Management of locoregional stage esophageal cancer: a single center experience.

Therapeutic options for locoregional esophageal cancer (EC) include primary surgery, neoadjuvant or definitive chemoradiation and systemic chemotherapy. The role of surgery in these multimodal strategies has recently been debated and definitive chemoradiation is being offered as an alternative to surgery at many centers. We examined our results with multimodal therapy and surgery in this patient population. We conducted a retrospective analysis of 172 patients with locoregional (AJCC stages I-III) EC treated at RPCI between February 14, 1990 and September 20, 2002. Median age was 65 years (range, 36-95); there were 136 male patients. There were 100 regional (stages IIB-III), 69 local (stages I-IIA) and three in situ cases. Initial therapy was either combined modality (n = 122) or single modality (surgery) (n = 50). There was 0%, 30-day, postoperative mortality. Median survival for all patients was 25.3 months and was better for local stage with surgery alone (75 months) than with neoadjuvant (35.7 months) or definitive chemoradiation (19.1 months, P < 0.001). Survival for patients with regional disease treated with surgery alone, neoadjuvant or definitive chemoradiation was 21.5, 24.4 and 11.8 months, respectively (P = not significant). The associations of prognostic factors with overall survival were evaluated using Cox proportional hazards regression analysis and 2-sided Wald's chi-square test. On multivariate analysis, carefully selected patients treated with surgery alone had better outcomes compared with those treated with definitive chemoradiation (P < 0.001). Patients with locoregional esophageal cancer who are eligible for surgical resection either alone or as a part of multimodal therapy may have better outcomes than those treated with non-surgical approaches.

Is glucagonoma of the pancreas a curable disease?

BACKGROUND: Glucagonomas are rare neuroendocrine tumors of the pancreas. Because of its rarity, its natural history is not well understood. AIM: We evaluated the natural history of glucagonomas treated at a tertiary care cancer center. METHODS: A retrospective analysis of 12 patients during 1970 to 2000 was performed. Six patients (50%) had a tumor located in the head of the pancreas. RESULTS: Abdominal pain (83%) and weight loss (75%) were the most common symptoms. Median tumor size was 6 cm (range 0.04-10). Seven patients (58%) had liver metastases. Five patients (42%) underwent curative resection. Overall median survival was 66 mo, and 5-yr overall survival was 66%. Five-yr overall survival was 83% for patients who had resection versus 50% for the non-resected patients (p = 0.04). Patients who were disease-free had a complete resection of the primary tumor and no liver involvement. CONCLUSIONS: Glucagonomas generally present with liver metastases at the time of diagnosis. Cure is only possible if the disease is localized and completely resected.

Iatrogenic esophagobronchial fistula arising in irradiated Barrett's esophagus.

A 47-yr-old male underwent a right upper lobectomy for stage IIB bronchoalveolar carcinoma followed by 4600 Gy of irradiation. One year later a fistula formed from an ulcerated region of Barrett's esophagus into the left main bronchus. Bronchotomy repair with onlay patch intercostal muscle flap and esophageal repair with serratus anterior muscle flap plus postoperative esophageal stent placement for stricture resulted in good functional results.

Small cell carcinoma of the gallbladder.

BACKGROUND AND OBJECTIVES: Small cell carcinoma of the gallbladder is rare with only 36 cases reported in the literature. Early reports demonstrated an extremely poor prognosis for this histologic type. Five new cases are reported and the previous experience in the literature is reviewed to further clarify the clinical behavior of this malignancy. METHODS: A retrospective analysis is performed on 5 new cases. An extensive review of the literature is also performed. RESULTS: Twenty-eight pure small cell carcinomas and 8 combined small cell carcinomas with adenocarcinoma are reported in the literature. Conclusions from the literature review reveal that small cell carcinoma of the gallbladder affects an elderly patient population (median age 65 years), has a female preponderance (76%), is associated with cholelithiasis (72%), metastasizes to nodes (88%), liver (88%), lung (23%), and peritoneum (19%), and has a median survival of 4 months. Pure tumors had median survivals of 9 months and combined tumors had median survivals of 4.5 months. The 5 patients in the literature treated with surgery and chemotherapy had improved median survival of 13 months. The 5 newly reported cases had similar epidemiological characteristics to the literature data, however, these cases were managed aggressively with surgery and chemotherapy, demonstrating a median survival of 31 months. CONCLUSIONS: Although small cell carcinoma of the gallbladder is a distinct histologic and clinical entity, it has many clinical characteristics similar to adenocarcinoma of the gallbladder including comparable natural history and tendency for locoregional spread. Aggressive multimodality therapy, especially the combination of surgery and chemotherapy, may improve survival.

Large Brunner's gland hamartoma simulating a pancreatic mass with obstruction and bleeding.

