Cancer Treatment Today » Surgery in Oncology

Octreotide for pancreatic fistula – pro

M Levin, MD — Sun, 24 Feb 2013 04:31:03 +0000

The principal effects of octreotide include inhibition of growth hormone (GH), glucagon, and insulin. However, there are other effects that have been attemtped to be exploited to therapeutic ends, including to help heal pancreatic and gastreointeistinal fistulas. Among themare reduction of splanchnic blood flow, and inhibition of release of several gastrointestinal hormones, including serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide.

Graham et al. conducted a prospective study of prophylactic long-acting octreotide to prevent postoperative pancreatic fistula (POPF) in high-risk patients undergoing
pancreaticoduodenectomy. The authors concluded that prophylactic use of depot octreotide in high-risk patients does not result in reduced incidence of POPF.

A recent Cochrane review of somatostatin analogues (SSAs) for pancreatic surgery concluded that SSAs reduce perioperative complications but do not reduce perioperative mortality. In those undergoing pancreatic surgery for malignancy, they shorten hospital stay. Further adequately powered trials with low risk of bias are necessary. 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., eight studies were reviewed to evaluate the efficacy of somatostatin and its analogues in the prevention of postoperative complications after
pancreaticoduodenectomy. The use of somatostatin or its analogues did not significantly benefit for reducing the incidence of pancreatic fistula (odds ratio [OR] 95% confidence interval [CI], 0.64-1.37; p=0.73), total pancreas-specific postoperative complications (OR 95% CI, 0.63-1.42; p=0.79), delayed gastric emptying (OR 95% CI, 0.50-1.78; p=0.86), total complication (OR 95% CI, 0.73-1.70; p=0.61), mortality (OR 95% CI, 0.59-7.72; p=0.97) and length of postoperative hospital stay (weighted mean difference 95% CI, -7.74 to 4.47; p=0.60). The use of somatostatin and its analogues does not significantly reduce postoperative complications after pancreaticoduodenectomy.

Several clinical trials have evaluated the use of octreotide to prevent the development of pancreatic fistula after pancreatic surgery with conflicting recommendations. A recent review on surgicalcreiticalcare.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.”

Graham JA, Johnson LB, Haddad N, et al. A prospective study of prophylactic long-acting
octreotide in high-risk patients undergoing pancreatticoduodenectomy. The American Journal of
Surgery. 2011;201(4):481-485.

Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin analogues for pancreatic surgery.
Cochrane Database of Systematic Reviews 2010, Issue 2.

Zeng Q, Zhang Q, Han S, et al. Efficacy of somatostatin and its analogues in prevention of
postoperative complications after pancreaticoduodenectomy: a meta-analysis of randomized
controlled trials. Pancreas. 2008 Jan;36(1):18-25.

OCTREOTIDE IN THE PREVENTION AND TREATMENT OF
GASTROINTESTINAL AND PANCREATIC FISTULAS – http://www.surgicalcriticalcare.net/Guidelines/octreotide%202009.pdf

For Lay version see here

Octreotide fir angiodyslpasia and for angiodysplasis and GI bleeding

Electrical stimulation for bone fusion – pro

M Levin, MD — Mon, 17 Sep 2012 16:51:57 +0000

Data from uncontrolled studies of patients with failed spinal fusion suggests that noninvasive electrical stimulation results in a significantly higher fusion rate. The lack of controlled clinical trials is balanced by the fact that these patients served as their own control. The most common bone stimulators include low-intensity pulsed ultrasound (LIPUS) and pulsed electromagnetic field therapy. Data from a randomized controlled clinical trial of patients meeting the criteria for high risk for development of failed fusion suggests that invasive or noninvasive electrical bone stimulation as an adjunct to spinal fusion surgery is associated with a significantly higher spinal fusion success rate in the treated group compared with the control group.
The Food and Drug Administration, in 1994, approved the use of LIPUS for use in accelerating fresh fracture healing, and in 2000, for treatment of established nonunions. Similarly, electrical stimulation has been approved for the treatment of nonunions in the United States. Basic science research supports the use of LIPUS in signal transduction, gene expression, blood flow, and tissue modeling and remodeling. Multiple, small randomized trials have also supported the use of LIPUS.

