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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999


REGIONAL NODE MANAGEMENT IN GASTROINTESTINAL CANCER AND BREAST CANCER
font=>By Paul Recchia, Ph.D.

Gastrointestinal Cancer

Fabrizio Michelassi, MD, University of Chicago Medical Center, addressed the gastrointestinal cancers where primary and secondary lymph nodes concerns are very relevant: gastric cancer, pancreatic cancer, and rectal cancer. In these gastrointestinal cancers, investigators have questioned whether resection of an organ excision and lymphectomy (D1 dissection) should be done together. Extended lymphectomy (D2 dissection) is believed to improve survival from cancer, but to also increase morbidity and mortality.

Dr. Michelassi reviewed the literature, analyzing a number of studies on mild to moderate gastric cancer showing no statistically significant differences between D1 and D2 dissection in terms of survival or morbidity and mortality. Similar results were found in studies on pancreatic cancer and rectal cancer. Lymphectomy, along with the addition of splenectomy and distal pancreatectomy were found to cause high morbidity and mortality. Spleen-sparing and tail-of-pancreas-sparing techniques are now common. One study on Stage 3a gastric cancer resulted in 5-year survival of 25% with D1 dissection verses 11% with D2 dissection. Large-scale, long-term prospective studies are needed to further follow up on Stage 3a gastrointestinal cancer patients to determine if there is any benefit to D2 dissection.

Breast Cancer

Monica Morrow, MD, Northwestern University Medical Center, discussed various aspects of node management in breast cancer.

Breast cancer was once seen as a systemic disease because once it was visible local treatment would not decide disease regression. However, it now seems that breast cancer includes a spectrum of disease: some patients have cancer in the breast, some patients have cancer in the breast area, and some are systemic-often as the disease progresses. Dr. Marrow predicts as adjuvant therapy improves that the systemic component may be curbed.

Axillary dissection is one method of containing systemic breast cancer, but may be overkill if milder methods can be found. To date, axillary dissection may be necessary because 25% of node negative patients have recurrent breast cancer disease. One recent attempt to reduce axillary dissections involved identifying low-risk patients, but a study on 1200 women could not find women less than 10% at risk for axillary node disease. A better understanding of sentinal node, nonsentinal node, and internal mammary node disease will better define the need for axillary dissection. Sentinal node is the only node containing disease in 40-70% of patients. Micrometastasis in nonsentinal nodes is rare as demonstrated by a study on 1087 nonsentinal nodes that found only one node with metastasis. Similarly, internal mammary nodes are rare as shown in a study on 7000 patients in which only 5% had metastasis. Questions remaining to determine the need for axillary dissection include long-term data on large volumes of surgery, prognostic importance of micrometastasis, and management of internal mammary nodes.

A current trial of note is the ACSOG sentinal node study Z0010. This is a prognostic study of sentinal node and bone marrow micrometastasis in women with clinical T1 or T2 N0 M0 breast cancer excised to negative margins to undergo breast-conserving surgery. Patients will have a sentinal node test. Negative patients will undergo blinded immunohistochemistry. Primary tumor characteristics will decide treatment. Positive patients will be randomized into complete axillary dissection or radiation therapy with adjuvant chemotherapy. The study is designed to answer whether axillary dissection will have therapeutic benefit or whether it is just a staging procedure. The study is open to surgeons and needs 7000 patients. Dr. Marrow encourages her peers to participate.

For professional correspondence, please contact Dr. Michelassi at fmichela@surgery.bsd.uchicago.edu and Dr. Morrow at m-morrow@nwu.edu.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.



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