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The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence
The American Journal of Surgery (2009) 198, 461– 464
Letters to the Editor
Risk factors for anastomotic leakage after resection for rectal cancer To the Editor: As a surgical trainee, I found the article by Eberl et al1 helpful in enhancing the current knowledge about rectal carcinoma surgery. It also stresses an important point about careful handling, and I think it should be practiced not only on large tumors but in every case. Surgical practices evolve with time as new evidences were shown. The authors were willing to modify theirs to incorporate new techniques and treatments (total mesenteric excision and colonic J-pouch). Even with 383 patients (44.8%) excluded, this study retains a relatively large number of cases. However, it would have been interesting to know if there were actually 736 or 726 patients that underwent curative resection of the rectum (25 ⫹ 64 ⫹ 40 ⫹ 597 ⫽ 726) and how the remaining 10 patients would have changed the final results of this study. Finally, in a broader perspective, although the authors did not show radiation therapy as a significant risk factor for
anastomotic leak, we should also consider the potential effects from such treatment.2 LingHong Lee, M.D. Department of Surgery Causeway Hospital Coleraine, UK doi:10.1016/j.amjsurg.2008.10.017
References 1. Eberl T, Jagoditsch M, Klingler A, et al. Risk factors for anastomotic leakage after resection for rectal cancer. Am J Surg 2008;196:592– 8. 2. Murata A, Brown CJ, Raval M, et al. Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer. Am J Surg 2008;195:611–5.
The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence To the Editor: The topic of treating local reappearance of breast cancer after a conservative approach is very controversial and we read with interest the article by Chen and Martinez,1 “The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence.” The authors reported on 747 patients who experienced ipsilateral breast cancer recurrence (IBTR) after conservative surgery and radiotherapy identified using the Surveillance, Epidemiology, and End Results database. They compared 179 patients receiving lumpectomy (24%) with 568 women who underwent mastectomy, showing 5-year overall survival rates of 67% and 78%, respectively. Both univariate and multivariable analyses identified mastectomy as the treatment achieving a better overall survival, and they concluded that the use of lumpectomy for IBTR 0002-9610/$ - see front matter © 2009 Published by Elsevier Inc.
previously treated with breast conservation therapy generally should be discouraged. Our main concern with the study by Chen and Martinez1 is that they compare groups that are fundamentally incomparable: women who underwent a second breast conserving surgery and women who underwent a mastectomy showed different tumor characteristics and received different adjuvant treatment. Multivariable analysis can only in part overcome this problem. Moreover, the multivariable analysis is weakened by the large amount of missing data: at least 28% of patients who underwent lumpectomy and 24% of patients who underwent mastectomy were excluded because of missing information on hormone-receptor status. Furthermore, because the 2 groups significantly differed in mean age, overall survival could be an inappropriate outcome measure and maybe should have been replaced with breast-related survival and/or disease-free survival. In
462
The American Journal of Surgery, Vol 198, No 3, September 2009
any case, causes of death should have been reported and the few metastatic patients should not have been included in the analysis. We recently published the results from a study on the same issue2 and we drew different and more cautious conclusions. In our experience, on 161 women treated at a single institution with a second conservative surgery, we reported a 5-year cumulative incidence of local relapse of 31.4%, which is definitively high and is similar to what happens after conservative surgery without radiotherapy. However, among 64 patients with recurrent tumor smaller than 2 cm and time to IBTR greater than 48 months, 8 patients (12.8%; 5-year cumulative incidence) had further local relapses. Furthermore, we showed a 5-year survival rate of 82%. We therefore believe that it is not a question of generally discouraging a second conservative approach, but a question of identifying a subset of motivated patients who can safely receive a second conservative surgery.
Oreste Gentilini, M.D. Division of Breast Surgery Edoardo Botteri, M.Sc. Division of Epidemiology and Biostatistics European Institute of Oncology Milan, Italy doi:10.1016/j.amjsurg.2008.11.027
References 1. Chen SL, Martinez SR. The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence. Am J Surg 2008; 196:495–9. 2. Gentilini O, Botteri E, Rotmensz N, et al. When can a second conservative approach be considered for ipsilateral breast tumour recurrence? Ann Oncol 2007;18:468 –72.