This modality may also be useful in patients at high risk of nonunion. These include: Fusion to be performed at more than one level
Current smoking habit
Diabetes or other metabolic diseases where bone growth is poor
Renal disease
Documented history of alcoholism
Obese patients who are at greater than 50% over their ideal body weight

Rubin C, Bolander M, Ryaby JP, Hadjiargyrou M. The use of low-intensity ultrasound to accelerate the healing of fractures. J Bone Joint Surg Am 2001;83:259-70.

5. Khan Y, Laurencin CT. Fracture repair with ultrasound: Clinical and cell-based evaluation. J Bone Joint Surg Am 2008;90:138-44.

Autologous hematopoietic tissue graft – pro

M Levin, MD — Mon, 17 Sep 2012 16:50:47 +0000

Autologous hematopoietic tissue graft is a collection of stem cells, paltelets and tissue factors that are placed into an operative site to promote healing and prevent infections. Much of the aplication has been in plastic and cardiac surgery as well as in wound healing. There are no guideliens that I could locate, cosnesnsus statemetns or large prospective studies and there are studies that show that this treatment is not effective as well as many reports of effectiveness.

Khalafi, Reza S., Bradford, Darien W., Wilson, Michael G.
Topical application of autologous blood products during surgical closure following a coronary artery bypass graft
Eur J Cardiothorac Surg 2008 34: 360-364

S Gunaydin, K McCusker, T Sari, M. Onur, A Gurpinar, H Sevim, P Atasoy, C Yorgancioglu, and Y Zorlutuna
Clinical impact and biomaterial evaluation of autologous platelet gel in cardiac surgery
Perfusion, May 1, 2008; 23(3): 179 – 186.

Gunaydin S, McCusker K, Sari T, Onur M, Gurpinar A, Sevim H, Atasoy P, Yorgancioglu C, Zorlutuna Clinical impact and biomaterial evaluation of autologous platelet gel in cardiac surgery.
Perfusion. 2008 May;23(3):179-86.

Bhanot S, Alex JC.Current applications of platelet gels in facial plastic surgery.
Facial Plast Surg. 2002 Feb;18(1):27-33.

Bilateral breast cancer – pro

M Levin, MD — Tue, 04 Sep 2012 03:59:10 +0000

Lay Summary: Bilateral mastectomies followed by standard adjuvant chemotherapy is the prevailing approach for bilateral breast cancer.

About 3% or breast cancers present with synchronous bilateral disease IBBC) and 11% are bilateral over the course of a patient’s lifetiime.Unlike unilateral breast cancer there are no clear treatment guidelines for BBC.In a recent retrospective review, thirty out of 1100 (2.7%) patients with breast cancer treated between 1993 and 2003 had BBC, of whom 20 patients had metachronous and 10 patients had synchronous BBC. Family history of breast cancer was present in five patients (16%) only. Contralateral breast cancer (CBC) was detected mammographically in three and by clinical examination in 27 patients. Most CBC patients had early-stage disease compared with the index side (73% versus 27%). Fifty-six out of 60 tumors were found to be invasive ductal carcinoma, and none of the patients had lobular carcinoma. Twenty-three patients had bilateral mastectomy, three had unilateral mastectomy and four had a combination of breast conservation and mastectomy. Sixteen patients had unilateral and six had bilateral adjuvant radiotherapy. All patients received adjuvant chemotherapy and/or hormonal therapy both for index and CBC based on the stage and hormone receptor status. At a median follow up of 31.5 months (3–142 months), 23 (76%) patients were disease free and seven (24%) patients had disease relapse. Mean overall survival of patients with MBBC was significantly longer than those with SBBC (30.4 months versus 19.2 months; P = 0.045).

