Combined intralesional Bacille Calmette-Guérin (BCG) and topical imiquimod for in-transit melanoma.

The introduction of numerous immunotherapeutic agents into the clinical arena has allowed the long-time promise of immunotherapy to begin to become reality. Intralesional immunotherapy has demonstrated activity in multiple tumor types, and as the number of locally applicable agents has increased, so has the opportunity for therapeutic combinations. Both intralesional Bacille Calmette-Guérin (ILBCG) and topical 5% imiquimod cream have been used as single agents for the treatment of dermal/subcutaneous lymphatic metastases or in-transit melanoma, but the combination has not previously been reported. We used this combination regimen in 9 patients during the period from 2004 to 2011 and report their outcomes here. All patients were initially treated with ILBCG, followed by topical imiquimod after development of an inflammatory response to BCG. In this retrospective study, we examined their demographics, tumor characteristics, clinical and pathologic response to treatment, associated morbidities, local and distant recurrence, and overall survival. The 9 patients (8 male) had a mean age of 72 years (range, 56-95 y). Mild, primarily local toxicities were noted. Five patients (56%) had complete regression of their in-transit disease and 1 had a partial response. The 3 others had "surgical" complete responses with resection of solitary resistant lesions. The mean interval between the first treatment and complete resolution of in-transit disease was of 6.5 months (range, 2-12 mo). With a mean follow-up of 35 months (range 12-58 mo), 7 patients (78%) had not developed recurrent in-transit disease. Two patients (22%) have died of nonmelanoma causes, and none have died due to melanoma.

Preoperative imaging of pulmonary metastases in patients with melanoma: implications for minimally invasive techniques.

HYPOTHESIS: Preoperative imaging underestimates the number of pulmonary melanoma metastases. Although thoracoscopic resection is less invasive than resection via thoracotomy, it does not allow manual palpation of the lung to identify any metastases not visible on the preoperative scan or at the time of resection. DESIGN: Retrospective review of a prospectively maintained database. SETTING: Tertiary referral center. PATIENTS: A total of 170 patients who underwent preoperative computed tomography of the chest, followed within 30 days by thoracotomy for resection of pulmonary metastatic melanoma. MAIN OUTCOME MEASURES: Number of pathology-confirmed pulmonary metastases detected by preoperative chest computed tomography vs intraoperative manual palpation. RESULTS: The mean age of the patients was 49.5 years at initial diagnosis of melanoma and 57.1 years at diagnosis of pulmonary metastases; 69% of patients were male. A total of 334 pulmonary metastases were resected; the mean lesion size was 2.0 cm (range, 0.1-14.0 cm). In 49 of 190 pulmonary resections (26%), manual palpation of the subpleural parenchyma revealed lesions not identified during preoperative imaging. The rate of 5-year overall survival was 33%. CONCLUSIONS: Preoperative imaging underestimates the number of pulmonary lesions in patients with metastatic melanoma. Because incomplete resection of metastatic disease is associated with worse outcomes, we recommend caution when considering a minimally invasive approach for the resection of pulmonary metastatic melanoma.

Should quality measures for lymph node dissection in colon cancer be extrapolated to rectal cancer?

BACKGROUND: A minimum of 12 lymph nodes has been endorsed as a quality measure to confirm node-negative colon cancer, but its relevance to early-stage rectal cancer is unclear. METHODS: Patients with stage I or II rectal cancer from the Surveillance, Epidemiology and End Results tumor registries from 1998 to 2002 were identified. Patients were grouped by the number of lymph nodes sampled. Groups were compared for patient demographics, tumor characteristics, and 5-year overall survival. RESULTS: Of the 6,214 patients (57% men) identified, only 33% had ≥12 lymph nodes examined in the surgical specimen. Multivariate analysis identified sex, race, age, T stage, and number of lymph nodes examined as independent predictors of 5-year overall survival. CONCLUSIONS: Five-year overall survival improved as the number of sampled nodes increased. A thorough lymphadenectomy should routinely be performed to optimize staging and to improve survival of patients with early-stage rectal cancer.

Epitrochlear sentinel lymph nodes in melanoma: interval or independent?

