Pathological responses after angiogenesis or EGFR inhibitors in metastatic colorectal cancer depend on the chemotherapy backbone.

BACKGROUND: Optimal preoperative treatment before colorectal cancer metastases (CRCM) resection remains unclear. This study evaluated pathological responses (pR) in CRCM resected after chemotherapy alone or combined with angiogenesis or epidermal growth factor receptor (EGFR) inhibitors. METHODS: Pathological response was retrospectively evaluated on 264 resected metastases from 99 patients. The proportion of responding metastases after different preoperative treatments was reported and compared. Patient's progression-free survival (PFS) and overall survival (OS) were compared based on pR. RESULTS: The combination of anti-angiogenics with oxaliplatin-based chemotherapy resulted in more pR than when they were combined with irinotecan-based chemotherapy (80% vs 50%; P<0.001). Inversely, the combination of EGFR inhibitors with oxaliplatin-based chemotherapy seemed to induce fewer pR than when they were combined with irinotecan-based treatment (53% vs 72%; P=0.049). Overall survival at 5 years was improved for patients with a pR in all resected metastases compared with those who did not achieve a pR (68.5% vs 32.6%; P=0.023) and this response was the only factor predicting OS in a multivariate analysis. CONCLUSION: The chemotherapy partner combined with angiogenesis or EGFR inhibitors influenced pR in resected CRCM. In our exploratory analysis anti-angiogenic/oxaliplatin-based regimens and anti-EGFR/irinotecan-based regimens were associated with the highest pR. Prospective randomised trials should be performed to validate these observations.

Pancreatic neuroendocrine tumour grading on endoscopic ultrasound-guided fine needle aspiration: high reproducibility and inter-observer agreement of the Ki-67 labelling index.

OBJECTIVES: Assessment of proliferation by the Ki-67 labelling index (Ki67-LI) is an important parameter of pancreatic neuroendocrine tumour (pNET) prognosis on resection specimens. Ki67-LI values for grading are not fully established on endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to determine the accuracy of Ki67-LI on EUS-FNA to predict a final grade of pNET and to analyse the relationship between cytological grading and progression-free survival (PFS). METHODS: Between 1996 and 2010, 46 pNETs (33 were resected) from 45 patients were diagnosed by EUS-FNA. Ki67-LI was evaluated on cytological and histological material for each tumour and classified according to the 2010 WHO grading system. RESULTS: A very good inter-observer agreement for Ki67-LI on EUS-FNA and surgical specimens, respectively, were obtained. Discrepancies were observed between histology and cytology, especially in grade 2 (G2) tumours, where cytology underestimated grading owing to tumour heterogeneity. Still, EUS-FNA was able to distinguish a poor prognostic group, as the actuarial PFS of cytological (c) G3 tumours was 10 ± 4 months versus 29 ± 7 and 68 ± 10 for cG2 and cG1 tumours, respectively (P < 0.0001). CONCLUSION: This study attests the reproducibility of Ki67-LI of pNETs whether counted on cytology or histology with a very good inter-observer correlation. Determination of Ki67-LI on EUS-FNA of pNETs should be included systematically in their prognostic work-up.

Is port-site resection necessary in the surgical management of gallbladder cancer?

INTRODUCTION: Gallbladder carcinoma is frequently discovered incidentally on pathologic examination of the specimen after laparoscopic cholecystectomy (LC) performed for presumed "benign" disease. The objective of the present study was to assess the role of excision of port-sites from the initial LC for patients with incidental gallbladder carcinoma (IGBC) in a French registry. METHODS: Data on patients with IGBC identified after LC between 1998 and 2008 were retrospectively collated in a French multicenter database. Among those patients undergoing re-operation with curative intent, patients with port-site excision (PSE) were compared with patients without PSE and analyzed for differences in recurrence patterns and survival. RESULTS: Among 218 patients with IGBC after LC (68 men, 150 women, median age 64 years), 148 underwent re-resection with curative intent; 54 patients had PSE and 94 did not. Both groups were comparable with regard to demographic data (gender, age > 70, co-morbidities), surgical procedures (major resection, lymphadenectomy, main bile duct resection) and postoperative morbidity. In the PSE group, depth of tumor invasion was T1b in six, T2 in 24, T3 in 22, and T4 in two; this was not significantly different from patients without PSE (P = 0.69). Port-site metastasis was observed in only one (2%) patient with a T3 tumor who died with peritoneal metastases 15 months after resection. PSE did not improve the overall survival (77%, 58%, 21% at 1, 3, 5 years, respectively) compared to patients with no PSE (78%, 55%, 33% at 1, 3, 5 years, respectively, P = 0.37). Eight percent of patients developed incisional hernia at the port-site after excision. CONCLUSION: In patients with IGBC, PSE was not associated with improved survival and should not be considered mandatory during definitive surgical treatment.