Bilateral mastectomies, as opposed to breast conserving surgey is supported by a supposition that bilateral breast cancer is more agressive, but this is not universally accepted. however, in the absence of guidelines, there is sufficient literature support for bilateral mastectomies to consider it to be a standard of care approach. Bilateral mastectomies followed by adjuvant standard chemotherapy is the most common approach.

MA Chaudary, RR Millis, EO Hoskins et al., Bilateral primary breast cancer: a prospective study of disease incidence. Br J Surg 71 (1984), pp. 711–714.

AD Rochefordiere, B Asselain, S Scholl et al., Simultaneousbilateral breast carcinomas: a retrospective review of 149 cases. Int J Radiat Oncol Biol Phys 30 (1994), pp. 35–41.

J. J. Jobsen, J. van der Palen, F. Ong and J. H. Meerwaldt
Synchronous, bilateral breast cancer: prognostic value and incidence
The Breast, Volume 12, Issue 2, April 2003, Pages 83-88

Prophylactic and reconstructive bilateral mastectomy – pro

M Levin, MD — Tue, 04 Sep 2012 03:20:14 +0000

Prophylactic mastectomy is the surgical removal of both breasts to help prevent breast cancer. Prophylactic mastectomy is a controversial procedure among members of the medical community. Based on recent scientific findings that show prophylactic mastectomy to be effective at preventing breast cancer, some physicians think that it is sometimes defensible. According to the American Cancer Society Board of Directors, “only very strong clinical and/or pathological indications warrant doing this type of ‘preventive operation.”

A contralateral mastectomy is a little different because it is removal of the non-diseased breast at the time of cancer surgery for the other breast. A recent study study examined 56,400 women with breast cancer diagnosed between 1979 and 1999, of whom 1.9% underwent a contralateral prophylactic mastectomy.The observed impact of contralateral mastectomy on the occurrence of breast cancer was profound. The risk was reduced by 97%, adjusting for primary and adjuvant therapy, characteristics of the tumor, and family history.Five women (0.5%) in the contralateral prophylactic mastectomy group developed a contralateral breast cancer despite this procedure. From these data, women may be counseled that their risk will be dramatically reduced but not completely eliminated.

This remains an area of disagreement and controversy. A survey of national policies for coverage, including various medicare policies, revealed that 24% had a formal policy on non-coverage for prophylactic mastectomy even with BRCA positivity. 45% had no policy. Some 30% covered for either BRCA or a strong family history.

Boughey et al states: “The majority of women will obtain no oncologic benefit from CPM, and therefore CPM should be discouraged in average-risk women with unilateral breast cancer. “

Judy C. Boughey et al,Contralateral Prophylactic Mastectomy Consensus Statement from the American Society of Breast Surgeons: Additional Considerations and a Framework for Shared Decision Making, Ann Surg Oncol. 2016; 23(10): 3106–3111.

Narendra Nath Basu et al, The Manchester guidelines for contralateral risk-reducing mastectomy World Journal of Surgical Oncology2015 13:237

NCCN, Breast Cancer 2017

Treatment of brain metastases – pro

admin — Sat, 01 Sep 2012 20:51:52 +0000

Lay Summary: We overview treatment options for brain metastases.

Surgical resection should be considered in patients with single brain metastasis in an accessible location, especially when the size is large, the mass effect is considerable and an obstructive hydrocephalus is present. Surgery is recommended when the systemic disease is absent/controlled and the Karnofsky Performance score is 70 or more (level A recommendation). When the combined resection of a solitary brain metastasis and a non-small cell lung carcinoma (stage I and II) is feasible, surgery for the brain lesion should come first, with a maximum delay between the two surgeries not exceeding 3 weeks. Patients with disseminated but controllable systemic disease (i.e. bone metastases from breast cancer) or with a radioresistant primary tumor (melanoma, renal cell carcinoma, and colon cancer) may benefit from surgery. Surgery at recurrence is useful in selected patients.