Most primary melanomas on the distal upper extremity metastasize to a sentinel lymph node (SLN) in the axillary basin, but occasionally a primary melanoma will drain to the epitrochlear basin. The relationship between tumor-draining axillary and epitrochlear SLNs is unclear. We hypothesize that the epitrochlear SLN functions in an interval manner with the axillary lymph node basin. We queried our melanoma database to identify patients who underwent SLN biopsy for a distal upper-extremity melanoma. Patient demographics, tumor characteristics, patterns of nodal drainage, and incidence of SLN metastasis were analyzed. Of 255 patients identified, 38 (14.9%) had an epitrochlear SLN. Mean Breslow thickness was 2.26 mm. All patients with epitrochlear drainage had concurrent axillary drainage and underwent axillary and epitrochlear SLN biopsies. Of these 38 patients, two (5.2%) had epitrochlear and axillary SLN metastasis, four (10.5%) had epitrochlear metastasis only, four (10.5%) had axillary metastasis only, and the remaining 28 (73.7%) had tumor-free SLNs. The invariable association of epitrochlear and axillary drainage in this study suggests that epitrochlear nodes function in an interval role with the axillary lymph node basin. Therefore we recommend that all patients with a positive epitrochlear SLN undergo completion axillary dissection.

Comparison of outcomes of breast conserving therapy in multifocal and unifocal invasive breast cancer.

BACKGROUND: There is controversy about whether breast conserving therapy (BCT) should be contraindicated in multifocal (MF) breast cancer. Few studies have reported on the oncologic safety of BCT in MF breast cancer. STUDY DESIGN: We reviewed a prospective database of 1,169 women with invasive breast cancer who were treated with segmentectomy and whole breast irradiation from 1991 through 2009 and followed at our institution. Multifocal breast cancer was defined as 2 or more distinct tumors excised with a single incision or segmentectomy. We compared 2 groups, MF and unifocal breast cancer patients, with respect to demographics, tumor characteristics, adjuvant systemic therapy, local recurrence (LR), disease-free survival (DFS), and overall survival (OS). RESULTS: One hundred sixty-four patients with MF and 999 with unifocal invasive breast cancer were treated with BCT. Median follow-up was 112 months. Compared with the unifocal group, patients in the MF group had higher 10-year LR (0.6% vs 6.1%, p < 0.001) and lower 10-year DFS (97.7% vs 89.3%, p < 0.001) and OS (98.4% vs 85.8%, p < 0.001). On multivariable analysis, multifocality was independently significantly associated with local recurrence-free survival (LRFS), DFS, and OS. CONCLUSIONS: Our data suggest that BCT in MF breast cancer is oncologically safe but may result in a slightly inferior outcome compared with BCT in unifocal breast cancer.

Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation.

PURPOSE: Wound infections after ileostomy closure are common with primary closure of the skin. Although this risk can be reduced by secondary closure, cosmetic outcomes are less than desirable. In an effort to balance these issues, we have used circumferential subcuticular wound approximation to decrease wound size. This study compares outcomes of primary closure vs. circumferential subcuticular wound approximation after ileostomy closure. METHODS: Forty-nine consecutive patients undergoing ileostomy closure over an 18-month period were reviewed. During the first half of this study, all ileostomy sites underwent primary closure, while during the second half all ileostomy sites underwent circumferential subcuticular wound approximation. Short-term outcomes were tabulated including wound infection. Long-term outcomes were assessed using a novel six-point patient satisfaction scale. RESULTS: Primary closure was performed in 25 patients and circumferential subcuticular wound approximation performed in 24 patients. No wound infections occurred in the circumferential subcuticular wound approximation group, compared to 40 percent wound infection rate observed in the primary closure group (P = 0.002). The mean patient satisfaction score was higher in the circumferential subcuticular wound approximation group (18.4) vs. the primary closure group (15.9; P > 0.05). CONCLUSIONS: Circumferential subcuticular wound approximation was associated with a significantly lower incidence of wound infection after ileostomy closure compared to primary closure. A trend was present toward better cosmetic results for circumferential subcuticular wound approximation than primary closure.

Advances in experimental and translational research in the treatment of hepatocellular carcinoma.

Hepatocellular cancer (HCC) is the fifth-leading cause of cancer and the third-leading cause of cancer related deaths world-wide. Current treatment options are limited, as HCC has been shown to be a highly resistant type of cancer to most current treatment modalities. Novel approaches are being explored in the fields of gene therapy, viral oncolytics, radioembolization, and several new biologic therapies. This article summarizes these recent clinical findings and discusses what role they will have in the future treatment of HCC.