Radical Resection in Entero-Pancreatic Neuroendocrine Tumors: Recurrence-Free Survival Rate and Definition of a Risk Score for Recurrence.

BACKGROUND: Surgery with radical intent is the only potentially curative option for entero-pancreatic neuroendocrine tumors (EP-NETs) but many patients develop recurrence even after many years. The subset of patients at high risk of disease recurrence has not been clearly defined to date. OBJECTIVE: The aim of this retrospective study was to define, in a series of completely resected EP-NETs, the recurrence-free survival (RFS) rate and a risk score for disease recurrence. PATIENTS AND METHODS: This was a multicenter retrospective analysis of sporadic pancreatic NETs (PanNETs) or small intestine NETs (SiNETs) [G1/G2] that underwent R0/R1 surgery (years 2000-2016) with at least a 24-month follow-up. Survival analysis was performed using the Kaplan-Meier method and risk factor analysis was performed using the Cox regression model. RESULTS: Overall, 441 patients (224 PanNETs and 217 SiNETs) were included, with a median Ki67 of 2% in tumor tissue and 8.2% stage IV disease. Median RFS was 101 months (5-year rate 67.9%). The derived prognostic score defined by multivariable analysis included prognostic parameters, such as TNM stage, lymph node ratio, margin status, and grading. The score distinguished three risk categories with a significantly different RFS (p < 0.01). CONCLUSIONS: Approximately 30% of patients with EP-NETs recurred within 5 years after radical surgery. Risk factors for recurrence were disease stage, lymph node ratio, margin status, and grading. The definition of risk categories may help in selecting patients who might benefit from adjuvant treatments and more intensive follow-up programs.

Double intestinal duplication and incidental neuroendocrine tumor of appendix, a rare case of acute abdomen.

INTRODUCTION: Intestinal duplication is rarely reported in adulthood and often remains undiagnosed until onset of complications. We describe the case of a 39 year old woman who came to our observation for acute abdomen due to a combination of double intestinal duplication (colon and ileum) and an incidental neuroendocrine tumor of the appendix. MATERIALS AND METHODS: A 39 year old woman who was admitted at with upper abdominal pain. Multisliced spiral CT scan showed a cystic lesion suggestive of an inflammed Meckel's diverticulum.The patient was underwent an urgent explorative laparoscopy. The intraoperative findings revealed a cystic lesion of the anti-mesenteric side of transverse colon, apparently dissectable from the bowel and a second lesion with a strongly adherent and unresectable from the anti-mesenteric aspect of the small bowel. A combined appendectomy was also performed. The histological diagnosis was consistent with a typical intestinal duplication for both intestinal lesionsand an incidental 2mm carcinoid tumor was also found in the appendix. The postoperative course was uneventful and the patient was discharged on p.o. day 5. At the presenttime she is well and following a regular oncologic follow-up. DISCUSSION: The rarity of this case is due to the concomitant presence of an incidental, sincronous, appendiceal NET. The elective treatment is surgical resection. CONCLUSION: Intestinal duplication in the adulthood is extremely rare and may either have an acute presentation as acute abdomen or represents an incidental finding of mass. We suggest that, once the diagnosis is suspected patient must undergo surgery.

Value of regional lymphadenectomy in pancreatic cancer.

Radical surgical resection and adjuvant chemotherapy are the goal standard to attempt significant long term survival in patients suffering from ductal pancreatic cancer. The role of extended lymph-node dissection is still a debated issue. In this paper a deep review of the experiences reported in the literature is carried out. Several studies are limited, not randomized and retrospective: generally speaking they seem to suggest a positive role in node dissection. Unfortunately, this trend is not confirmed in the only two trials conducted in a prospective and randomized setting. Moreover the results of these studies are also difficult to compare. At the moment we can say that extended lymphadenectomy does not play a determinant role for long term survival but a positive trend has been shown for node positive patients.

Cytoreductive surgery in advanced endocrine tumours of the pancreas.

Surgery still plays an important role even in advanced endocrine tumours of the pancreas, owing to their biological behaviour. Sometimes it is possible to attempt a radical approach, but more often only cytoreduction is feasible. In fact, when the malignancy is not completely resectable on account of vessel involvement or extensive liver metastases, surgical reduction of the tumour burden (debulking) can be proposed, aimed at improving the clinical conditions and survival of these patients. Forty-one patients suffering from advanced endocrine tumour of the pancreas were observed from 1985 to 1996. In 13 patients, the disease was locally advanced as far as concerns lymph node metastases and/or vessel involvement, while the other 28 patients presented liver metastases. In the former group, we performed 6 radical resections, in the latter we submitted 2 patients to radical resection and 12 patients to cytoreductive surgery, with complete removal of the pancreatic malignancy. The overall survival of the resected patients was 87% (7/8). Three patients (37.5%) are alive and free of disease, while the other 4 have subsequently developed liver metastases. One patient died with hepatic recurrence. Half the patients (6/12) undergoing cytoreductive surgery are alive, 3 with stable and 3 with progressive disease. The other 6 patients have died due to liver progression of the disease. As data in the literature concerning the role of debulking as regards the survival are conflicting, we have modified our surgical approach in patients with advanced disease. We perform cytoreductive surgery whenever complete removal of the pancreatic tumour is feasible. The rationale of this approach is to leave only a liver with residual disease, with a view to giving targeted adjuvant treatment.

