Total Lymphadenectomy and Nodes-Based Prognostic Factors in Surgical Intervention for Esophageal Adenocarcinoma.

BACKGROUND: To evaluate prognostic factors based on the number of resected lymph nodes, we considered 202 patients who underwent radical resection and "total lymphadenectomy" for esophageal adenocarcinoma according to a prospective protocol. METHODS: Fifty-eight tumors surrounded by Barrett's epithelium underwent esophagectomy and esophagogastrostomy, and 144 tumors without Barrett's epithelium underwent esophageal resection at the azygos vein level, total gastrectomy, and Roux-en-Y esophagojejunostomy. All nodes and fat tissue were resected at the following stations: chest 4L and R3, R4, R7, R8, and R9 (TNM seventh edition) and abdomen 1-12 according to the Japanese Classification of Gastric Carcinoma (1998). The nodes were counted, excluding fragments. The correlations between the number of nodes yielded and the ratio of the metastatic lymph nodes/lymph nodes yielded with pT stage, grading measurements, and cancer-specific survival (CSS) were calculated. RESULTS: A total of 6,270 nodes were yielded (interquartile range per patient, 22-38; minimum, 4 nodes; maximum, 61 nodes). In 3 of 21 (14%) stage pT1 cases, less than 10 nodes were counted, in 2 of 27 (8%) stage pT2 cases, less than 20 were counted, and in 73 of 154 (47%) stage pT3-4 cases, less than 30 nodes were counted. The lymph node yield (LNY) and T stage were not correlated (r = 0 .048; p = 0.5). The metastatic lymph nodes to lymph nodes yielded ratio was correlated with pT stage (r = 0.272; p = 0.0001), and G (r = 0.385; p = 0.0001). CSS positively correlated with pT stage (p = 0.02), G (p = 0.001), and metastatic lymph nodes/lymph nodes yielded ratio (p = 0.01) (multivariate analysis). CONCLUSIONS: The total number of lymph nodes to be removed in total and within each T stage indicated as thresholds could not be reached in up to 38.6% of patients. The metastatic lymph nodes/lymph nodes yield ratio not the total LNY, did correlate with cancer-specific survival.

Collis-Nissen gastroplasty for short oesophagus.

The Collis-Nissen procedure is performed for the surgical treatment of 'true short oesophagus'. When this condition is strongly suspected radiologically, the patient is placed in the 45° left lateral position on the operating table with the left chest and arm lifted to perform a thoracostomy in the V-VI space, posterior to the axillary line. The hiatus is opened and the distal oesophagus is widely mobilized. With intraoperative endoscopy, the position of the oesophago-gastric junction in relationship to the hiatus is determined and the measurement of the length of the intra-abdominal oesophagus is performed to decide either to carry out a standard anti-reflux procedure or to lengthen the oesophagus. If the oesophagus is irreversibly short ('true short oesophagus'), the short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The left thoracoscopic approach is suitable to control effectively the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used). The tip of the stapler is clearly visible while 'walking' on the left diaphragm. The Collis gastroplasty is performed over a 46 Maloney bougie. A floppy Nissen fundoplication and the hiatoplasty complete the procedure.

Prognostic factors in a multicentre study of 247 atypical pulmonary carcinoids.