Stereotactic radiosurgery (SRS) should be considered in patients with metastases of a diameter of <3–3.5 cm and/or located in eloquent cortical areas, basal ganglia, brain stem or with comorbidities precluding surgery. Gamma-knife or linear accelerator (Linac) are equally effective. SRS may be effective at recurrence after prior radiation treatment.

The role of adjuvant whole-brain radiotherapy (WBRT) after surgery or radiosurgery remains to be clarified. In case of absent/controlled systemic disease and Karnofsky Performance score of 70 or more, one can either withhold initial WBRT if close follow-up with MRI (every 3 to 4 months) is performed or deliver early WBRT with fractions of 1.8–2 Gy to a total dose of 40–55 Gy to avoid late neurotoxicity. Whole-brain radiotherapy alone is the therapy of choice for patients with active systemic disease and/or poor performance status and should employ hypofractionated regimens such as 30 Gy in 10 fractions or 20 Gy in five fractions. For elderly patients with poor performance status WBRT can be withheld and supportive care only employed .

In patients with up to three brain metastases, good performance status (KPS of 70 or more) and controlled systemic disease, SRS is an alternative to WBRT (level B recommendation), whilst surgical resection is an option when the lesions are in an accessible location (level C recommendation). In patients with more than three brain metastases WBRT with hypofractionated regimens is the treatment of choice (level B recommendation). In bedridden patients it should be considered to withhold active radiation treatment and restrict therapy to supportive care.

There appears to not be a role for IMRT since it is neither a good therapy for overall brain like WBRT not specific enought for the tumor alone, like radiosurgery.

The Role of Chemotherapy

Chemotherapy may be the initial treatment for patients with brain metastases from chemosensitive tumors, like small cell lung cancers, lymphomas, germ cell tumors and breast cancers, especially for chemonaive patients or if an effective chemotherapy schedule for the primary is still available. Radiation therapy, with or without chemotherapy, is still the treatment of choice for patients needing a palliation of neurological symptoms

In two phase II trials of temozolomide in heavily pretreated patients with various solid tumor brain metastases, temozolomide was safe and generally well tolerated and showed clinical activity, with three partial responses and 19 disease stabilizations. Results of a third randomized phase II trial of concurrent administration of temozolomide and radiation therapy followed by adjuvant temozolomide therapy compared with radiation alone showed a higher rate of complete and partial responses (objective response of 96% v 67%) and significantly more complete responses (38% v 33%, P =.017), primarily in patients with newly diagnosed brain and lung metastases.

While Avastin does penetrate the blood brain barrier, it’s use specifically to treat brain metastasis is largely unexplored. A 2010 Cochrane panel considered Avastin and did not recommend it. A recent study presented at the ASCO Annual Meeting investigated the use of carboplatin and bevacizumab (Avastin) in progressive brain metastases (including HER2-positive and HER2-negative patients), demonstrating a very promising response rate of 63% in the central nervous system. 3 This remains something that needs to be confirmed.

In terms of surveillance, both NCCN and ACR recommend MRI imaging every three months for one year and no systemic surveillance imaging.

Mintz AP, Perry J, Laperriere N, Cairncross G, Chambers A, Spithoff K, Neuro-oncology Disease Site Group. Management of single brain metastases: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Aug 15. 26 p. (Evidence-based series; no. 9-1). [29 references]

Soffietti R, Cornu P, Delattre JY, Grant R, Graus F, Grisold W, Heimans J, Hildebrand J, Hoskin P, Kalljo M, Krauseneck P, Marosi C, Siegal T, Vecht C. EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force. Eur J Neurol 2006 Jul;13(7):674-81. [44 references]

Abrey LE, Christodoulou C. Temozolomide for treating brain metastases.Semin Oncol. 2001 Aug;28(4 Suppl 13):34-42.

