Morbidity and mortality associated with gastrectomy for gastric cancer.

BACKGROUND: Surgery alone is often inadequate for advanced-stage gastric cancer. Surgical complications may delay adjuvant therapy. Understanding these complications is needed for multidisciplinary planning. MATERIAL AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent gastrectomy for malignancy (ICD-9 code 151.x) from 2005 to 2010. Thirty-day mortality and morbidity were evaluated. RESULTS: Overall, 2,580 patients underwent gastrectomy for malignancy, divided as total gastrectomy 999 (38.7 %) and partial gastrectomy 1,581 (61.3 %). Overall, serious morbidity occurred in 23.6 %, and the 30-day mortality was 4.1 %. Patients receiving a total gastrectomy were younger and healthier than those receiving a partial gastrectomy for the following measured criteria: age, diabetes, chronic obstructive pulmonary disease and hypertension. Serious morbidity and mortality were significantly higher in the total gastrectomy group than the partial gastrectomy group (29.3 vs. 19.9 %, p < 0.001; and 5.4 vs. 3.4 %, p < 0.015, respectively). The inclusion of additional procedures increased the risk of mortality for the following: splenectomy (odds ratio [OR] 2.8; p < 0.001), pancreatectomy (OR 3.5; p = 0.001), colectomy (OR 3.6; p < 0.001), enterectomy (OR 2.7; p = 0.030), esophagectomy (OR 3.5; p = 0.035). Abdominal lymphadenectomy was not associated with increased morbidity (OR 1.1; p = 0.41); rather, it was associated with decreased mortality (OR 0.468; p = 0.028). CONCLUSIONS: Gastrectomy for cancer as currently practiced carries significant morbidity and mortality. Inclusion of additional major procedures increases these risks. The addition of lymphadenectomy was not associated with increased morbidity or mortality. Strategies are needed to optimize surgical outcomes to ensure delivery of multimodality therapy for advanced-stage disease.

Hepatocellular carcinoma masquerading as a large renal mass with hepatic invasion.

Large masses are evaluated with imaging to assess primary origin and tumor spread. We present the unusual case of a 53-year-old male with a 17-cm right upper quadrant mass suspected to be renal or adrenal in origin based on radiographic findings. After surgical excision, the mass was subsequently discovered to be primary hepatocellular carcinoma with direct extension to the kidney and adrenal gland. A diagnosis of chronic hepatitis B was made postoperatively. Primary hepatocellular carcinoma with direct renal extension is an exceedingly rare occurrence based on our experience and review of the published literature.

Long-term survival results of surgery alone versus surgery plus 5-fluorouracil and leucovorin for stage II and stage III colon cancer: pooled analysis of NSABP C-01 through C-05. A baseline from which to compare modern adjuvant trials.

BACKGROUND: The objective of this study is to conduct a pooled analysis of National Surgical Adjuvant Breast and Bowel Project (NSABP) colon trials involving surgery and surgery plus 5-fluorouracil and leucovorin (5-FU/LV) to compare survival and establish a baseline from which to evaluate future studies. METHODS: All patients enrolled in NSABP adjuvant trials C-01 through C-05 with stage II and III disease who were treated with surgery or with surgery plus 5-FU/LV were examined for overall survival (OS), disease-free survival (DFS), and recurrence-free interval (RFI). Time-to-event by treatment group was examined using adjusted Kaplan-Meier estimates and multivariable Cox regression analysis. RESULTS: There were 2,966 eligible patients: 693 (23%) surgery and 2,273 (77%) surgery plus 5-FU/LV; 1,255 (42%) stage II and 1,711 (58%) stage III. Age > or =60 years [hazard ratio (HR) = 1.36, P < 0.0001], male gender (HR = 1.20, P = 0.0012), and more nodes positive or fewer nodes examined (P < 0.0001) were associated with worse survival. At 5 years, the adjusted OS was 0.62 [confidence interval (CI) = 0.60-0.63] in the surgery group and 0.76 (CI = 0.74-0.78) in the surgery plus 5-FU/LV group. Treatment with 5-FU/LV was associated with improved outcome compared with surgery: OS (HR = 0.62, P < 0.0001), DFS (HR = 0.66, P < 0.0001) and RFI (HR = 0.64, P < 0.0001). Improved OS with adjuvant treatment was seen in both stage II (HR = 0.58, 95% CI = 0.48-0.71) and stage III disease (HR = 0.65, 95% CI = 0.55-0.75). CONCLUSIONS: This analysis demonstrates that treatment of colon cancer patients with 5-FU/LV following surgery provides benefit over surgery alone and can provide anticipated survival outcomes with which to compare modern adjuvant trials.

