Enhanced postoperative recovery with minimally invasive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies of gastrointestinal origin.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are the treatment of choice for select patients with peritoneal surface malignancies; however, the traditional open approach may be associated with significant morbidity. We evaluated postoperative outcomes with minimally invasive (MI) CRS and HIPEC. METHODS: Review of our institutional database identified 47 patients who underwent optimal cytoreduction (CC0 or CC1). Those with a PCI ≤ 15 and primary malignancy of gastrointestinal origin were then selected for subgroup analysis. Multivariable regression was performed to identify factors impacting postoperative outcomes. RESULTS: Demographic data did not significantly differ between open (n = 24) and minimally invasive (n = 9) groups. The MI group had a mean age of 57.34 ± 14.92, BMI of 27.03 ± 4.27, Charlson comorbidity score of 1.78 ± 1.72, and PCI of 5.56 ± 5.08. Mean time to flatus (days) was 2.78 in the MI group and 5.04 in the open group (p < 0.001), and mean length of IV analgesic use (days) was 3.11 in the MI group compared to 6.00 in the open group (p = 0.006). Mean length of stay (days) was 5.11 in the MI group and 8.67 in the open group (p = 0.033). Surgical approach (p = 0.037) and BMI (p = 0.039) were the only factors impacting length of stay. CONCLUSIONS: Minimally invasive CRS and HIPEC is an excellent option for low volume peritoneal disease of gastrointestinal origin. A minimally invasive approach yields faster return of bowel function, reduced postoperative analgesia requirements, and shorter hospital stay.

Improved outcomes with surgery compared to radiofrequency ablation in the treatment of resectable hepatocellular carcinoma.

BACKGROUND: While overall cancer incidence and mortality have decreased over the last decade, hepatocellular carcinoma (HCC) cases have increased sharply. OBJECTIVE: This study set out to evaluate the utility of surgery for resectable single tumor HCC in this setting. PATIENTS AND METHODS: This study analyzed the National Cancer Database, selecting all patients with a histological diagnosis of HCC and an isolated tumor (≤5 cm) treated with radiofrequency ablation (RFA) or surgical resection. RESULTS: A total of 7821 patients were identified for this study. In the patients with a single tumor up to 3 cm, 40% had a surgical resection and 60% had RFA. In the group with a tumor 3.01-5 cm, 62% had a surgical resection and 38% had RFA. Patients with a single tumor up to 5 cm had a 3-year survival of 60% after resection compared to 42% with RFA. When the patients were split into those with a tumor up to 3 cm or a tumor 3.01-5 cm, there was a survival benefit in the surgical resection cohort. CONCLUSION: Surgical resection may be underutilized in the USA for resectable HCC, especially in patients with a tumor up to 3 cm.

Venous thromboembolism in patients with cancer undergoing surgical exploration.

Malignancy and surgery are both independent risk factors for venous thromboembolism (VTE) events. The current NCCN guidelines recommend VTE prophylaxis for up to 28 days after major abdominal or pelvic surgery for malignancy. We set out to evaluate the rate and timing of VTEs among patients with gastric, pancreatic, colorectal, and gynecologic malignancies who underwent surgery. We performed a retrospective review of the NSQIP database (2005-2013) focusing on patients with gastric, colorectal, pancreatic, and gynecologic malignancies. Our primary endpoint was a diagnosis of VTE within 30 days of surgery. We analyzed 128,864 patients in this study. On multivariable analysis, patients with pre-operative sepsis (OR 2.36, CI 2.04-2.76, p < 0.001), disseminated cancer (OR 1.73, CI 1.55-1.92, p < 0.001), congestive heart failure (OR 1.69, CI 1.25-2.28, p = 0.001), gastric cancer (OR 1.3, CI 1.09-1.56, p = 0.004), and pancreatic cancer (OR 1.2, CI 1.03-1.30, p = 0.021) were more likely to have a VTE. Of patients who had a VTE event, 34% occurred after discharge from surgery (gastric: 25%, colorectal 34%, pancreatic 31%, gynecologic malignancy 42%). Our study demonstrates that patients who undergo an operation for malignancy with pre-operative sepsis, disseminated cancer, congestive heart failure, gastric cancer, or pancreatic cancer are more likely to develop a VTE within 30 days of their operation. Of those patients who developed a VTE, approximately one-third occurred after discharge during a 30 day post-operative period. This data supports that further studies are needed to determine the appropriate length of post-operative VTE chemoprophylaxis in patients with cancer.

