Surgery No More? Managing the Primary Tumor in Stage IV Breast Cancer.

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Changing practice patterns of adjuvant radiation among elderly women with early stage breast cancer in the United States from 2004 to 2014.

Randomized controlled trials (RCTs) have challenged the need for routine radiation therapy (RT) in women ≥ age 70 with favorable early stage breast cancer (BC) due to modest improvement in local control and no survival benefit. We studied practice patterns in RT among elderly women in the United States. We analyzed data from the National Cancer Database (NCDB) of women ≥age 70 diagnosed with T1 or T2 and N0 invasive BC treated with breast conservation surgery (BCS) between 2004 and 2014. Patients were divided into four groups: (1) no RT, (2) partial breast irradiation (PBI); (3) hypofractionation (HF); and (4) conventional whole breast RT (CWBI). Univariable and multivariable analyses (MVA) were performed to compare characteristics among the four RT groups. A subgroup analysis of women with favorable disease (T1N0 ER + HER2-) was also performed with similar statistical comparisons. Of the 66,126 meeting eligibility, 9,570 (14.5%) had PBI, 16,340 (24.7%) had HF, and 40,117 (60.7%) had CWBI. Only 99 patients (0.15%) had RT omitted. Omission of RT increased marginally from 0.04% in 2004 to 0.24% in 2014. MVA identified older age (OR 1.18, CI 1.08-1.28), more comorbidities (Charlson-Deyo Score of 1) (OR 3.36, CI 1.29-8.72), and no hormone therapy (OR 22.07, CI 5.79-84.07) as more likely to have RT omitted. The use of HF increased from 3.9% to 47.0%, P < .001 with a concomitant decrease in CWBI from 88% to 41%, P < .001. MVA identified older age, treatment location, and omission of chemotherapy as associated with HF. No significant differences from the larger cohort were found among the T1N0 subgroup analysis. Despite RCT evidence, omission of RT was rare in the United States, suggesting that more effective outreach methods to disseminate clinical guideline information may be needed.

Late malignant change in an ileal conduit.

Around 3000 bowel segment transpositions are performed in the UK each year and although malignancy is well-recognized following ureterosigmoidostomy, reports of similar changes in ileal conduits are sparse. We report a case of ileal adenocarcinoma in a 67-year-old lady some 49 years after ileal conduit, demonstrating previously unassociated histopathological features similar to those seen in collagenous colitis.

The tip of the iceberg: a giant pelvic atypical lipoma presenting as a sciatic hernia.

BACKGROUND: This case report highlights two unusual surgical phenomena: lipoma-like well-differentiated liposarcomas and sciatic hernias. It illustrates the need to be aware that hernias may not always simply contain intra-abdominal viscera. CASE PRESENTATION: A 36 year old woman presented with an expanding, yet reducible, right gluteal mass, indicative of a sciatic hernia. However, magnetic resonance imaging demonstrated a large intra- and extra-pelvic fatty mass traversing the greater sciatic foramen. The tumour was surgically removed through an abdomino-perineal approach. Subsequent pathological examination revealed an atypical lipomatous tumour (synonym: lipoma-like well-differentiated liposarcoma). The patient remains free from recurrence two years following her surgery. CONCLUSION: The presence of a gluteal mass should always suggest the possibility of a sciatic hernia. However, in this case, the hernia consisted of an atypical lipoma spanning the greater sciatic foramen. Although lipoma-like well-differentiated liposarcomas have only a low potential for recurrence, the variable nature of fatty tumours demands that patients require regular clinical and radiological review.

Early experiences with computed axial tomography colonography.

BACKGROUND: Computed axial tomography (CT) colonography is the latest radiologic technique to be used to image the large bowel. We studied its role as a diagnostic tool in colorectal practice. METHODS: One hundred and three patients suspected of having colorectal pathology underwent CT colonography. RESULTS: CT colonography suggested a diagnosis of colonic carcinoma in 18 patients, and 17 of these underwent surgery. A colorectal neoplasm was not found in only 1 patient who had extrinsic colonic compression by an ovarian cyst. Twenty-one patients had suspected colonic polyps on scanning. Subsequent endoscopy in 19 of these patients confirmed the presence of polyps in only 10. CT colonography also revealed valuable extracolonic pathology: 8 occult noncolonic neoplasms and 163 other incidental findings. CONCLUSIONS: CT colonography has good patient compliance and is a useful diagnostic modality in detecting colorectal neoplasms. Its main advantage over other such investigative tools is its ability to detect extracolonic pathology.