the liver only in 38 percent, and both in the liver and in other organs in 26 percent. The authors did not report how many recurrences were detected by serum tumor markers versus CT scans.

In total, recurrent disease was treated surgically in 124 patients. At every time point (within one year of original surgery, one to two years, beyond two years), those patients treated by liver and/or lung resection had significantly better median survival than did those who received palliative chemotherapy alone. The mean number of scans performed per resectable recurrence was 35.3, and the cost per life-year gained was £2883, a value that compares favorably to other cost-effectiveness ratios that are considered acceptable in the US and elsewhere. UPTODate recommends the following surveillance strategy for patients with stage IV disease who are rendered surgically NED (no evidence of disease):

CEA every three months for two years, then every six months for three to five years

• CT of the chest/abdomen and pelvis every three to six months for two years, then every 6 to 12 months up to a total of five years
• Colonoscopy in one year; if no advanced adenoma repeat in three years, then every five years; if advanced adenoma is found, repeat in one year

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The role of chemotherapy and radiation for advanced head and neck cancer has evolved considerably over the last 20 years. Several studies, most prominently the Radiation Therapy Oncology Group (RTOG) study 91-11, which was undertaken in collaboration with the Head and Neck Intergroup and published in 2003, established the use of concurrent chemotherapy with radiation as the superior nonsurgical, larynx preservation strategy. The RTOG study demonstrated that patients with advanced laryngeal cancer receiving concurrent cisplatin and radiation had a better larynx preservation rate (84%) at a median follow-up of 3.8 years compared to that afforded either by radiation alone or by induction cisplatin/fluorouracil followed radiation (rates of 67% and 72%, respectively). This was confirmed by other studies.

Two large, randomized trials — the Veterans Affairs Laryngeal Cancer Study Group trial and a phase 3 trial conducted by the European Organization for Research and Treatment of Cancer (EORTC) — have demonstrated the benefit of induction chemotherapy with PF (100 mg/m2 of cisplatin on day 1 and 1000 mg/m2 of 5-FU by continuous infusion on days 1-5) with respect to organ preservation. In these trials, overall survival rates were similar in patients receiving either induction PF chemotherapy and radiation or surgery and radiation therapy. In patients with larger tumors that could not resected, PF induction therapy has been shown to produce long-term survival benefits, with overall survival times in a subset of inoperable patients receiving chemotherapy of 21% at 5 years and 16% at 10 years compared with 8% and 6%, respectively, in patients not receiving chemotherapy. In a phase 3 trial of neoadjuvant chemotherapy in patients with moth and pharyngeal cancer conducted by the French Groupe d’Etude des Tumeurs de la Tete et du Cou (GETTEC), the median overall survival time for patients with both resectable and unresectable tumors was 5.1 years when PF induction chemotherapy was followed by locoregional therapy vs 3.3 years for those who did not receive PF induction chemotherapy (P = .03).

Nonetheless, there have been strong and persistent undercurrents of interest in farther improving the induction chemotherapy for patients with locoregionally advanced head and neck cancer.  The standard neoadjuvant chemotherapy regimen has consisted of a platinum agent and 5-fluorouracil (5-FU), a regimen known as PF. More recently, the addition of a taxane such as docetaxel (or, less commonly, paclitaxel) to the PF regimen (a triple combination known as TPF) is emerging as a more effective and less toxic standard for induction chemotherapy. The potential for induction chemotherapy before concurrent treatment to improve survival, through patient selection or better disease control such as by reducing distant metastases, as well as to enhance larynx preservation while decreasing the morbidity of treatment, is of great interest. However, more data are needed before such sequential approaches, or as appears in this case, chemotherapy alone, can be promulgated as new treatment standards. The VA guidelines state: “Treatment options for stage III and IV (laryngela) patients include surgery plus postoperative radiation and induction chemotherapy followed by radiation”.
NCCN recommends both options, with induction or without but only lists the TPF regimen for induction.

In regard to using Taxol and carboplatin instead of TPF, a number of phase II trials suggest that it is a well tolerated and effective approach but the phase III trial did not confirm them. The Cancer and Leukemia Group B (CALGB) initially evaluated the combination of induction carboplatin and paclitaxel for two cycles followed by low-dose weekly concurrent chemotherapy with RT. They found a median survival time of 15.1 months, and the trial demonstrated the feasibility of this regimen]. A phase III trial, CALGB 39801, was then completed, in which all patients received low-dose weekly carboplatin and paclitaxel with concurrent RT to 66 Gy and were randomized to two cycles of induction chemotherapy. Both arms of that trial showed disappointing results, with a median survival time of 11–13 months, demonstrating that this was not an efficacious regimen.

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One of these new situations is the use of MRI to decide between a mastectomy and the lumpectomy. In the presence of DCIS lumpectomy also leaves behind disease, requiring re-resections. It might, therefore, be useful to know about the presence of the CAS before lumpectomy. Some physicians adopt the strategy of using MRI to identify DCIS and to eschew lumpectomy based on results. The reasoning is that if widespread DCIS is found, a mastectomy would be performed rather than a lumpectomy. This strategy has not been formally evaluated and is not currently recommended by guidelines. A clinical trial is ongoing: Breast MRI as a Preoperative Tool for DCIS, NCT00605982. The purpose of this study is to see how often MRI can find other areas of cancer in women with one area of breast cancer, and to determine how having the MRI test affects their treatment.  The study also aims to follow women who enter the study over a 10-year period to determine how often the breast cancer comes back.

American College of radiology (ACR) says: ” Invasive carcinoma and ductal cardinoma in situ (DCIS) – Breast MRI may be useful to determine the extent of disease and the presence of multifocality and multicentricity in patients with invasive carcinoma and ductal carcinoma in situ (DCIS). MRI can detect occult disease up to 15% to 30% of the time in the breast containing the index malignancy. MRI determines the extent of disease more accurately than standard mammography and physical examination in many patients. It remains to be conclusively shown that this alters recurrence rates relative to modern surgery, radiation, and systemic therapy.”

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