The diagnosis and staging of pancreatic cancer: A comparison of endoscopic ultrasound and computed tomography with pancreas protocol.

BACKGROUND: Pancreatic cancer is the fourth leading cause of cancer-related death in United States. We compared Computed Tomography (CT) with pancreas protocol and Endoscopic Ultrasound (EUS) in terms of mass detection, mass size, vascular involvement and lymph node involvement. METHODS: We retrospectively evaluated 93 patients. Concordance between CT and EUS, and accuracy of CT and EUS were assessed using a retrospective chart review and statistical analysis. RESULTS: CT and EUS agreed on mass detection in 88% of the cases and mass size in 67% of the cases. They agreed in 74% of cases about the presence or absence of vascular involvement and 82% in lymph node involvement. Cohen's kappa indicated that the concordance between two tests was moderately reliable. CONCLUSION: CT and EUS agree moderately well in identifying characteristics of pancreatic masses, but discrepancies between the two modalities are common, particularly with respect to involvement of specific blood vessels and lymph nodes. Clinicians should use caution in relying on a single modality to make decisions.

Establishing a complex surgical oncology program with low morbidity and mortality at a community hospital.

BACKGROUND: We report our experience with a large volume of complex oncologic resections and describe the framework necessary to develop a program with low morbidity and mortality in a community hospital. METHODS: From August 2010 to May 2014, 224 consecutive patients underwent abdominal oncological resection, at a community hospital by a single surgeon (R.N.B.). Cases included pancreatic, gastric, hepatobiliary, colorectal, hyperthermic intraperitoneal chemotherapy with cytoreduction, splenic, and sarcoma resections. We retrospectively reviewed our prospectively maintained database and evaluated postoperative complications. RESULTS: There was no 0, 30-, 60-, or 90-day mortality. The complication rate was 44%, including 5% grade I, 28% grade II, 9% grade III, and 1% grade IV complications. The median length of stay was 8 days. Mean follow-up for the entire group was 643 days. CONCLUSION: Our study demonstrates that complex oncologic resections can be safely performed in the community setting if a well-organized, surgeon-led multidisciplinary team is assembled.

Serum brain naturietic peptide measurements reflect fluid balance after pancreatectomy.

BACKGROUND: Overaggressive fluid resuscitation in elderly patients requiring pancreatectomy can delay recovery and increase morbidity. Despite advancements, no accurate and reproducible methods exist to evaluate effective intravascular volume status in the postoperative setting. We hypothesized that sequential measurement of currently available serum proteins will indicate fluid balance. STUDY DESIGN: Clinicopathologic (n = 44) and echocardiogram (echo) data (n = 18) were collected on patients receiving pancreatectomy or diagnostic laparoscopy (n = 5). Measured fluid balance, serum BUN, creatinine (CR), and brain natriuretic peptide (BNP) levels were recorded on postoperative days (POD) 1 to 7 (only POD1 for diagnostic laparoscopy). ANOVA and bivariate random effect models examined the correlation between BNP and BUN/CR and fluid balance. Linear mixed-effect models examined the correlation between factors associated with vascular stiffness and BNP, BUN/CR, and fluid balance. RESULTS: On POD1 after diagnostic laparoscopy, the fluid balance was positive by 3,265 mL and was accompanied by a >300-point increase in BNP (p = 0.0083). After pancreatectomy, a similar increase in BNP (250 pg/mL) and fluid balance (4,492 mL) on POD1 was observed. During the return to euvolemia, the change in serum BNP levels correlated with fluid balance changes during POD 1 to 3 (p = 0.039), and BUN/CR levels correlated with fluid balance during POD 4 to 7. Patients with risk factors associated with cardiovascular stiffness or echo evidence of poor compliance experienced higher BNP during the postoperative period. CONCLUSIONS: Fluid loading at surgery is accompanied by an increase in serum BNP, and return to a balanced fluid state after pancreatectomy is paralleled by changes in BNP and BUN/CR levels.

Desmoid tumor: current multidisciplinary approaches.