Arteriovenous fistula versus arteriovenous graft as a permanent vascular access for hemodialysis To the Editor: Regarding the valuable article, “Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans’ Affairs medical center,”1 which published in The American Journal of Surgery, we want to mention a few points. The authors compared patency rate and required interventions for maintaining the vascular access in 64 arteriovenous grafts (AVGs) and 50 arteriovenous fistulas (AVFs). They found no significant differences between 1- and 2-year patency rates between AVFs and AVGs. First, this study is interesting because it reports a comparison between AVFs and AVGs from a center a few years after changing the face of vascular accesses type from AVGs to AVFs. It seems that in the future the patency rate of AVFs in their center will increase, especially by using other types of AVFs at the midforearm2 and elbow,3 which have been introduced recently. Second, although in 41 of the 47 (87%) patients the AVF was the first permanent vascular access, they reported a 16% primary failure rate (8 of 50 AVFs) and 4% (n ⫽ 2) poorly maturated AVFs. These findings may be explained by high associated comorbidities of the patients in their series. However, it has been shown that a creation of elbow AVFs is possible in a high number of patients with failed previous permanent vascular accesses, including diabetic and older patients (⬎65 y).4 Third, 29 of 50 AVFs (58%) were upper-arm brachiobasilic AVFs, while it has not proved the brachiobasilic AVF has prominent superiority to the brachiocephalic ones. In addition, creation of a brachibasilic AVF is more time
consuming than brachiocephalic AVFs.5,6 However, it may be owing to inclusion criteria of their study (vein diameter ⬎ 3 mm). Fourth, according to a recent meta-analysis, radiocephalic AVFs have a 15.3% primary failure rate.7 Thus, reporting the number of failed AVFs and the patency rates of each subgroup of AVFs (radiocephalic, brachiocephalic, and brachiobasilic) would be useful to the readers. Mohammad R. Rasouli, M.D. Shahram Salehirad, M.D. Sina Trauma and Surgery Research Center Majid Moini, M.D. Division of Vascular Surgery Sina Hospital School of Medicine Tehran University of Medical Sciences Tehran, Iran doi:10.1016/j.amjsurg.2008.11.028
References 1. Snyder DC, Clericuzio CP, Stringer A, et al. Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans’ Affairs medical center. Am J Surg 2008;196:641– 6. 2. Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients. Arch Surg 2006;141:27–32. 3. Moini M, Williams GM, Pourabbasi MS, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg 2008;47:1274 – 8.
Letters to the Editor
Risk factors for anastomotic leakage after resection for rectal cancer To the Editor: As a surgical trainee, I found the article by Eberl et al1 helpful in enhancing the current knowledge about rectal carcinoma surgery. It also stresses an important point about careful handling, and I think it should be practiced not only on large tumors but in every case. Surgical practices evolve with time as new evidences were shown. The authors were willing to modify theirs to incorporate new techniques and treatments (total mesenteric excision and colonic J-pouch). Even with 383 patients (44.8%) excluded, this study retains a relatively large number of cases. However, it would have been interesting to know if there were actually 736 or 726 patients that underwent curative resection of the rectum (25 ⫹ 64 ⫹ 40 ⫹ 597 ⫽ 726) and how the remaining 10 patients would have changed the final results of this study. Finally, in a broader perspective, although the authors did not show radiation therapy as a significant risk factor for
anastomotic leak, we should also consider the potential effects from such treatment.2 LingHong Lee, M.D. Department of Surgery Causeway Hospital Coleraine, UK doi:10.1016/j.amjsurg.2008.10.017
References 1. Eberl T, Jagoditsch M, Klingler A, et al. Risk factors for anastomotic leakage after resection for rectal cancer. Am J Surg 2008;196:592– 8. 2. Murata A, Brown CJ, Raval M, et al. Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer. Am J Surg 2008;195:611–5.
The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence To the Editor: The topic of treating local reappearance of breast cancer after a conservative approach is very controversial and we read with interest the article by Chen and Martinez,1 “The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence.” The authors reported on 747 patients who experienced ipsilateral breast cancer recurrence (IBTR) after conservative surgery and radiotherapy identified using the Surveillance, Epidemiology, and End Results database. They compared 179 patients receiving lumpectomy (24%) with 568 women who underwent mastectomy, showing 5-year overall survival rates of 67% and 78%, respectively. Both univariate and multivariable analyses identified mastectomy as the treatment achieving a better overall survival, and they concluded that the use of lumpectomy for IBTR 0002-9610/$ - see front matter © 2009 Published by Elsevier Inc.
