Laparoscopic HIPEC in the treatment of advanced ovarian cancer.

BACKGROUND/AIMS: HIPEC has been recently recommended as the 'new standard of care' for advanced ovarian cancer patients to treat residual disease, a recommendation based on the good results reported by many single institution studies. This study aims to elucidate whether cyto-reductive surgery for advanced stage IV ovarian cancer combined with laparoscopic HIPEC has any value in the management of advanced ovarian cancer. METHODOLOGY: From January 2007 to October 2011, 31 patients with stage IV ovarian cancer were enrolled. The inclusion criteria were stage IV epithelial ovarian cancer, with no evidence of extra-abdominal metastasis, and without previous systemic chemotherapy. Patients were randomly divided into two groups, group A and group B, which consisted of 12 patients who received laparoscopic HIPEC in a neo-adjuvant setting, and 19 patients who received laparoscopic HIPEC in an adjuvant setting, respectively. RESULTS: Overall response rate after Laparoscopic HIPEC (neo-adjuvant and adjuvant) was 100%. Macroscopic images recorded during initial laparoscopy and subsequent laparoscopies revealed a dramatic decrease in the size of the neoplastic deposits accompanied with a decrease in their absolute number. DISCUSSION: The results of this study indicate that laparoscopic HIPEC preceding multi-organ radical surgery has been seen to be associated with optimal short and long-term results, and promising OS and DFS. They also demonstrate the therapeutical advantage of neo-adjuvant initial approach over adjuvant approach.

Hepatitis B today.

Hepatitis B remains a major problem for public health worldwide and represents a challenging disease for practicing physicians. Of the 2 billion people who have been infected with the hepatitis B virus, more than 350 million have chronic infections. These chronically infected individuals are at high risk of death from cirrhosis and liver cancer. The use of new antiviral drugs, such us nucleotides analogues, offer good hope in the prognosis of patients suffering from chronic hepatitis B.

EGFR alterations in pancreatic ductal adenocarcinoma: a chromogenic in situ hybridization analysis based on tissue microarrays.

BACKGROUND/AIMS: To evaluate epidermal growth factor receptor (EGFR) gene status in pancreatic ductal adenocarcinoma correlating the results to protein expression and clinicopathological features METHODOLOGY: Using tissue microarray technology (TMArrayer 100), fifty (n = 50) paraffin-embedded tissue samples of histologically-confirmed primary tumors were cored twice at a diameter of 1 mm and re-embedded into the final recipient block. Immunohistochemistry was performed by the use of anti-EGFR monoclonal antibody (31G7). Also, a chromogenic in situ hybridization protocol was applied based on the use of EGFR gene and chromosome 7 centromeric probes, respectively. RESULTS: EGFR protein overexpression was observed in 29/50 (58%) cases and correlated to stage (p = 0.001) but not to grade (p = 0.206). EGFR gene analysis identified numerical alterations in 6/50 (12%), including 2 cases characterized by low-level gene amplification and 4 by absence of one allele. Gene status was associated to tumor grade (p = 0.023) and stage (p = 0.02). Chromosome 7 analysis detected aneuploidy in 14 (28%) cases. CONCLUSIONS: A subset of pancreatic ductal adenocarcinomas (PDACs) is characterized by EGFR gene numerical alterations including sporadic cases of amplification or absence of one allele (maybe due to gene deletion or intragenic point mutation and allelic silence). Those alternative mechanisms maybe influence the efficacy of novel targeted therapeutic strategies based on monoclonal antibodies or intracellular tyrosine-kinase inhibitors in PDACs.

Local recurrence following curative low anterior resection for rectal carcinoma.