Incidental finding of mammary carcinoma in lumpectomy specimens.

More and more breast lumpectomies are being performed due to mammographic screening, and both in situ and invasive breast carcinomas are being detected earlier and smaller in size. The objective of this study was to determine the presence of incidental microscopic breast carcinoma in mammography-guided lumpectomy specimens. A prospective study was carried out by processing in surgical pathology approximately 9,000 breast lumpectomy specimens during a 2.5-yr period so that the entire specimens were embedded for microscopic examination. Excluded from the study were cases with grossly or microscopically identified carcinomas greater than 10 mm2, and non-invasive carcinomas diagnosed in association with invasive carcinoma. Cases with multifocal carcinomas, prior diagnosis of breast cancer, or prior history of breast biopsy were also excluded. Carcinomas present in the same tissue blocks as the clinically suspected lesions such as palpable nodules, microcalcification, or other mammographic abnormalities were excluded as well. Fifty cases of incidental microscopic mammary carcinoma were found including 8 infiltrating ductal carcinomas (IDC), 2 infiltrating lobular carcinomas (ILC), 21 intraductal carcinomas (DCIS), and 19 lobular carcinomas in situ (LCIS). All of the lesions were solitary, located in indistinct loosely arranged fibrous and adipose stromal tissues, and the majority of them were near or at the inked excisional margins. Physicians who care for patients with breast cancer should be aware of the existence of these minute breast carcinomas that are often near or at the surgical margins. The significance of these microscopic findings for therapeutic strategy and prognosis should be determined by long-term follow-up.

Combined adenocarcinoma and carcinoid tumor in atrophic gastritis.

The development of adenocarcinoma or carcinoid tumors in atrophic gastritis is widely documented. We report the simultaneous occurrence of gastric adenocarcinoma and carcinoid (composite tumor) in atrophic gastritis, a finding reported only twice before in the literature. This 52-yr-old man with rectal bleeding, epigastric pain, and iron deficiency anemia was noted to have multiple polypoid masses on upper endoscopy. Biopsy revealed features of both adenocarcinoma and carcinoid tumor in a background of atrophic gastritis, leading to a total gastrectomy, lymph node dissection, and liver biopsy. The gastrectomy specimen was characterized by a 6 cm pedunculated polyp and multiple sessile nodular masses between 0.4 and 2.5 cm in the background of a granular mucosa. On microscopic examination, the large polypoid mass corresponded to a well-differentiated adenocarcinoma, intestinal type, infiltrating the wall. The smaller nodules were composed of carcinoid tumors, restricted to the mucosa, or infiltrating the gastric wall. Carcinoid tumor was also seen in the large polypoid mass closely intermingled with adenocarcinoma. The carcinoid tumor metastasized to the liver. Lymph nodes showed both adenocarcinoma and carcinoid tumor. The gastric mucosa was characterized by atrophic gastritis with intestinal metaplasia, neuroendocrine hyperplasia, and microcarcinoids. The adenocarcinoma stained strongly for CK7, CK 20, MIB-1, and focally for chromogranin and synaptophysin. The carcinoid tumor was negative for CK7, CK 20 and MIB-1, and was positive for chromogranin and synaptophysin. Overexpression of p53 was noted only in the adenocarcinoma. Electron microscopy revealed neurosecretory granules in the carcinoid characteristic of a neuroendocrine tumor. Composite tumor can occur in the setting of atrophic gastritis. The findings in this patient reinforce the concept that the epithelial and neuroendocrine cells of the gastrointestinal tract both result from multidirectional differentiation of a primitive cell.