Differences in the pattern of presentation and treatment of proximal and distal gastric cancer: results of the 2001 gastric patient care evaluation.

BACKGROUND: While the overall incidence of gastric cancer has declined in the United States of America, the incidence of proximal gastric cancers has increased. The purpose of this analysis was to highlight key differences between proximal and distal gastric cancer as they relate to presentation and treatment. METHODS: Data on 6,099 patients diagnosed with gastric adenocarcinoma were collected as a patient care evaluation under the auspices of the American College of Surgeons Commission on Cancer. The chi-square (chi (2)) test was used for comparisons of proportions across levels of categorical variables by site. RESULTS: The proximal cancer group included 1,924 patients (87% cardia, 13% fundus) and the distal cancer group included 1,311 patients (85% antrum, 15% pylorus). Proportionately, proximal cancer cases were male (P < 0.01), younger (P < 0.01), and White (P < 0.01); whereas, distal gastric cancer cases were Black (P < 0.01), Hispanic (P < 0.01), and Asian (P = 0.01). Surgery alone (without adjuvant chemotherapy or radiation) was utilized more frequently in distal disease (39.5%) compared to proximal disease (25.7%) (P < 0.01). Preoperative adjuvant therapy was utilized more frequently in proximal disease (41.7%) compared to distal disease (2.1%) (P < 0.01). CONCLUSIONS: The populations that developed proximal verses distal gastric cancer differed with respect to sex, age, and racial background. Cancer-directed treatments also differed based upon tumor location. Understanding these differences may someday enable us to identify important high-risk populations, prevention strategies, and ultimately best treatment strategies. Long-term survival differences will be explored when follow-up data become available.

Mediastinal pancreatic pseudocyst with acute airway obstruction.

Pancreatic pseudocysts are usually located in the peripancreatic area, but on rare occasion a pseudocyst can reach the mediastinum. The natural history of mediastinal pseudocysts is poorly understood and seldom reported in the literature. We treated a patient who presented with an acute airway obstruction from a mediastinal pancreatic pseudocyst. Initial acute airway management and stabilization proved successful. A staged cyst decompression via a cervical and abdominal transhiatal approach was ultimately required. The natural history, potential complications, and management of pancreatic mediastinal pseudocysts are reviewed.

Epidermal growth factor receptor expression correlates with histologic grade in resected esophageal adenocarcinoma.

Activation of the epidermal growth factor receptor (EGFR) has a role in oncogenesis and may correlate with prognosis. The aim of this study was to examine EGFR expression in esophageal adenocarcinoma and correlate EGFR status with pathologic and clinical prognostic features. An exploratory retrospective review of 38 patients with surgically resected esophageal adenocarcinoma was performed. All patients underwent an esophagogastrectomy with regional lymphadenectomy; 24 patients underwent primary resection and 14 patients had surgery after preoperative chemoradiation therapy. Immunohistochemical analysis was performed on paraffin-embedded tissue samples using an EGFR monoclonal antibody. Low- and moderate-grade tumors were positive for EGFR expression in 2 of 15 patients; poorly differentiated tumors were positive for EGFR expression in 13 of 23 patients (p=0.02). The median survival was 35 months (confidence interval [CI]: 29-40) for EGFR negative patients (n=23) and 16 months (CI: 10-22) for EGFR positive patients (n=13) (p=0.10). Disease recurred in 3 of 21 EGFR negative patients and 6 of 13 EGFR positive patients (p=0.06). Poorly differentiated adenocarcinomas of the esophagus demonstrated higher EGFR expression compared to low-grade tumors based upon immunohistochemical analysis. A trend toward improved disease-free and overall survival was seen in EGFR negative patients.