BACKGROUND/AIMS: Local recurrence is a formidable problem after potentially curative resection for rectal cancer. We attempted to identify possible factors affecting the frequency of local recurrence, focusing on the clearance of the tumor and the margin of resection. METHODOLOGY: The clinical cohort consisted of 66 patients suffering from rectal carcinoma. All patients underwent a low anterior resection with meticulous pelvic preparation and dissection. The proximal and distal margins of the tumor were measured before fixing for permanent sections. RESULTS: Analysis by distance of the tumor from the anal verge revealed that 5 out of 33 patients (15.15%) from the upper rectal group and 7 out of 19 patients (36.8%) from the mid rectal group developed local recurrences (36.8% vs. 15.15% P=0.0369). Analysis by distance of the distal resection margins revealed that 8 out of 12 patients with local recurrence had distal margins less than 2cm, whereas 7 out of 40 patients free of local relapse had margins less than 2cm. Therefore 8 out of 15 patients with distal margins less than 2cm developed local recurrence (53.5%) whereas 4 patients among 37 with margins greater than 2cm developed a local failure (10.8%) (53.5% vs. 10.8% P=4.88E-04). The median survival in all patients of our series was 23 months. The median survival in 52 patients who underwent a potentially curative resection was 42 months. CONCLUSIONS: Tumors located in the upper portion of the rectum presented a minor tendency for local recurrence compared to tumors located in the middle of the rectum. Our study provides strong indications that high rate of local recurrences are probably related to the limited anatomic margins that can be obtained in the pelvis during primary resections.

How necessary is vagotomy after pancreaticoduodenectomy and total pancreatectomy.

BACKGROUND/AIMS: Gastrectomy with gastrojejunostomy is a fundamental step used for the restoration of the alimentary tract after pancreaticoduodenectomy or total pancreatectomy. Anastomotic ulcers occurring after pancreaticoduodenectomy, is a well known problem. The aim of our study is to investigate the incidence of anastomotic ulcer after pancreaticoduodenectomy or total pancreatectomy and to elucidate whether vagotomy is necessary. METHODOLOGY: In this study we reviewed the medical records of 94 patients who underwent pancreaticoduodenectomy or total pancreatectomy without vagotomy and we report the results after systemic follow-up 3-14 years, emphasizing the cases in which anastomotic ulcer is jeopardized. RESULTS: A total of 78 Whipple procedures and 16 total pancreatectomies without vagotomy were performed. The overall incidence of anastomotic ulceration following pancreatectomy was 11.7%. In our series the symptoms and complications associated with anastomotic ulceration were pain in 6 patients, bleeding in 4 patients and free perforation in one patient. Six patients needed a reoperation, the 4 patients with bleeding that underwent truncal vagotomy, the patient with free perforation in which oversew and bilateral vagotomy was performed and a patient with refractory pain who underwent a bilateral vagotomy. Among the 11 patients with anastomotic ulcer, the overall postoperative mortality rate was 27.3%. CONCLUSIONS: It seems reasonable to perform bilateral truncal vagotomy only in patients with a history of peptic ulceration and for patients with favorable prognosis and potential for long survival.

Regional targeting chemoimmunotherapy in patients undergoing pancreatic resection in an advanced stage of their disease: a prospective randomized study.

PURPOSE: To evaluate in a prospective randomized study the long-term results of adjuvant locoregional chemoimmunotherapy in a number of patients with stage III pancreatic duct cancer who underwent pancreatic resection between November 1993 and October 2000. METHODS: One hundred twenty-eight patients were divided into three groups. Group A (n = 40) patients had surgical resection alone. Group B (n = 45) patients had, using a side arterial branch of the jejunal artery, an arterial catheter advanced under fluoroscopic control into the superior mesenteric artery. Group B patients also received adjuvant chemotherapy. Group C (n = 43) patients had the same kind of arterial catheter and received as an adjuvant treatment locoregional chemoimmunotherapy. During the initial surgical exploration, all patients underwent pancreatic resection. Pancreatic resection involved a standard technique of extended duodenopancreatectomy with regional lymphadenectomy and was carried out in all patients by the first author. At the end of intervention, all patients were randomly assigned to the above-mentioned groups. Randomization was based mainly on histologic evidence of the stage of the disease. RESULTS: The 2- and 5-year survival rates were 29% and 0% for group A, 52% and 10% for group B, and 65% and 18% for group C. The respective percentages for disease-free survival were 20% and 0% for group A, 35% and 7% for group B, and 58% and 11% for group C. Since statistical differences among groups were observed from the second and third years, the study was interrupted early for ethical reasons. CONCLUSIONS: When applied regionally, combined chemoimmunotherapy is simple, safe, and effective. This type of therapy offers substantial advantages in terms of prolonging overall survival and improving disease-free survival compared to surgical resection alone or to surgical resection and adjuvant regional chemotherapy.