OBJECTIVES: To analyse clinical and biomolecular prognostic factors associated with the surgical approach and the outcome of 247 patients affected by primary atypical carcinoids (ACs) of the lung in a multi-institutional experience. METHODS: We retrospectively evaluated clinical data and pathological tissue samples collected from 247 patients of 10 Thoracic Surgery Units from different geographical areas of our country. All patients were divided into four groups according to surgical procedure: sub-lobar resections (SURG1), lobar resections (SURG2), tracheobronchoplastic procedures (SURG3) and pneumonectomies (SURG4). Overall survival analysis was performed using the Kaplan-Meier method and log-rank test. Survival was calculated from the date of surgery to the last date of follow-up or death. The parameters evaluated included age, gender, smoking habits, laterality, type of surgery, 7th edition of TNM staging, mitosis Ki-67 (MIB1), multifocal forms, tumourlets, type of lymphadenectomy and neo/adjuvant therapy. For multivariate analysis, a Cox regression model was used with a forward stepwise selection of covariates. RESULTS: Two hundred and forty-seven patients (124 females and 123 males; range 10-84, median 60 years) underwent surgical resection for AC in the last 30 years as follows: n = 38 patients in SURG1, 181 in SURG2, 15 in SURG3 and 14 in SURG4. A smoking history was present in 136 of 247 (55%) patients. The median follow-up period was 98.7 (range 11.2-369.9) months. The overall survival probability analysis of the AC was 86.7% at 5 years, 72.4% at 10 years, 64.4% at 15 years and 58.1% at 20 years. Neuroendocrine multicentric forms were detected in 12 of 247 patients (4.8%; 1 of 12 pts) during the follow-up (range 11.2-200.4, median 98.7 months) and 33.4% had recurrence of disease. There were no significant differences between gender, tumour location and type of surgery at the multivariate analysis. Age [P < 0.001, hazard ratio (HR) 0.60; confidence interval (CI) 0.32-1.12], smoking habits (P = 0.002; HR 0.43, 95% CI 0.23-0.80) and lymph nodal metastatic involvement (P = 0.008; HR 0.46, 95% CI 0.26-0.82) were all significant at multivariate analysis. CONCLUSIONS: ACs of the lung are malignant neuroendocrine tumours with a worst outcome in patients over 70 years and in smokers. With the exception of pneumonectomy, the extent of resection does not seem to affect survival and should be accompanied preferably by lymphadenectomy. Pathological staging, along with a mitotic index more than Ki-67 (MIB1), appears to be the most significant prognostic factor at the univariate analysis.

Esophagogastric metaplasia relates to nodal metastases in adenocarcinoma of esophagus and cardia.

BACKGROUND: Immunohistochemical profiles of esophageal and cardia adenocarcinoma differ according to the presence or absence of Barrett's epithelium (BIM) and gastric intestinal metaplasia (GIM) in the fundus and antrum. Different lymphatic spreading has been demonstrated in esophageal adenocarcinoma. We investigated the correlation among the presence or absence of intestinal metaplasia in the esophagus and stomach and lymphatic metastases in patients who underwent radical surgery for esophageal and cardia adenocarcinoma. METHODS: The mucosa surrounding the adenocarcinoma and the gastric mucosa were analyzed. The BIM+ patients underwent subtotal esophagectomy and gastric pull up, and the BIM- patients underwent esophagectomy at the azygos vein, total gastrectomy, and esophagojejunostomy. The radical thoracic (station numbers 2, 3, 4R, 7, 8, and 9) and abdominal (station numbers 15 through 20) lymphadenectomy was identical in both procedures except for the greater curvature. RESULTS: One hundred ninety-four consecutive patients were collected in three major groups: BIM+/GIM-, 52 patients (26.8%); BIM-/GIM-, 90 patients (46.4%); BIM-/GIM+, 50 patients (25.8%). Two patients (1%) were BIM+/GIM+. A total of 6,010 lymph nodes were resected: 1,515 were recovered in BIM+, 1,587 in BIM-/GIM+, and 2,908 in BIM-/GIM- patients. The percentage of patients with pN+ stations 8 and 9 was higher in BIM+ (p=0.001), and the percentage of patients with pN+ perigastric stations was higher in BIM- (p=0.001). The BIM-/GIM- patients had a number of abdominal metastatic lymph nodes higher than did the BIM-/GIM+ patients (p=0.0001). CONCLUSIONS: According to the presence or absence of BIM and GIM in the esophagus and cardia, adenocarcinoma correspond to three different patterns of lymphatic metastasization, which may reflect different biologic and carcinogenetic pathways.

Does anatomical segmentectomy allow an adequate lymph node staging for cT1a non-small cell lung cancer?