Inflammatory myofibroblastic tumor of the pancreatic head.

Inflammatory myofibroblastic tumors are rare, especially in the pancreas. It is sometimes difficult to obtain a definitive diagnosis with radiological imaging and there is not yet consensus about treatment. We report a case of a 56-year-old man with recurrent abdominal pain particularly in the right upper quadrant without other symptoms. The imaging results showed a pancreatic hypovascularized mass with stenosis of the main pancreatic duct and the common bile duct without metastasis. The FDG PET scanner showed two hypermetabolic foci in the head of the pancreas. The biopsies of the mass were not diagnostic. The therapy adopted was Whipple's pancreaticoduodenectomy with a histological diagnosis of the inflammatory myofibroblastic tumor.

Endoscopic ultrasound-guided transluminal drainage of pancreatic duct obstruction: long-term outcome.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided pancreatic drainage (EUS-PD) has been reported as an alternative to surgery, when transpapillary access to the main pancreatic duct (MPD) is impossible. The aim of the study was to investigate the feasibility of the procedure and long-term clinical outcome in patients treated with EUS-PD. PATIENTS AND METHODS: We retrospectively analyzed our single-center experience over a 10-year period. RESULTS: EUS-PD was attempted in 20 patients (24 interventions), with a median age of 64 years (range 36 - 78). Indications for the procedure were post-Whipple symptomatic anastomotic stricture (n = 10) and chronic pancreatitis (n = 10). EUS-PD was performed by a transgastric (n = 16) or transbulbar (n = 3) route or with a rendezvous technique (n = 5). Wirsungography was performed in all interventions and successful drainage was achieved in 18 / 20 (90 %) patients. There were two minor procedure-related complications: bleeding that was treated endoscopically, and a perigastric collection that resolved spontaneously. Median follow up was 37 months (range 3 - 120 months), stent dysfunction occurred in 9 / 18 (50 %) patients. Out of 18 patients with successful EUS-PD, long-term pain resolution was observed in 13 (72 %). At the last follow-up visit, there were significant decreases in pain scores, from 7.5 to 1.6, and in MPD size from 8.1 mm to 3.9 mm. Failure was associated with cancer presence or recurrence. CONCLUSIONS: Technical success rate of EUS-PD and clinical long-term pain resolution were 90 % and 72 %, respectively. EUS-PD is a reliable procedure with a low complication rate. It might therefore replace surgery at expert centers.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS. METHODS: An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon. RESULTS: Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS. CONCLUSION: Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Adjuvant therapy for pancreatic cancer: current status and future directions

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[Laparoscopic pancreatic resections]. / Résections pancréatiques par laparoscopie.

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

Elective Laparoscopic Splenectomy: Person Experience and Literature Review.

Laparoscopic splenectomy has become an attractive treatment for patients with selected hematologic disorders. Almost 200 observations have been reported. The rate of conversion to laparotomy is 10% to 15%, and the complication rate is between 0% and 30%. Adequate selection of patients, preoperative administration of intravenous immunoglobulin in patients with idiopathic thrombocytopenic purpura, meticulous surgical techniques, and careful preoperative and intraoperative search for accessory spleen are critical factors for success in these patients. The procedure should be confined to expert laparoscopic surgeons with considerable experience in the management of hematologic diseases.