Olson JJ, Paleologos NA, Gaspar LE, Robinson PD, Morris RE, Ammirati M, Andrews DW, Asher AL, Burri SH, Cobbs CS, Kondziolka D, Linskey ME, Loeffler JS, McDermott M, Mehta MP, Mikkelsen T, Patchell RA, Ryken TC, Kalkanis SN. The role of emerging and investigational therapies for metastatic brain tumors: a systematic review and evidence-based clinical practice guideline of selected topics. J Neurooncol. 2010 Jan;96(1):115-42. [78 references]

Patel SH, Robbins JR, Videtic GM, Gore EM, Bradley JD, Gaspar LE, Germano I, Ghafoori P, Henderson MA, Lutz ST, McDermott MW, Patchell RA, Robins HI, Vassil AD, Wippold FJ II, Expert Panel on Radiation Oncology-Brain Metastases. ACR Appropriateness Criteria® follow-up and retreatment of brain metastases. [online publication]. Reston (VA): American College of Radiology (ACR); 2011. 8 p. [33 references]

Lin NU, Gelman RS, Younger J, et al: Phase II trial of carboplatin (C) and bevacizumab (BEV) in patients (pts) with breast cancer brain metastases (BCBM). J Clin Oncol 31(suppl):Abstract 513, 2013.

Gastric bypass – pro

M Levin, MD — Fri, 31 Aug 2012 13:13:53 +0000

As weight loss begins to slow down after gastric bypass, the risk of nutritional problems increases. This is due to dysfunctional or bypassed small bowel. B12 and iron deficiency are two of the most common problems and often do not respond to typical multivitamin supplementation.

Iron deficiency after gastric bypass is usually only seen in menstruating women or in patients who are actively and chronically bleeding. Ferritin or iron levels and erythrocyte counts need to be monitored after a bypass, as iron deficiency can develop early after surgery or years later; one study found that iron stores continuously declined up to 7 years after bypass surgery. Due to bypass of the lower stomach, in which iron is absorbed, it is very difficult for iron-deficient patients to absorb sufficient oral iron. Many cannot tolerate read meat. Intramuscular iron can be impractical over the long run. Usually, intravenous iron dextran or iron sucrose is used regularly; many patients require intravenous iron several times a year. This is done as an outpatient procedure and is well tolerated by patients.

Brolin RE et al. Prophylactic iron supplementation after Roux-en Y gastric bypass: a prospective, double blind, randomized study. Arch Surg. 1998;133(7):740-744.

Dimitrios V Avgerinos, Omar H Llaguna, Matthew Seigerman, Amanda J Lefkowitz, and I Michael Leitman
Incidence and risk factors for the development of anemia following gastric bypass surgery, World J Gastroenterol. 2010 April 21; 16(15): 1867–1870.

Love AL, Billett HH. Obesity, bariatric surgery, and iron deficiency: true, true, true and related.Am J Hematol. 2008 May;83(5):403-9.

Posttreatment surveillance after hepatic metastases resection for colorectal cancer – pro

M Levin, MD — Fri, 24 Aug 2012 19:56:26 +0000

There are few guidelines on how to follow metastatic colon cancer patients with no evidence of disease because it is fairly new situation, with wider use of metasatectomy and after new effective drugs came on the scene and there are no mature studies. For high risk non-metastatic colon cancer, NCCN guidelines for high risk colon cancers recommend annual CT of chest, abdomen and pelvis. Post-surgery surveillance is also warranted following resection of isolated colorectal cancer metastases because a minority of the recurrent patients can be treated with metastatectomy from the liver and lung, and some fo them will enjoy long-term survival and even cure. The liver is the only site of recurrence in approximately 35 to 40 percent. Five-year survival rates up to 43 percent are reported following repeat liver resection for a second recurrence, with acceptable morbidity and perioperative mortality.