Brunner's gland hamartomas can present as a mass lesion causing obstruction but are also an uncommon cause of upper gastrointestinal bleeding. These tumors may not be accurately identified on radiographic study. Endoscopic examination may be used for diagnostic purposes and may also have therapeutic benefits. Endoscopy can complement surgical intervention, when necessary, for the proper treatment of these lesions.

Pneumatosis intestinalis and portal venous air associated with needle catheter jejunostomy.

Pneumatosis intestinalis is an unusual postoperative complication. In some cases, immediate surgical intervention may be necessary. This report describes pneumatosis intestinalis with portal venous air attributed to enteral nutritional support via needle catheter jejunostomy. The etiology, radiographic findings, and management of this problem are reviewed.

Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial.

BACKGROUND: Photodynamic therapy (PDT) is a different type of laser treatment from Nd:YAG thermal ablation for palliation of dysphagia from esophageal cancer. METHODS: In this prospective, multicenter study, patients with advanced esophageal cancer were randomized to receive PDT with porfimer sodium and argon-pumped dye laser or Nd:YAG laser therapy. RESULTS: Two hundred thirty-six patients were randomized and 218 treated (PDT 110, Nd:YAG 108) at 24 centers. Improvement in dysphagia was equivalent between the two treatment groups. Objective tumor response was also equivalent at week 1, but at month 1 was 32% after PDT and 20% after Nd:YAG (p < 0.05). Nine complete tumor responses occurred after PDT and two after Nd:YAG. Trends for improved responses for PDT were seen in tumors located in the upper and lower third of the esophagus, in long tumors, and in patients who had prior therapy. More mild to moderate complications followed PDT, including sunburn in 19% of patients. Perforations from laser treatments or associated dilations occurred after PDT in 1%, Nd:YAG 7% (p < 0.05). Termination of laser sessions due to adverse events occurred in 3% with PDT and in 19% with Nd:YAG (p < 0.05). CONCLUSIONS: Photodynamic therapy with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy.

The effect of extended lymphadenectomy on survival in patients with gastric adenocarcinoma.

BACKGROUND: In the United States of America, the five-year survival rate among patients surviving curative resection for gastric carcinoma will range between 20 and 25 percent. In Japan, early diagnosis and an aggressive surgical approach including planned lymph node dissection has resulted in the five-year survival rate exceeding 50 percent for all patients with newly diagnosed gastric carcinoma. This report is a retrospective review evaluating the effect of extended lymph node dissection (D2) on overall survival in 101 patients with gastric adenocarcinoma who underwent a potentially curative gastric resection from 1975 to 1990 at Roswell Park Cancer Institute. STUDY DESIGN: Gastric carcinomas were staged according to the revised 1987 TNM classification. Lymph node dissections were defined according to the General Rules of the Japanese Research Society for Gastric Cancer. Gastric resections in this study were classified as D2.5, D2, D1.5, and D1 and divided into two groups, the extended resection group (D2, D2.5) and the limited resection group (D1, D1.5). RESULTS: The median follow-up period was 33 months. The entire group (n = 101) had an estimated five-year survival rate of 36 percent with a median survival rate of 33 months. The estimated five-year survival rate for the extended resection group (n = 46) was 49 percent with a median of 50 months compared with 27 percent and 25.7 months, respectively, for the limited resection group (n = 55, p = 0.01). Following extended resection, 74 percent of patients with stage I gastric carcinoma survived five years, 75 percent of patients with stage II carcinoma were alive at five years as were 13 percent with stage IIIA, and 30 percent with stage IIIB. Patients whose tumors fell into the classifications of T2-4, N0-1, M0 and required a total or proximal gastrectomy enjoyed a significant survival advantage undergoing an extended resection, with 44 percent surviving five years with a median of 43 months compared with 16 percent and 25 months, respectively, for patients undergoing a limited resection (p = 0.05). Of 13 patients treated with a D2 or greater resection whose gastric carcinomas metastasized to N2 lymph nodes, four patients (31 percent) survived at least five years. Only the extent of lymph node dissection and type of gastric resection proved to be significant independent predictors of overall survival. CONCLUSIONS: Patients treated by extended resection (D2, D2.5) were more likely to survive five years and had prolonged median survival times when compared with patients treated with limited resection (D1, D1.5). For patients with T2-4, N0-1, M0 gastric carcinomas treated with extended resection, their differences reached levels at or approaching statistical significance.

Adenocarcinoma of the small intestine: 21-year review of diagnosis, treatment, and prognosis.

