Gastric cancer: D2 dissection or low Maruyama Index-based surgery--a debate.

This article provides perspectives on the surgical approaches required optimally to manage patients with respectable gastric adenocarcinoma. The status of techniques of surgical resection in the management of gastric cancer is reviewed. The premise of this approach is that extended gastrectomy with D2 lymph node dissection is good. Also addressed are prognostic and predictive factors in the surgical treatment of stomach cancer.

D2.5 dissection for gastric carcinoma.

Worldwide, gastric cancer ranks second only to lung cancer in mortality and accounts for 500 000 deaths annually. Since 1930, the incidence of gastric carcinoma in the United States has been declining steadily and plateaued during the 1980-1990 decade. Mortality rates for white males in the United States were approximately 40 per 100000 in 1930, compared with 5.4 per 100000 in 1994. For nonwhite males the rates were 23.7 per 100 000 in 1955 and 12 per 100 000 in 1985. In the United States in 2002, an estimated 21 600 new cases and 12 400 deaths were attributable to gastric carcinoma.

Should adjuvant therapy remain the standard of care for patients with resected adenocarcinoma of the pancreas?

Adenocarcinoma of the pancreas continues to be a formidable disease. In the United States, patients who have had resected disease are generally offered adjuvant chemoradiation. The current National Comprehensive Cancer Network practice guidelines uniformly support this practice. We reviewed seven selected series to evaluate the efficacy of adjuvant therapy for patients who had resected adenocarcinoma of the pancreas. Current evidence-based analysis demonstrates that an adjuvant therapy regimen as a standard of care is lacking. We, therefore, believe that it should be used judiciously because its benefit is confined to only a fraction of patients treated by complete resection (R0); patients with residual microscopic disease (R1) derived negligible benefits. Given the financial constraints and the small effect that current therapies have on this fatal disease, clinicians should concentrate on developing novel therapies and new paradigms to address this age-old problem.

Effect of concurrent radiation therapy and chemotherapy on pulmonary function in patients with esophageal cancer: dose-volume histogram analysis.

PURPOSE: The pulmonary effects of concurrent radiation therapy and chemotherapy were studied in patients enrolled in a phase I trial for esophageal cancer. MATERIALS AND METHODS: Pulmonary function tests were performed prospectively before and after combined-modality therapy (oxaliplatin, 5-fluorouracil, and radiation therapy) in 20 patients with esophageal cancer. Cumulative and differential lung DVH analysis from 0 to 5400 cGy in 25-cGy intervals was performed for the last 15 patients. Correlation between radiation exposure in various dose ranges and percent reduction in pulmonary function tests was calculated as an exploratory analysis. RESULTS: Significant reductions in carbon monoxide diffusion capacity corrected for hemoglobin (12.3%) and total lung capacity (2.5%) were evident at a median of 15.5 days after radiation therapy. DVH analysis revealed that the single dose of maximum correlation between lung volume radiation exposure and lung function reduction was less than 1000 cGy for all pulmonary functions. The percent lung volume that received a total dose between 700 and 1000 cGy maximally correlated with the percent reductions in total lung capacity and vital capacity, and the absolute lung volume that received a total dose between 700 and 1000 cGy maximally correlated with the percent reductions in total lung capacity, vital capacity, and carbon monoxide diffusion capacity. DISCUSSION: Significant declines in carbon monoxide diffusion capacity and total lung capacity are evident immediately after the administration of conformal radiation therapy, oxaliplatin, and 5-fluorouracil for esophageal cancer. Other lung functions remain statistically unchanged. The percent or absolute lung volume that received a total dose between 700 and 1000 cGy may be significantly correlated with the percent decline of carbon monoxide diffusion capacity, total lung capacity, and vital capacity. These associations will be evaluated further in a follow-up study.

Predictive factors associated with long-term survival in patients with neuroendocrine tumors of the pancreas.

BACKGROUND: Neuroendocrine tumors of the pancreas are rare tumors. We identified predictive factors that are associated with long-term survival (> or=5 years). METHODS: Fifty patients with a diagnosis of neuroendocrine tumors of the pancreas were retrospectively evaluated. The following factors were evaluated for disease-specific mortality: age, sex, primary tumor location, functional status, type of primary tumor treatment, presence or absence of liver metastases, timing of liver metastases occurrence, and type of liver metastases treatment. Aggressive treatment of the liver metastases included surgery, chemoembolization, or intrahepatic arterial infusion chemotherapy. RESULTS: Twenty-three patients (47%) had tumor located in the head of the pancreas, and 29 patients (58%) had nonfunctioning tumor. Thirty-nine patients (78%) had liver metastases. The median follow-up for the entire group was 35 months (range,.76-206 months). The median survival for the entire group was 40 months, and the overall 1-, 2-, and 5-year survival rates were 84%, 69%, and 36%, respectively. Factors that had a significant favorable effect on survival included curative resection of the primary tumor, metachronous liver metastases, absence of liver metastases, and aggressive treatment of the liver metastases. CONCLUSIONS: Definitive surgical resection of the primary tumor, absence of liver metastases, metachronous liver metastases, and aggressive treatment of the liver metastases were predictors of long-term survival in patients with neuroendocrine tumors of the pancreas.

Esophageal resection for carcinoma in patients older than 70 years.

BACKGROUND: A larger number of older patients are presenting as candidates for esophageal resection. An aggressive surgical approach in this population is controversial. METHODS: Four hundred thirteen patients with esophageal cancer who presented to Roswell Park Cancer Institute from 1991 to 1998 were retrospectively reviewed. Clinical data, perioperative details, and postoperative courses were compared for patients older and younger than 70 years. RESULTS: One hundred forty-seven patients (36%) were older than 70 years. Risk factors, clinical symptoms, histology, and stage at presentation were equivalent for both age groups. A higher percentage of patients <70 years were candidates for curative resection. There were no significant differences between groups for estimated blood loss, intraoperative transfusions, length of stay, overall morbidity, or mortality. Only postoperative myocardial infarction and atrial fibrillation were increased in the older group. Excluding stage IV disease, there was a significant and similar improvement in median survival after resection for patients both <70 years and >70 years. CONCLUSIONS: In conclusion, esophageal cancer in older patients warrants surgical resection because the benefit to the patient is the same as it is for younger patients, without a significant increase in operative morbidity or mortality.

High-grade dysplasia within Barrett's esophagus: controversies regarding clinical opinions and approaches.

Barrett's esophagus with high-grade dysplasia is a well-known risk factor for the development of esophageal adenocarcinoma, which has become the predominant form of esophageal cancer in the United States. This review addresses four major fundamental issues that shape our treatment decisions regarding high-grade dysplasia within Barrett's esophagus: (1) the poorly defined natural history of high-grade dysplasia in its progression to adenocarcinoma, (2) the potentially high morbidity and mortality of esophageal resection for high-grade dysplasia, (3) the difficulty in detecting cancer among dysplastic cells during endoscopy, and (4) the controversial role of endoscopic mucosal ablative therapy for high-grade dysplasia. Until there are more accurate surveillance methods, better biochemical or molecular markers in predicting cancerous progression, or more effective minimally invasive methods of treatment, esophagogastrectomy must be considered the standard means of managing patients with Barrett's esophagus and high-grade dysplasia. Regular rigorous systematic surveillance and endoscopic mucosal ablation are alternative treatment options that are available but should be used only under strict conditions. The decision to proceed in a certain direction is quite complex and challenging and ideally requires the feedback of patients who are properly educated about the controversies surrounding this disease.