Peritoneal metastases in patients with neuroendocrine neoplasms: a challenging site of metastases with clinical and prognostic implications.

PURPOSE: Peritoneal metastases (PM) of neuroendocrine neoplasm (NEN) origin are identified with increasing frequency and exert a significant effect on quality of life and clinical status of the patients. The aim of this study was to identify the characteristics and the prognostic significance of PM in patients with NENs. METHODS: A retrospective analysis of the data of patients from two tertiary referral centers was performed. We defined a control group of age- and gender-matched NEN patients with comparable stage IV disease but no PM. RESULTS: We analysed 70 patients (41 females) with PM. Small intestine was the most common primary NEN site (87.1%). PM prevalence was 10.3%. Forty-four patients presented with synchronous PM, whereas 26 developed metachronous PM. The majority of patients had other concomitant metastases (50 hepatic, 6 lung and 12 bone metastases). Twelve patients developed intestinal obstruction. After PM diagnosis, 76% of patients received treatment with somatostatin analogues while six patients (8.6%) were treated with peptide receptor radionuclide therapy (PRRT). The median progression-free survival (PFS) in the PRRT-treated group was 15 months (95% CI 2-28). Median overall survival (OS) in the PM group was 142 months [95% CI 71-213] while it was not reached in the control group. CONCLUSION: Peritoneal metastases show low prevalence among NEN patients and are most likely to develop in patients with small intestinal NENs and advanced metastatic disease. The presence of PM does seem to be associated with a negative prognostic impact on OS of NEN patients and their identification and prompt treatment is of major importance.

Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation.

Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.

Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy improves survival in patients with colorectal peritoneal metastases compared with systemic chemotherapy alone.

BACKGROUND: Colorectal cancer peritoneal metastasis (CPM) confers an exceptionally poor prognosis, and traditional treatment involving systemic chemotherapy (SC) is largely ineffective. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly advocated for selected patients with CPM; however, opinions are divided because of the perceived lack of evidence, high morbidity, mortality, and associated costs for this approach. As there is no clear consensus, the aim of this study was to compare outcomes following CRS+HIPEC vs SC alone for CPM using meta-analytical methodology, focusing on survival outcomes. Secondary outcomes assessed included morbidity, mortality, quality of life (QOL), and health economics (HE). METHODS: An electronic literature search was conducted to identify studies comparing survival following CRS+HIPEC vs SC for CPM. The odds ratio (OR) was calculated using the Mantel-Haenszel method with corresponding 95% confidence intervals (CI) and P-values. Heterogeneity was examined using the Q-statistic and quantified with I(2). The fixed-effect model (FEM) was used in the absence of significant heterogeneity. For included studies, 2- and 5-year survival was compared for CRS+HIPEC vs SC alone. RESULTS: Four studies (three case-control, one RCT) provided comparative survival data for patients undergoing CRS+HIPEC (n=187) vs SC (n=155) for CPM. Pooled analysis demonstrated superior 2-year (OR 2.78; 95% CI 1.72-4.51; P=0.001) and 5-year (OR 4.07; 95% CI 2.17-7.64; P=0.001) survival with CRS+HIPEC compared with SC. Mortality ranged from 0 to 8%. No data were available for the assessment of QOL or HE. CONCLUSIONS: Although limited by between-study heterogeneity, the data support the assertion that in carefully selected patients, multimodal treatment of CPM with CRS+HIPEC has a highly positive prognostic impact on medium- and long-term survival compared with SC alone. There is a paucity of comparative data available on morbidity, QOL, and HE.

Robotic colorectal surgery: hype or new hope? A systematic review of robotics in colorectal surgery.

AIM: Robotic colorectal surgery is an emerging field and may offer a solution to some of the difficulties inherent to conventional laparoscopic surgery. The aim of this review is to provide a comprehensive and critical analysis of the available literature on the use of robotic technology in colorectal surgery. METHOD: Studies reporting outcomes of robotic colorectal surgery were identified by systematic searches of electronic databases. Outcomes examined included operating time, length of stay, blood loss, complications, cost, oncological outcome, and conversion rates. RESULTS: Seventeen Studies (nine case series, seven comparative studies, one randomized controlled trial) describing 288 procedures were identified and reviewed. Study heterogeneity precluded a meta-analysis of the data. Robotic procedures tend to take longer and cost more, but may reduce the length of stay, blood loss, and conversion rates. Complication profiles and short-term oncological outcomes are similar to laparoscopic surgery. CONCLUSION: Robotic colorectal surgery is a promising field and may provide a powerful additional tool for optimal management of more challenging pathology, including rectal cancer. Further studies are required to better define its role.