previously treated with breast conservation therapy generally should be discouraged. Our main concern with the study by Chen and Martinez1 is that they compare groups that are fundamentally incomparable: women who underwent a second breast conserving surgery and women who underwent a mastectomy showed different tumor characteristics and received different adjuvant treatment. Multivariable analysis can only in part overcome this problem. Moreover, the multivariable analysis is weakened by the large amount of missing data: at least 28% of patients who underwent lumpectomy and 24% of patients who underwent mastectomy were excluded because of missing information on hormone-receptor status. Furthermore, because the 2 groups significantly differed in mean age, overall survival could be an inappropriate outcome measure and maybe should have been replaced with breast-related survival and/or disease-free survival. In
462
The American Journal of Surgery, Vol 198, No 3, September 2009
any case, causes of death should have been reported and the few metastatic patients should not have been included in the analysis. We recently published the results from a study on the same issue2 and we drew different and more cautious conclusions. In our experience, on 161 women treated at a single institution with a second conservative surgery, we reported a 5-year cumulative incidence of local relapse of 31.4%, which is definitively high and is similar to what happens after conservative surgery without radiotherapy. However, among 64 patients with recurrent tumor smaller than 2 cm and time to IBTR greater than 48 months, 8 patients (12.8%; 5-year cumulative incidence) had further local relapses. Furthermore, we showed a 5-year survival rate of 82%. We therefore believe that it is not a question of generally discouraging a second conservative approach, but a question of identifying a subset of motivated patients who can safely receive a second conservative surgery.
Oreste Gentilini, M.D. Division of Breast Surgery Edoardo Botteri, M.Sc. Division of Epidemiology and Biostatistics European Institute of Oncology Milan, Italy doi:10.1016/j.amjsurg.2008.11.027
References 1. Chen SL, Martinez SR. The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence. Am J Surg 2008; 196:495–9. 2. Gentilini O, Botteri E, Rotmensz N, et al. When can a second conservative approach be considered for ipsilateral breast tumour recurrence? Ann Oncol 2007;18:468 –72.
Arteriovenous fistula versus arteriovenous graft as a permanent vascular access for hemodialysis To the Editor: Regarding the valuable article, “Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans’ Affairs medical center,”1 which published in The American Journal of Surgery, we want to mention a few points. The authors compared patency rate and required interventions for maintaining the vascular access in 64 arteriovenous grafts (AVGs) and 50 arteriovenous fistulas (AVFs). They found no significant differences between 1- and 2-year patency rates between AVFs and AVGs. First, this study is interesting because it reports a comparison between AVFs and AVGs from a center a few years after changing the face of vascular accesses type from AVGs to AVFs. It seems that in the future the patency rate of AVFs in their center will increase, especially by using other types of AVFs at the midforearm2 and elbow,3 which have been introduced recently. Second, although in 41 of the 47 (87%) patients the AVF was the first permanent vascular access, they reported a 16% primary failure rate (8 of 50 AVFs) and 4% (n ⫽ 2) poorly maturated AVFs. These findings may be explained by high associated comorbidities of the patients in their series. However, it has been shown that a creation of elbow AVFs is possible in a high number of patients with failed previous permanent vascular accesses, including diabetic and older patients (⬎65 y).4 Third, 29 of 50 AVFs (58%) were upper-arm brachiobasilic AVFs, while it has not proved the brachiobasilic AVF has prominent superiority to the brachiocephalic ones. In addition, creation of a brachibasilic AVF is more time
consuming than brachiocephalic AVFs.5,6 However, it may be owing to inclusion criteria of their study (vein diameter ⬎ 3 mm). Fourth, according to a recent meta-analysis, radiocephalic AVFs have a 15.3% primary failure rate.7 Thus, reporting the number of failed AVFs and the patency rates of each subgroup of AVFs (radiocephalic, brachiocephalic, and brachiobasilic) would be useful to the readers. Mohammad R. Rasouli, M.D. Shahram Salehirad, M.D. Sina Trauma and Surgery Research Center Majid Moini, M.D. Division of Vascular Surgery Sina Hospital School of Medicine Tehran University of Medical Sciences Tehran, Iran doi:10.1016/j.amjsurg.2008.11.028
References 1. Snyder DC, Clericuzio CP, Stringer A, et al. Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans’ Affairs medical center. Am J Surg 2008;196:641– 6. 2. Jennings WC. Creating arteriovenous fistulas in 132 consecutive patients. Arch Surg 2006;141:27–32. 3. Moini M, Williams GM, Pourabbasi MS, et al. Side-to-side arteriovenous fistula at the elbow with perforating vein ligation. J Vasc Surg 2008;47:1274 – 8.