The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma.

OBJECTIVE: Groin dissection is performed for the treatment of melanoma and other malignancies. Lymphedema rates as high as 47% have been reported. In 1996, we began using complete decongestive physiotherapy (CDP) in selected patients with lymphedema following groin dissection. Here, we review our results in a small cohort of patients. METHODS: A retrospective review of the medical records of 14 patients, treated with CDP for lymphedema secondary to groin dissection for melanoma was conducted. All patients were treated with CDP at Roswell Park Cancer Institute (RPCI), between 1996 and 2002. Of the 14 patients, 12 underwent groin dissection at RPCI. Response to therapy was measured by limb volume determinations. Patient gender, age, body mass index (BMI), type of operation, type of adjuvant therapy, time to treatment, patient compliance, lymphedema stage, and initial edema were analyzed for association with response to treatment. Incidence was estimated by a review of the operative logs. RESULTS: Fourteen patients were treated with CDP for lymphedema secondary to groin dissection for melanoma, with a median decrease in lymphedema of 60% (range: 35-145%; P = 0.0003). Increased BMI was associated with a decreased response to treatment (P = 0.02). Response to CDP was not effected by time to treatment, patient compliance, lymphedema stage, and initial edema. During this time, 39 groin dissections were done at RPCI. The incidence of lymphedema treated with CDP at RPCI was 31% (12/39; standard error 7.4%). CONCLUSIONS: With a decrease in lymphedema of 60%, CDP may provide relief for patients with lymphedema following groin dissection. Elevated BMI was associated with a decreased response to CDP.

Splenic infarction following laparoscopic Nissen fundoplication: management strategies.

Techniques for mobilizing the greater curve of the stomach during laparoscopic Nissen fundoplication (LNF) include division of the short gastric vessels (SGV). The splenic artery and vein lie directly posterior to the proper plane of dissection. Uncontrolled bleeding during SGV division places the splenic vessels at risk for inadvertent injury or ligation. We report herein on 2 patients referred to our institution who had left upper quadrant pain and radiographic evidence of segmental splenic infarction (SI) that resulted from a peripheral splenic artery branch injury during LNF. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from SI. Intense inflammation and adhesion formation making laparoscopic splenectomy difficult should be anticipated when operating on the infarcted spleen.

Adenoviral-mediated gene transfer of interleukin-2 in a human breast cancer cell line and a fresh primary breast cancer culture.

Adenovirally-mediated cytokine gene transfer has proven safe in the treatment of metastatic breast cancer. Unfortunately, the optimal conditions for gene transfer in the human breast remain largely unknown. Viral-mediated gene transfer was studied in a human breast cancer cell line and a fresh primary breast cancer culture using a type five adenoviral vector (AD5) containing the human interleukin 2 (IL-2) gene driven by a cytomegalovirus (CMV) promoter (AD5.CMV-IL2). IL-2 production was measured using an enzyme-linked immunosorbent assay (ELISA). In the human breast cancer cell line (MCF-7), IL-2 production increased logarithmically with viral dose and demonstrated peak production at 2000 ng/10(6) cells/24 h using a multiplicity of infection (MOI) of 3000:1. Transduction at a higher MOI resulted in cell death. IL-2 concentration reached over 2000 ng/ml 2 days after transduction and peaked 13 days after transduction at 5700 ng/ml. IL-2 levels declined thereafter. A fresh primary breast cancer culture, transduced with Ad5.CMV-IL2 at an MOI of 1000:1, secreted IL-2 at 15 ng/24 h 1 day after transduction and peaked at 85 ng/24 h 5 days after transduction. Adenoviral-mediated gene transfer was accomplished in breast cancer cells with high efficiency across a wide range of conditions. The optimal IL-2 dose required to maximally stimulate the immune system remains unknown.