Presentation and survival of operable esophageal cancer in patients 55 years of age and below.

BACKGROUND: The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer. METHODS: This study was conducted from 2000 to 2007 in a specialized esophagogastric center. All patients who had esophageal cancer operations were included. Variables collected included ages, duration of symptoms, presenting symptoms, tumor characteristics, and follow-up data. RESULTS: In total, 365 esophagectomies were performed for cancer, of which 76 patients were younger than aged 55 years (20.8%) and 289 were older than aged 55 years. In patients younger than aged 55 years, 15 patients had symptoms for 6 months or more, 54 had dysphagia, 35 had weight loss compared with 220 and 175 respectively of patients older than aged 55 years. On histopathology, 48 had T3 tumors (63.2%), 17 had T2 (22.4%), and 10 had T1 (13.2%) for patients younger than aged 55 years compared with 141 had T3 (48.7%), 85 had T2 (29.4%), and 55 had T1 (19%) for patients older than aged 55 years. These differences in tumor stage at presentation between groups were significant (p < 0.05 with 3DF). In-hospital mortality was 0 for the group younger than aged 55 years and 5 for those older than aged 55 years. Average follow-up was 35 (minimum, 15) months. Thirty patients had locoregional recurrence in the first group and 110 in the latter group. Survival at 1 year after surgery was 79.6%, at 2 years 65.1%, and at 5 years 42.3% compared with 78.4, 60.6, and 45.9%, respectively, for the group older than aged 55 years, but this was not significant using log-rank (p = 0.99). CONCLUSIONS: A significant proportion (20.8%) of patients presenting with operable esophageal cancer was younger than aged 55 years. Almost two-thirds of those presenting younger than aged 55 years had T3 stage tumors, which was significantly different than those older than aged 55 years. Despite more advanced tumor stage at presentation, the prognosis of esophageal cancer for patients younger than aged 55 years is similar to those older than aged 55 years (log-rank = 0.99).

Chemical mapping of the colorectal cancer microenvironment via MALDI imaging mass spectrometry (MALDI-MSI) reveals novel cancer-associated field effects.

Matrix-assisted laser desorption ionisation imaging mass spectrometry (MALDI-MSI) is a rapidly advancing technique for intact tissue analysis that allows simultaneous localisation and quantification of biomolecules in different histological regions of interest. This approach can potentially offer novel insights into tumour microenvironmental (TME) biochemistry. In this study we employed MALDI-MSI to evaluate fresh frozen sections of colorectal cancer (CRC) tissue and adjacent healthy mucosa obtained from 12 consenting patients undergoing surgery for confirmed CRC. Specifically, we sought to address three objectives: (1) To identify biochemical differences between different morphological regions within the CRC TME; (2) To characterise the biochemical differences between cancerous and healthy colorectal tissue using MALDI-MSI; (3) To determine whether MALDI-MSI profiling of tumour-adjacent tissue can identify novel metabolic 'field effects' associated with cancer. Our results demonstrate that CRC tissue harbours characteristic phospholipid signatures compared with healthy tissue and additionally, different tissue regions within the CRC TME reveal distinct biochemical profiles. Furthermore we observed biochemical differences between tumour-adjacent and tumour-remote healthy mucosa. We have referred to this 'field effect', exhibited by the tumour locale, as cancer-adjacent metaboplasia (CAM) and this finding builds on the established concept of field cancerisation.

Day-case and short-stay surgery: the future for thyroidectomy?

Day-case and short-stay thyroid surgery is carried out routinely around the world. In the UK longer postoperative stay is usually advocated to circumvent/identify potentially catastrophic complications following thyroidectomy. In the current climate of the National Health Service with focus on patient-centred service, reduced hospital stay and cost cutting, we conducted a review to provide a comprehensive assessment of day-case and short-stay thyroidectomy. A systematic electronic literature search using MEDLINE, Ovid, Embase, PubMed and Cochrane databases revealed 22 original studies that met our inclusion criteria. Generally studies demonstrated encouraging results regarding the feasibility of these approaches. Complication rates appeared equivocal to traditional longer stay thyroidectomy and only one patient died. The majority of life-threatening complications occurred in the immediate postoperative period. Of concern, some late haemorrhage has been documented at 5 days postsurgery. Complication rates following day-case/short-stay thyroid surgery appears comparable with inpatient thyroidectomy. Further study is required to determine whether this approach is truly safe.