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, extrahepatic only in 38 percent, and both hepatic and extrahepatic sites 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

Gomez D, Sangha VK, Morris-Stiff G, Malik HZ, Guthrie AJ, Toogood GJ, Lodge JP, Prasad KR

SO Outcomes of intensive surveillance after resection of hepatic colorectal metastases. Br J Surg. 2010;97(10):1552.

Yan TD, Sim J, Black D, Niu R, Morris DL Systematic review on safety and efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma. Ann Surg Oncol. 2007;14(7):2069.

http://www.uptodate.com/contents/management-of-potentially-resectable-colorectal-cancer-liver-metastases#H650939148

Read the Layperson version here.

Taxol carboplatin induction for head and neck cancer – pro

M Levin, MD — Fri, 24 Aug 2012 19:50:34 +0000

Induction chemotherapy before chemoradiation is becoming standard for many types of head and neck cancer.

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 more advanced unresectable tumors, 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 oropharyngeal 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 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 and lsits this regimen for induction (CHEM-A, 1).

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. 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.

Shao H. Huang et al., Oral cancer: Current role of radiotherapy and chemotherapy. Oral Patol Oral Cir Bucal. 2013 Mar; 18(2): e233–e240

Pignon JP, Ie Maitre A, Bourhis J, MACH-NC Collaborative Group: Meta-analyses of Chemotherapy in Head and Neck Cancer (MACH-NC). Int J Radiat Oncol Biol Phys 2007, 69(2 suppl):S112-114.

Hoebers FJP, Heemsbergen W, Balm AJ, van Zanten M, Schornagel JH, Rasch CR: Concurrent chemoradiation with daily low dose cisplatin for advanced stage head and neck carcinoma.
Radiother Oncol 2007, 85(1):42-47

nccn.org, head and neck cancer, 2016

SS Agarwala et al, Long-term outcomes with concurrent carboplatin, paclitaxel and radiation therapy for locally advanced, inoperable head and neck cancer Ann Oncol (2007) 18 (7): 1224-1229

MICHELLE L. MIERZWA, MUKESH K. NYATI, MEREDITH A. MORGAN, THEODORE S. LAWRENCE, Recent Advances in Combined Modality Therapy The Oncologist April 2010 vol. 15 no. 4 372-381

Akerley BW, Herndon J, Turrisi AT et al. Induction chemotherapy with paclitaxel and carboplatin followed by concurrent thoracic radiotherapy and weekly PC for patients with unresectable stage III non-small cell lung cancer: Preliminary analysis of a phase II trial by the CALGB [abstract 1915]. Proc Am Soc Clin Oncol 2000;19.

Vokes EE, Herndon J, Kelley MJ et al. Induction chemotherapy followed by concomitant chemoradiotherapy (CT/XRT) versus CT/XRT alone for regionally advanced unresectable non-small cell lung cancer: Initial analysis of a randomized phase III trial. J Clin Oncol 2004;22(14 suppl):7005.

Read the Layperson version here.

Laparascopic liver resection for benign lesions – pro

M Levin, MD — Fri, 24 Aug 2012 16:59:38 +0000

It is a fairly rare for benign liver lesions to cause pain and there are no specific guidelines for how to treat such situations. However, the literature contains many reports of laparoscopic partial liver resections for non-cancer diagnosis. In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection appear to be comparable to those after open resections.

1.http://www.hpblondon.com/assets/Laparoscopic%20liver%20re%20EC5A1.pdf

2.Simillis C, Constantinides V, Tekkis P, et al. Laparoscopic versus open hepatic resections for benign and malignant neoplasms- a meta-analysis. Surgery. 2007;141:203–211.

3.Vibert E, Perniceni T, Levard C, et al. Laparoscopic liver resection. Br J Surg. 2006;93:67–72.

4.Laparoscopic Liver Resection for Malignant and Benign Lesions Ten-Year Norwegian Single-Center Experience Airazat M. Kazaryan,Arch Surg. 2010;145(1):34-40

Read the Layperson version here.