Practice patterns and outcomes for anorectal melanoma in the USA, reviewing three decades of treatment: is more extensive surgical resection beneficial in all patients?

INTRODUCTION: Historically, the treatment of anorectal melanoma has been abdominoperineal resection (APR), but more recently local resection alone. Although treatment at melanoma centers has become less aggressive, the adoption of this approach and related outcomes across the USA is unknown. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried to identify patients treated for anorectal melanoma (1973-2003). Treatment patterns and survival were studied. Frequency of treatment was compared using the chi-square test; survival was calculated using the Kaplan-Meier method. RESULTS: The 183 patients identified from the SEER database had a median age of 68 years. Of the 143 patients whose data were included, 51 underwent APR and 92 underwent transanal excision (TAE). Despite similar pathologic characteristics, median survival was similar in the two groups: 16 months for APR and 18 months for TAE (P = ns). Five-year survival also was similar in the two groups: 16.8% for APR and 19.3% for TAE (P = ns). The rate of APR was 27.0% between 1973 and 1996, as compared with 43.2% between 1997 and 2003 (P = ns). CONCLUSION: This study, the largest series to analyze widespread practice patterns and outcomes for anorectal melanoma in the USA, did not reveal a survival difference comparing TAE with APR. Moreover, the study did not reveal a trend toward less aggressive surgical resection. Since the extent of surgical intervention did not correlate with survival or extent of primary tumor, APR should be reserved for selected patients in whom TAE is not technically feasible.

A rare cause of primary hepatic neoplasm: malignant peripheral nerve sheath tumor in the age of modern liver surgery.

Primary malignant peripheral nerve sheath tumor (MPNST) of the liver is rare. Histologic identification of spindle cells from a biopsy specimen and the potential clinical diagnoses are discussed. Potential metastatic and primary spindle cell lesions, as well as their impact on treatment decisions are considered. This was successfully treated with ablation assisted surgical resection and minimal blood loss.

Management of T2 gallbladder cancer: are practice patterns consistent with national recommendations?

BACKGROUND: The national recommendation for the management of localized T2 gallbladder cancer (GBCA) is radical cholecystectomy. Although reported survival for localized T2 disease has been poor, groups have documented improvement with radical resection. We hypothesized that a discrepancy exists between national recommendations and current practice patterns. METHODS: Patients diagnosed with localized T2 GBCA between 1988 and 2002 were identified from the Surveillance, Epidemiology, and End Results registry. Age, sex, race, ethnicity, extent of surgery, and overall survival were assessed. Surgical procedure was categorized as cholecystectomy alone (CS), cholecystectomy plus lymph node dissection (CS+LN), radical cholecystectomy (RCS), or other. Survival calculations were made using the Kaplan-Meier method and compared with the log-rank test. RESULTS: Of 382 patients with pathologically confirmed T2 GBCA, 280 were women. The median patient age was 75 years. A total of 238 patients underwent CS, 76 underwent CS+LN, and 14 underwent RCS. The remaining 54 patients underwent a lesser or no procedure and were excluded from comparative analysis. The median survival was 14 months for all patients and 14, 14, and 8 months for subgroups treated with CS, CS+LN, and RCS, respectively. Rates of 5-year survival were 23%, 24%, and 36% for CS, CS+LN, and RCS subgroups, respectively. There was no significant difference in survival rates between RCS and CS+LN, or between RCS and CS. CONCLUSIONS: The majority of patients with T2 GBCA in the United States are not managed according to current national recommendations.

Association of angiogenesis markers with lymph node metastasis in early colorectal cancer.

HYPOTHESIS: We hypothesized that p53 mutations (mp53) are associated with decreased expression of thrombospondin 1 (TSP-1) and that decreased TSP-1 expression is associated with lymph node metastases. DESIGN: A retrospective study of lymphatic mapping and pathologic determination of angiogenesis markers in primary colorectal cancer. SETTING: Tertiary care cancer institute. PATIENTS: Sixty-one patients with colorectal cancer underwent lymphatic mapping. Lymph nodes that stained negative by hematoxylin-eosin were examined with immunohistochemistry for micrometastases. Primary tumors were analyzed by immunohistochemistry for mp53 and TSP-1 expression. The t test and the Mann-Whitney U test were used to examine the mean difference in TSP-1 expression between tumors. MAIN OUTCOME MEASURES: Mutant p53 expression, TSP-1 expression, and metastatic progression. RESULTS: Thirty-six of the 61 patients (59%) had nodal metastases shown by hematoxylin-eosin or immunohistochemistry in the sentinel node (N2, N1, N1mi, or N0[i+]). Patients with a truly negative sentinel node (pN0[i-][sn]) had significantly higher TSP-1 expression compared with those with some degree of nodal metastases (57.7 vs 30.1; P < .001). Acquisition of mp53 was associated with a decreased mean TSP-1 expression. Tumors without mp53 expression had a mean TSP-1 optical density value of 51.3 while tumors with elevated mp53 had a mean TSP-1 optical density value of 31.8 (P < .03). CONCLUSIONS: Patients with primary colorectal cancer with low TSP-1 expression, with or without detection of mp53 gene product, are more likely to harbor lymph node metastasis than patients with higher expression. Patients with a truly negative sentinel node (pN0[i-][sn]) frequently have higher expression of TSP-1 that may have inhibited metastatic progression. Further studies will investigate the relationship between mp53, TSP expression, and disease progression.

Lymphatic mapping and sentinel node analysis: current concepts and applications.

Since the introduction of sentinel node biopsy in 1990 as a minimally invasive surgical technique for the diagnosis of melanoma lymphatic metastases, the number of applications has expanded. We review applications and the current status of sentinel node biopsy in melanoma, breast, colon, gastric, esophageal, head and neck, thyroid, and lung cancer. Variations on techniques specific to each organ are explained, and the current role of sentinel node biopsy in diagnosis and treatment is discussed.