BACKGROUND: The purpose of this study was to evaluate the tumor characteristics and treatment associated with an improved overall survival in patients with adenocarcinoma of the small intestine. METHODS: The records of all patients with primary adenocarcinoma of the small bowel seen between January 1971 and December 1991 were reviewed retrospectively. The study comprised 38 patients, 22 (58%) with duodenal tumors, 11 (29%) with jejunal tumors, and five (13%) with ileal tumors. RESULTS: Although not statistically significant, the patients with duodenal adenocarcinoma lived longer than the patients with jejunal or ileal lesions (p = 0.77). The overall survival was 23% and seemed to correlate best with absence of lymph node metastases (p = 0.04) and pancreaticoduodenectomy for localized duodenal tumors (p = 0.04). The patient's age, duration of symptoms, disease-free interval, tumor location, type of recurrence, and histologic grade did not significantly influence survival. CONCLUSIONS: The lethality of small-intestinal adenocarcinoma appears to be related to a delay in diagnosis and treatment. When a definitive surgical procedure is performed before lymph node metastases appear, the patient's chance for long-term survival is greatly improved.

Percutaneous endoscopic gastrostomy (PEG) in cancer patients.

Ninety-nine cancer patients underwent PEG placement attempt at Rosewell Park Cancer Institute between January 1, 1985, and December 1, 1987. Ninety-eight of these were successful and were retrospectively reviewed to determine if cancer patients constitute a high-risk group for PEG placement. Procedure-related mortality was 2% and morbidity was 19%. Morbidity of 17% was noted at less than 30 days and 2% had late complications. Six complications were considered serious with peritonitis in 3 and tube loss in 3 patients; an additional 4 patients had a failure of adequate GI tract decompression which was the indication for their PEG placement. Ascites was a major factor in morbidity with 4 of 5 patients with ascites having complications including the 2 deaths. Overall major morbidity was not increased in cancer patients without ascites including a group of patients with carcinomatosis (18 patients) and 22 patients requiring preoperative dilatation and/or tumor ablative procedures. We conclude that morbidity in cancer patients is not increased if one excludes those with ascites from the procedure.

Neutropenic enterocolitis. Clinical diagnosis and treatment.

Review of the consultation records of the Gastrointestinal Surgical Oncology service at Roswell Park Memorial Institute from 1982 to 1987 revealed 22 patients with a clinical diagnosis of neutropenic enterocolitis. Ninety-one percent of the patients had hematologic malignancies, and 95% were receiving cytotoxic chemotherapy. Sixteen patients were treated nonsurgically; 11 died. Of those 11 cases, autopsies were performed in 9. At autopsy, the clinical diagnosis was confirmed in four cases; four cases were found to have normal intestinal tracts, and one case had a small bowel volvulus. In none of the four cases for which autopsy proved neutropenic enterocolitis was transmural bowel necrosis or perforation found. Laparotomy was performed in six patients; three survived. The clinical diagnosis was verified in four of the six patients. Neutropenic enterocolitis must be considered a diagnosis of exclusion. Care of these patients should be individualized. Nonoperative management with bowel rest, decompression, nutritional support, and broad spectrum antibiotics is recommended initially. Operative intervention is recommended for those with perforation or those whose condition deteriorates clinically during close, frequent observation.

Impact of splenectomy on survival following gastrectomy for adenocarcinoma.

From 1972 to 1985, 161 palliative and 99 curative gastrectomies were performed, including splenectomy (SPL), in 49 and 42 patients, respectively. The relative contribution of tumor histology and location of primary tumor within the stomach to median survival times in months (MST) was examined by chi-square analysis for patients who had SPL and those who did not. MST for the 40 patients treated by curative gastrectomy and SPL was 33 months compared with 43.5 months in the 56 patients treated by curative gastrectomy without SPL (P = .24). Three postoperative deaths were excluded from this analysis. Neither tumor location nor the histological type had a statistically significant impact on MST within these two groups. SPL was not found to have statistically significant impact on survival following curative gastrectomy. In 46 patients treated by palliative gastrectomy with SPL the MST was 10.5 months compared with 15.5 months in 110 patients who were treated by palliative gastrectomy without SPL (P = .007). Five postoperative deaths and three patients in which primary tumor location could not be accurately determined were excluded from this analysis. The MST of 23 patients treated by SPL who had poor or undifferentiated histology was 8 months, compared with 15 months in 73 patients with similar histology not treated by SPL (P = .02). There was no statistically significant difference in MST between palliative gastrectomy patients who had well or moderately differentiated histology treated with (n = 23) and without (n = 37) SPL (P = .11). The impact of SPL on MST following palliative gastrectomy was not significantly influenced by tumor location in the stomach.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal pain in neutropenic patients.

The records of 50 patients with abdominal pain and severe neutropenia were retrospectively reviewed to identify factors that may have influenced survival and surgical decisions. Ninety-two percent of these patients had hematologic malignant neoplasms. The patients were divided into four groups: 23 treated nonsurgically who died in the hospital, 10 treated nonsurgically who survived, 10 treated surgically who survived, and 7 treated surgically who died. Abdominal distention was the only symptom or sign found to be associated with mortality. Ninety-five percent of survivors recovered their white blood cell count above 1.0 x 10(9)/L, while 70% of nonsurvivors did not. No symptom or sign was found to be pivotal in the decision for or against surgical intervention. Overall, 60% of the patients in this series died. Thirty-four percent of patients underwent a surgical procedure, the majority of whom survived. We designed an algorithm for the evaluation and treatment of neutropenic patients with abdominal pain.