INTRODUCTION: Anatomical segmentectomy is again under evaluation for the cure of T1a N0 non-small cell lung cancer and carcinoid tumors. Whether anatomical segmentectomy does permit or not, an adequate resection of nodal stations for staging or cure is still pending. METHODS: A case-matched study was ruled on patients with peripheral cT1a N0 M0 tumors that underwent anatomical segmentectomy or lobectomy. Dissection of lymph node stations 4, 5, 6, and 7 was identical in anatomical segmentectomy and lobectomy; stations 10, 11, 12, and 13 were also dissected carefully during anatomical segmentectomy. RESULTS: We individually matched 46 (69% men) anatomical segmentectomy with 46 (71% men) lobectomy for age, anatomical segment, and size of the tumor. The median (interquartile range) size of the resected lesions was 1.7 cm (1.35-1.95 cm) in anatomical segmentectomy and 1.6 cm (1.3-1.9 cm) (p = 0.96) in lobectomy. The anatomical segmentectomy and lobectomy resection margins were free of cancer. The median number (interquartile range) of total dissected lymph nodes was 12 (8-5-14) in anatomical segmentectomy compared with 13 (12-14.5) in lobectomy (p = 0.68), with a number of N1 nodes being 6 (4-7.5) and 7 (4.5-9.5) (p = 0.43), respectively, and N2 nodes 5.5 (4-7.7) and 5 (4-6.5) (p = 0.88). Only 1 patient of 46 (2%) anatomical segmentectomy was N1, whereas in lobectomy, 4% had N1 (2 patients). Freedom from recurrence at 36 months was 100% for anatomical segmentectomy and 93.5% for lobectomy (p = 0.33). CONCLUSIONS: Anatomical segmentectomy for cT1a tumors compared with lobectomy procures an adequate number of N1 and N2 nodes for pathological examination. Cancer-specific survival was equivalent at 36 months.

Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia.

OBJECTIVE: Quality of outcome of the Heller-Dor operation is sometimes different between studies, likely because of technical reasons. We analyze the details of myotomy and fundoplication in relation to the results achieved over a 30-year single center's experience. METHODS: From 1979-2008, a long esophagogastric myotomy and a partial anterior fundoplication to protect the surface of the myotomy was routinely performed with intraoperative manometry in 202 patients (97 men; median age, 55.5 years; interquartile range, 43.7-71 years) through a laparotomy and in 60 patients (24 men; median age, 46 years; interquartile range, 36.2-63 years) through a laparoscopy. The follow-up consisted of periodical interview, endoscopy, and barium swallow, and a semiquantitative scale was used to grade results. RESULTS: Mortality was 1 of 202 in the laparotomy group and 0 of 60 in the laparoscopy group. Median follow-up was 96 months (interquartile range, 48-190.5 months) in the laparotomy group and 48 months (interquartile range, 27-69.5 months) in the laparoscopy group. At intraoperative manometry, complete abolition of the high-pressure zone was obtained in 100%. The Dor-related high-pressure zone length and mean pressure were 4.5 ± 0.4 cm and 13.3 ± 2.2 mm Hg in the laparotomy group and 4.5 ± 0.5 cm and 13.2 ± 2.2 mm Hg in the laparoscopy group (P = .75). In the laparotomy group poor results (19/201 [9.5%]) were secondary to esophagitis in 15 (7.5%) of 201 patients (in 2 patients after 184 and 252 months, respectively) and to recurrent dysphagia in 4 (2%) of 201 patients, all with end-stage sigmoid achalasia. In the laparoscopy group 2 (3.3%) of 60 had esophagitis. CONCLUSIONS: A long esophagogastric myotomy protected by means of Dor fundoplication cures or substantially reduces dysphagia in the great majority of patients affected by esophageal achalasia and effectively controls postoperative esophagitis. Intraoperative manometry is likely the key factor for achieving the reported results.

Do bone marrow isolated tumor cells influence long-term survival of non-small cell lung cancer?