[Pain in the elderly. A study of 183 consecutive subjects hospitalized in a geriatric medical ward]. / La douleur chez le sujet âgé. Etude de 183 sujets hospitalisés de façon consécutive en médecine gériatrique.

OBJECTIVES: Determine the prevalence of pain and related demographic, somatic, emotional, and therapeutic variables in hospitalized elderly subjects. PATIENTS AND METHODS: One hundred eighty-three elderly patients consecutively hospitalized in the geriatric medical unit were included in a cross-sectional study. RESULTS: Pain was observed in 48.3% of patients with sustained cognitive function and 67.7% of patients with impaired cognitive function. In the first group (sustained cognitive function) no variable was significantly associated with pain except the diagnosis of general geriatric problems (falls, dehydration, drug intoxication). Conversely, in the second group (patients with impaired cognition) the presence of pain was significantly associated with a serious alteration of the somatic status (malnutrition, inflammation, bedridden status), poor prognosis (long-lasting hospitalization, death), and the presence of anxiety. Finally, patients suffering from pain did not receive pore pain killers than patients without pain. CONCLUSION: This study clearly demonstrates that pain has a high prevalence in aged hospitalized patients, especially those who have impaired cognitive function. It reveals a relationship between pain, somatic and psychic deterioration, and deficiency in pain-killer prescriptions.

Assessment and treatment of severe pancreatitis. Protease inhibitor.

From the theoretical point of view, antiproteolytic therapy would seem to be the rationale for acute pancreatitis management. Unfortunately, clinical human trials studying the role of antiproteases in the treatment of acute pancreatitis differ in several respects in terms of their basic design. As a consequence, any form of homogeneous analysis of the reported data as a whole is impossible. Considering the data emerging from a meta-analysis of five trials a rational use of antiproteases may result in a reduction of complications requiring surgery and of patient management costs only in selected cases, meaning by that severe and necrotic forms. As regards presumptive applications, over 400 patients were prospectively tested versus placebo in a double-blind trial with the aim of preventing acute pancreatitis after ERCP. The complication incidence was significantly lower among the pretreated patients; anyway, also in this field of protease inhibitor clinical application it is necessary to identify the patients with the greatest risk to develop post-ERCP acute pancreatitis. In conclusion, antiproteases can still play a role when given prophylactically or when used in the very early phases of the disease; moreover a 'multiple drugs approach' (including, for example, suitable antibiotics) seems to represent nowadays the most modern and rational treatment of acute pancreatitis.

To what extent is surgery superior to endoscopic therapy in the management of chronic pancreatitis?

The surgeon was the only figure involved in the management of chronic pancreatitis patients unresponsive to medical treatment, until a few years ago. Nowadays, because of less invasive, endoscopy offers a seductive alternative to surgery. Up to now no clinical prospective and randomized data comparing the results of the two different approaches are available. Surgery seems to be the only solution for chronic pancreatitis with duodenal stenosis and the last chance of eliminating diagnostic uncertainty. Also in the case of biliary tract involvement surgery should be regarded as the procedure of choice, inasmuch as the stenosis is benign and generally long-lasting, and endoscopic treatment would have to be repeated several times; endoscopy, in this indication, should be reserved only for patients who present contraindicating surgery conditions (such as severe jaundice, colangitis etc.); the endoscopist should assess whether to insert a stent or a naso-biliary drainage tube referring the patient back to the surgeon once good clinical conditions have been restored. Endoscopy and surgery should be regarded not as adversaries in the management of chronic pancreatitis and its complications, but as complementary procedures in an integrated approach. The maximum degree of complementarity should be achieved in the management of pseudocysts and in cases presenting severe, incapacitating pain. In selected cases endoscopy can play a definitive role. The generally good surgical outcomes, moreover, should convince endoscopists not to insist with repeated, hazardous manoeuvres in cases of failure. Particularly interesting is the possibility of performing endoscopic sphincterotomy combined with extracorporeal shock-wave lithotripsy prior to surgical treatment in cases of chronic calcifying calcific pancreatitis. The crushing of the calculi and partial clearance of the duct have simplified surgery and complete clearance of the duct in those patients receiving such treatment in our experience.