Adjuvant 5-FU and MeCCNU improves survival following curative gastrectomy for adenocarcinoma.

During the 13-year period ending December 31, 1984, 51 patients treated by curative gastrectomy for gastric adenocarcinoma invasive beyond the submucosa were eligible to enter adjuvant chemotherapy trials. Twenty-one of 22 patients in the first treatment group (FMe) received 5-fluorouracil and a nitrosourea. The second group of eight patients received the same drugs plus Adriamycin (FAMe). Twenty-one patients were observed as surgical controls. Each adjuvant treatment group was subdivided into groups of patients with zero to four or five or more lymph node metastases for survival analysis. Fifteen patients were alive without evidence of disease at five years. Analysis of variance of survival times showed that lymph node status (P = 0.0001) and adjuvant chemotherapy (P = 0.01) were statistically significant prognostic variables. The FMe group had the best survival. A Fisher's exact test showed that the FMe group had a greater proportion of five-year survivors (P = 0.0217) than the no treatment arm. Patients with only zero to four positive lymph nodes in the FMe group had a statistically greater number of five-year survivors than patients in the no treatment arm (P = 0.0155). In this series, postoperative 5-fluorouracil and MeCCNU significantly improved the survival times of patients after curative gastrectomy for adenocarcinoma as compared with surgical controls.

Carcinoma of the gallbladder. The Roswell Park experience.

The median survival, from diagnosis, of patients with cancer of the gallbladder is 6 months. Our purpose in reviewing our experience was to identify factors, either in patient characteristics or treatment, that influence this statistic. In 22 years 71 cases of gallbladder carcinoma were referred to Roswell Park Memorial Institute in Buffalo, New York. Most had a cholecystectomy that revealed an unsuspected neoplasm, before referral. Mean age was 62 years and 75% were female. Symptoms, signs, and laboratory and imaging studies were uniformly unhelpful in determining the diagnosis. Early diagnosis at a stage amenable to surgical excision remains the sole salvation. Patients who receive chemotherapy did better than those who did not, but this is probably a reflection of patient selection. Newer treatment modalities are urgently needed.

A new technique for decompression of the biliary tract.

Using techniques originally developed for roentgenologic placement of much smaller bore catheters, a large bore, thick wall Silastic catheter has been used to decompress and internally drain the right hepatic biliary system, while a more traditional approach was used on the left. By avoiding the trap of standard procedures and retaining the ability to innovate, a good surgeon will be able to work out a satisfactory solution for a difficult problem for the ultimate betterment of the patient and self.

Endoscopic ablation of esophageal malignancies with the neodymium-YAG laser and electrofulguration.

The case reports of 40 patients with obstructive esophageal cancer treated with electrofulguration (EF) or neodymium (Nd)-YAG laser were reviewed. Surgery was contraindicated because of advanced carcinoma (17 patients), recurrence after resection (13 patients), recurrence after irradiation (four patients), and poor medical condition (four). Two patients refused surgery. There were 31 men and four women; mean age was 62 years. There were 31 adenocarcinomas, eight squamous cell carcinomas, and one metastatic breast carcinoma. Tumor locations were lower esophagus in 35 patients, middle esophagus in three, and cervical esophagus in two. Thirty-five patients had obstructions; two, bleeding, and three, both. None of the patients could swallow solids. A total of 255 treatments were given (mean, 6.6 per patient). The mean number of Nd-YAG treatments was 1.9; for EF, 1.3. All 40 patients tolerated solid food after treatment and the esophagus remained open from three to 14 weeks. Mean survival from first treatment was 11 months; from diagnosis, 17 months. Both techniques were safe and effective.

Radio-protective effect of sodium meclofenamate. A prospective clinical trial.

Twentyfour patients treated with irradiation to either their pelvis or their chest for neoplastic disease were included in a randomized study of radioprotection with sodium meclofenamate (Meclomen) (SM). Seventeen patients received SM 100 mg, p.os, t.i.d., and seven received placebo. The long-range radiation related chronic gastrointestinal and urinary tract toxicity was diminished by SM. At 12 months post irradiation, SM treated patients experienced less gastrointestinal and urinary symptoms, as well as less measured bladder contraction, than the controls. Acute gastrointestinal signs of radiotoxicity, however, seemed to have been enhanced by SM. The treated patients suffered from nausea, vomiting, and diarrhea. These acute toxic effects were temporary and reversible.