INTRODUCTION: Inconsistent information on the prognostic significance of non-small cell lung cancer (NSCLC) isolated tumor cells (ITC) has been reported to date. We sought to evaluate the survival for NSCLC in a group of patients in which the presence of bone marrow isolated tumor cells and their DNA ploidy was assessed. MATERIALS AND METHODS: Seventy patients (58 males [83%]; median age 70 years, range 49-89) with T1-4, N0, M0 clinical staging entered the study; 68 who underwent complete resection, were included in the follow-up. Two patients with clinical stage T2 and T4, N0, M0 were excluded because of pleural carcinosis discovered at thoracotomy. Recruitment ended in 2002. None received neoadjuvant therapy. The rib bone marrow was extracted and assessed for ITC by hematoxylin and eosin (H&E) staining, immunohistochemistry and flow cytometry. The latter was regarded as positive when >10% of cells reacted to pan-cytokeratin antibody MNF116. DNA ploidy was studied by propidium iodide staining. Patient follow-up was with chest X-ray and abdominal US every 6 months, and CT-PET scan every 12 months for at least 5 years after surgery. Causes of death were assessed. RESULTS: Rib bone marrow ITC were documented in 17 patients (25%), 6 with DNA euploidy (p stage: I 4; III 2), and 11 with DNA aneuploidy (p stage: I 5; II 4; III 2) while 51 (75%) patients were free of ITC (p stage: I 32; II 8; III 9; IV 2). The median follow-up was 61 months, 21 patients died from causes unrelated to NSCLC and 12 patients died from causes related to tumor relapse. Significant survival differences were observed according to stage, presence of ITC and DNA aneuploidy. In particular free from recurrence survival was significantly reduced in stage IA and IB patients presenting aneuploid ITC (Wilcoxon (Gehan) test p=0.031). CONCLUSIONS: The prognostic role of bone marrow ITC seems to be corroborated by DNA ploidy studies. Patients with bone marrow ITC with abnormal DNA content showed a significantly reduced survival particularly in stage I NSCLC.

Immunopathological patterns of the stomach in adenocarcinoma of the esophagus, cardia, and gastric antrum: gastric profiles in Siewert type I and II tumors.

BACKGROUND: The morphologic and immunohistochemical profiles of gastric mucosa and of the tumor were assessed in Siewert type I, type II, and gastric antrum adenocarcinomas. METHODS: Sixty-two patients, prospectively operated upon, were included in the study: 37 type II, 15 type I, and 10 antrum adenocarcinoma. Samples of the tumor, the surrounding area, and the gastric corpus and antrum were analyzed histologically, and immunostained for cytokeratins (CK)7/20 (staining positive for cells labeled > or = 50%). RESULTS: Among the 37 type II adenocarcinomas were the following: (1) 13 of 37 (35%) had intestinal metaplasia (IM) in the stomach; (2) 24 of 37 (65%) did not show IM at any level; (3) 34 of 37 (92%) had Helicobacter pylori (HP) infection; (4) 13 of 37(35%) had CK7/20 expression of "Barrett's type" (CK7+/20-); 24 of 37 (65%) had a "no Barrett's type" profile (10 of 37 with CK7-/CK20+ and 14 of 37 with CK7+/CK20+); (5) 100% showed the same CK immunoprofile, both in IM and adenocarcinoma (measure of agreement k = 1, p = 0.000). Type I adenocarcinomas showed the following: (1) 87.5% CK Barrett's type, both in the tumor, and in the surrounding IM; (2) 100% gastric samples devoid of both IM and HP infection. Comparison between CK immunoprofiles in type I and type II tumors showed a difference within the two groups (p = 0.002). One hundred percent of antrum adenocarcinomas showed a no Barrett's type CK profile, both in the tumor and in the IM of the entire stomach. CONCLUSIONS: Data suggest that type II adenocarcinoma cannot be always considered a gastroesophageal reflux disease-related tumor; other pathogenetic pathways should be taken into consideration.

Cutaneous granulomatous reaction to injectable hyaluronic acid gel: another case.

We report a case of a granulomatous reaction in the melolabial folds, occurring 10 days after treatment with Restylane. The patient, who had previously been treated with the same product in the last 2 years without any adverse effect, developed an unusual early fibrotic reaction that we hypothesized related to hypersensitivity after repeated use. The lesions slowly disappeared with topical steroid therapy. An improved knowledge of the modality of these uncommon adverse effects is necessary to assess the long-term safety and efficacy of this product.

Long-term results after Heller-Dor operation for oesophageal achalasia.