Concordance with breast cancer pathology reporting practice guidelines.

BACKGROUND: Accurate pathology reporting is important for treatment of breast cancer. The College of American Pathologists (CAP) distributed guidelines for reporting cancer specimens in 1998. The aim of this study was to determine community-wide concordance with CAP breast cancer reporting guidelines. STUDY DESIGN: Pathology reporting of stage I and II breast cancers was examined for adherence to CAP guidelines. Pathology reports were reviewed from 100 consecutive cases of invasive breast cancers referred to Roswell Park Cancer Institute in 1998 to 1999 from community hospitals after excisional breast biopsy and 20 consecutive cases with excisional biopsy at RPCI. Adherence to CAP guidelines for clinically relevant items was determined from the original pathology report in each case. RESULTS: One hundred one cases met the inclusion criteria. Most reports did not include at least one of the guideline required elements. Surgical margins were inked in only 77%, and the margins oriented in only 25% of patients. Many specimens were not oriented by the surgeon. Grade was reported in most cases, but the Bloom Scarf Richardson grade was reported in only 6%. The presence or absence of lymphovascular invasion, and of coexisting in situ disease, was reported in 57% and 71%, respectively. The extent and type of in situ disease was reported in 47% and 49%, respectively. CONCLUSIONS: Breast cancer pathology reporting varies widely. Key elements that affect treatment are often omitted. These include gross description and size, orientation and involvement of surgical margins, and description of histologic features, including Bloom Scarf Richardson reporting of grade and the extent of an in situ component. Passive distribution of CAP practice guidelines might be insufficient to accomplish community-wide quality improvement in breast pathology reporting.

The evolution of lung cancer screening.

In the 1970s, four trials failed to demonstrate any mortality reduction using a combination of chest X-ray (CXR) and/or sputum cytology. The recent early lung cancer action project (ELCAP) demonstrated that modern screening is capable of detecting Stage I lung cancers. Bronchial epithelial changes leading up to cancers are now being understood to include histologic changes and genetic alterations. Emerging molecular markers detected in sputum and serum show promise in the future of lung cancer screening.

The effect of erythromycin on bile excretion and proximal small bowel motility following divided gastric bypass surgery: a prospective randomized placebo-controlled trial.

BACKGROUND: No conclusive data exists supporting the use of any prokinetic agent in the postoperative setting. The study was designed to examine the effect of erythromycin on small bowel motility in a placebo-controlled trial of post gastric bypass patients utilizing a standardized nuclear medicine test. METHODS: A consecutive series of 21 patients undergoing elective gastric bypass surgery for morbid obesity between September 1999 and March 2001 were enrolled in this prospective double-blind randomized controlled trial. Standard open, divided gastric bypass was performed. Patients were randomized to receive either erythromycin 250 mg i. v. (11 patients) or placebo (10 patients) every 8 hours. On postoperative day 2, a hepatic iminodiacetic acid (HIDA) scan was obtained. Tracer movement through the biliary tree and proximal small bowel was quantified and compared. RESULTS: Tracer clearance from the liver and biliary tree was no different between groups from time of injection through 1 hour. Tracer material clearance from the duodenum into the jejunum was no different between the erythromycin and control groups at 1 hour, 37% +/- 13% and 37% +/- 22% respectively (P = 0.95). At 4 hours, clearance was greater in the erythromycin group, 77% +/- 6%, compared to control, 60% +/- 20% (P = 0.036). The rate of tracer change between hour 1 and 4 (slope) was steeper in the erythromycin group (P = 0.048). CONCLUSIONS: Erythromycin increases intestinal transit in the postoperative setting.