Desmoid tumor, also known as aggressive or deep fibromatosis or musculoaponeurotic fibromatosis, is a rare tumor. Desmoids are characterized by their ability to locally infiltrate; while frequently locally recurrent, they lack metastatic potential. Desmoids typically arise within the abdomen or abdominal wall, but can be extra-abdominal, most commonly in the proximal extremities. The infiltrative and recurrent nature of desmoid tumors can render surgical resection challenging if acceptable function and cosmesis is to be maintained. Consequently, desmoid management frequently involves a multidisciplinary approach that combines the expertise of several surgical specialists, for example, surgical oncologists and plastic surgeons, and also medical and radiation oncologists. As will be reviewed in this article, working together before undertaking any definitive therapies, such expert teams may be optimally positioned to offer patients superior functional and aesthetic outcomes based on maximizing therapeutic efficacy while minimizing treatment-related morbidities.

Curable metastatic colorectal cancer: recommended paradigms.

"Cure" for patients with stage IV colorectal cancer remains elusive, but for a growing subset of patients with colorectal liver metastases (CLMs), cure (ie, > 10-year survival without evidence of disease) is achieved in at least 17% of resected patients. Candidates for resection include those with limited and in some cases extensive hepatic disease, and in highly selected cases, patients with extrahepatic disease. Number, size, and bilaterality of CLMs no longer stand as absolute contraindications to surgery. Chemotherapy has further advanced the field of surgery for CLMs, enabling an additional group of patients who present with unresectable disease to undergo surgery after downsizing with chemotherapy. Modern surgical techniques and liver preparation allow resection after chemotherapy, with excellent results. This article summarizes the current multidisciplinary approach to treatment of CLMs. The definition of resectability, conversion of unresectable CLMs to resectable ones, advances in surgical techniques, advances in chemotherapy, and predictors of outcome are detailed.

Defining the role of fine-needle aspiration of thyroid nodules in male patients: is it necessary?

BACKGROUND: The purpose of this investigation was to show that fine-needle aspiration (FNA) of thyroid nodules in male patients may not be necessary in diagnosing thyroid cancer. METHODS: We performed a retrospective review of 130 adult male patients who underwent total thyroidectomy from January 2000 to January 2006 at a single institution. The preoperative FNA data for these subjects were reviewed and compared with the surgical pathology reports. RESULTS: During the study period, 70 of 130 (54%) had FNA, whereas 60 of 130 (46%) did not have FNA. Among all patients, 66 of 130 (51%) had a final pathology diagnosis of thyroid cancer and FNA was performed in 41 of 66 (62%) of these patients. The FNA pathology then was compared with the final pathology. CONCLUSIONS: In our study there was a high false-negative rate for FNA biopsy in the detection of thyroid malignancy in males. An alternative to FNA biopsy in male patients with thyroid nodules may be to go directly to surgery.

Detection of parathyroid adenoma in patients with primary hyperparathyroidism: the use of office-based ultrasound in preoperative localization.

BACKGROUND: The purpose of this investigation is to show that preoperative localization of the parathyroid gland using office-based ultrasound (US) and Tc-99m sestamibi scan is superior to all other approaches in detecting a parathyroid adenoma. METHODS: We performed a retrospective analysis of 43 patients who underwent parathyroidectomy for primary hyperparathyroidism. All patients underwent office-based US and sestamibi scintigraphy. Upon completion of the localization studies, a plan for focused or full operation was determined. RESULTS: In 42 of 43 patients, office-based US performed by a surgeon and sestamibi scintigraphy successfully detected the location of a parathyroid abnormality (42/43 cases, sensitivity = 98%, P < .05 =.0001). Office-based US localized the abnormal gland to the specific side (right/left) in 36 of 43 cases (84%). Sestamibi alone localized to the specific side in 29 of 43 cases (67%) for a statistically significant difference (P = .03). US localized the abnormal gland to the specific quadrant (34/43 cases [79%] sensitivity versus 23/43 cases [53%] sensitivity using sestamibi scan alone to localize to the specific quadrant, P = .03). CONCLUSION: It is clear that the combined modalities of office-based US and sestamibi scintigraphy in preoperative localization have a high success rate and should be considered in parathyroid surgery.