OBJECTIVE: In the literature, reports on the definitive rate of cure of the surgical treatment of oesophageal achalasia are not numerous. The aim of this study is to assess the clinical-instrumental-based patient's outcome related to long-term follow-up. METHODS: One hundred and seventy-four patients (80 men, median age 57 years, range 7-83) consecutively submitted to first instance transabdominal Heller-Dor in the period 1978-2002 were considered. Follow-up consisted of clinical interview, endoscopy, barium-swallow and oesophageal manometry if required. Twenty-six cases (15%) were sigmoid achalasias. RESULTS: One patient died post-operatively (severe haemorrhage in a patient previously operated upon for a cardiovascular malformation and suffering for portal hypertension), 173 were followed-up (mean 109 months, range 12-288, median 93 months) of whom 68 for more than 15 years. On the whole 151 patients (87.3%) had satisfactory and 22 (12.7%) had poor long-term results. Seven out of 173 patients (4%), 6 of whom were pre-operatively classified as sigmoid achalasia, subsequently underwent oesophagectomy, 3 for epidermoid cancer, 1 for Barrett's adenocarcinoma, 2 for stasis oesophagitis and recurrent sepsis, 1 for severe dysphagia. Fifteen patients (8.7%) had an insufficient result due to reflux oesophagitis which appeared in 2 (one erosion) after 184 and 252 months. All 22 patients, whether surgically or medically retreated, achieved satisfactory control of dysphagia and reflux symptoms. CONCLUSIONS: In the long term, insufficient results strictly related to Heller-Dor failure, always due to reflux oesophagitis, were recorded in 15/173 patients (8.7%) although it is questionable whether reflux oesophagitis appearing after more than 15 years is due to the Dor incompetence or to ageing. In sigmoid achalasia, oesophagectomy rather than myotomy should be taken into consideration in the first instance. In the long-term, surgery is the best definitive treatment for oesophageal achalasia.

[Laparoscopic and left thoracoscopic Collis-Nissen procedure: technique and short term results]. / Intervento di Collis-Nissen per via laparoscopica e toracoscopica sinistra: tecnica e risultati a breve termine.

The aim of this paper is to illustrate a laparoscopic-thoracoscopic technique for the surgical management of foreshortened esophagus in patients affected by severe gastro-esophageal reflux disease. The patient is placed on the operating table with the left chest and arm lifted to perform a thoracostomy in theV-VI space, posterior to the axillary line. The hiatus is opened and the distal esophagus is mobilized. With intraoperative endoscopy the position of the gastroesophageal junction in relationship to the hiatus is determined in order to decide whether to perform a standard procedure for reflux or to lengthen the esophagus. In the second case, short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The Collis gastroplasty is performed over a 42 Maloney bougie. A floppy Nissen and the hiatoplasty complete the procedure. Twenty-two procedures of laparoscopic-thoracoscopic Collis gastroplasty were performed. The postoperative course was regular in 17 patients and complicated in 5 cases. Two procedures were converted for split of the endosuture caused by an oversized Maloney bougie (52 Ch). Other complications included intrathoracic migration of the fundoplication with need for repeating laparoscopic surgery, an empyema without fistula and atrial fibrillation. In conclusion, this technique corresponds to all principles of anti-reflux surgery and makes it possible to properly treat any anatomical condition.

Transthoracic endosonography for the intraoperative localization of lung nodules.

BACKGROUND: Transthoracic ultrasonography has been advocated for the localization of lung nodules during video-assisted thoracoscopic surgery (VATS) for nonperipheral nodules. METHODS: Video-assisted thoracoscopic surgery for lung nodules was performed in 54 consecutive patients. Preoperative computed tomography (CT) diagnosed 65 lesions. Positron emission tomography (PET) identified 2 lesions not revealed by CT. All nodules were judged whether visible and/or palpable. Diameter and distance of the nodule from the anterior, lateral, and posterior chest wall were measured on CT scan and served in a discriminant analysis to predict which nodule would be neither visible nor palpable. The deflectable multifrequency (7.5 to 10 MHz) endosonography probe was used to identify the nonvisible and nonpalpable nodules. RESULTS: Resected nodules were 69; 67 diagnosed preoperatively, and 2 intraoperatively by ultrasonography. At VATS exploration 16 of 65 (25%) of the CT diagnosed nodules were nonvisible and nonpalpable. The discriminant analysis failed to predict correctly whether nodules would be visible and/or palpable in 33% because of surrounding severe emphysema, proximity to a fissure, or to the hylum. The endosonography identified 15 out of 16 of the nonvisible and nonpalpable nodules, thus conversion to thoracotomy was necessary for one nodule. The combination of video, palpatory, and endosonographic inspections had 98% sensitivity and 100% specificity in localizing the nodules. CONCLUSIONS: Intraoperative transthoracic ultrasonography is useful to guide VATS resection of lung nodules. It is a bedside tool, not requiring planning and coordination with the interventional radiology suite, thus you use it if you need it. It has no related morbidity, and may also have a role in revealing lesions occult at preoperative work-up.