Lymph node retrieval in pancreaticoduodenectomy specimens: does educating the pathologist matter?

BACKGROUND: Many previous studies have suggested that the number of lymph nodes retrieved should serve as a benchmark for assessing the adequacy of the resection. The aim was to retrospectively observe the impact of nodal retrieval after educating the pathologist. METHODS: Patients undergoing a pancreaticoduodenectomy (PD) between September 2005 and March 2009 were included in the study. The PDs performed between September 2005 and March 2008 were designated as Group A. The pathologists were educated regarding the importance of nodal counts in PD by the surgeon on the 1st April 2008. PDs performed between April 2008 and March 2009 were designated as Group B. RESULTS: Ninety-eight PDs performed by a single surgeon (D.R.J.) for peri-ampullary malignancy were evaluated. The median number of lymph nodes retrieved in Group A was 11(3-32) nodes. The median number of lymph nodes retrieved in Group B was 22 (10-29) nodes (P < 0.001).The lymph node ratio (positive/total nodes), median number of positive nodes retrieved, and the node positivity (node positive compared to node negative) rate did not change. DISCUSSION: A single intervention with the pathologists did impact the number of lymph nodes retrieved from PD specimens. However, the lymph node ratio and lymph node positivity rate remained unchanged. The pathologist is critical to nodal retrieval in PD, but the use of this lymph node number for benchmark of surgical adequacy may be simplistic.

Outcome and natural history of patients with stage IV colorectal cancer receiving chemotherapy without primary tumor resection.

BACKGROUND: There is a trend toward nonsurgical management of patients with nonobstructing metastatic (stage IV) colorectal cancer (CRC), although some will eventually undergo surgery. We examined patients with metastatic CRC who were managed with an intact primary tumor. METHODS: An institutional review board (IRB)-approved database was retrospectively reviewed. All patients presenting with stage IV CRC from 2000 to 2008 were identified and analyzed. RESULTS: Among the 255 patients identified, 112 were taken directly to the operating room for either primary tumor resection or colostomy/bypass. Among the remaining 143 patients, 97 were managed without developing primary tumor-related symptoms, and 14 (9.8%) developed significant primary tumor-related symptoms necessitating operative or endoscopic management. Of the patients who developed symptoms, oxaliplatin and/or irinotecan was used among 71.4% of patients, and bevacizumab in 50%. Forty-two patients in the series underwent elective primary tumor resection after receiving chemotherapy. No independent predictors for development of primary tumor-related symptoms could be identified after controlling for age, gender, tumor location, number of metastatic sites, and type of chemotherapy. Median overall survival was 34 months for those who underwent elective primary tumor resection after chemotherapy, and 16 months for those who failed chemotherapy and developed symptoms. CONCLUSIONS: Among patients with metastatic CRC without an initial indication for surgery, incidence of obstruction or perforation after initiating chemotherapy was low (9.8%). No predictors of primary tumor-related complications could be identified. Survival was favorable among the highly selected cohort of patients who underwent elective primary tumor resection after chemotherapy.

DBC2 significantly influences cell-cycle, apoptosis, cytoskeleton and membrane-trafficking pathways.

The tumor suppressor DBC2 belongs to a previously uncharacterized gene family, RHOBTB (Bric-a-brac, Tramtrack, Broad-complex). The biological roles of RHOBTB proteins, including DBC2, remain unclear. To understand the physiological functions of DBC2, a global approach was applied. Expression of DBC2 was manipulated in HeLa cells and RNA profiling of the cells was performed by microarray analyses. DBC2 was introduced into HeLa cells by a mammalian expression vector with a constitutive promoter. DBC2 knockdown was achieved by RNA interference with small interfering RNA. RNA profiles of these samples were performed by microarray analysis using Affymetrix GeneChip HG-U133A 2.0. The microarray data were analyzed by Microarray Suite 5.0 (MAS 5.0) and Robust Multichip Average (RMA). A list of genes whose expression was significantly altered (p<0.001) was generated and overlaid onto a cellular pathway map in the Ingenuity Systems' Pathway Knowledge Base (Winter'04 Release). Two networks were found to react substantially to DBC2 expression; namely, more than half of participating genes are affected. One of the networks regulates cell growth through cell-cycle control and apoptosis. The other network is related to cytoskeleton and membrane trafficking. Our findings suggest that the biological roles of DBC2 are related directly and/or indirectly to these cellular machineries.

Partial stomach-partitioning gastrojejunostomy and the success of this procedure in terms of palliation.

BACKGROUND: In the 1990s, partial stomach-partitioning gastrojejunostomy (PSPG) was introduced. Benefits of this method are that it preferentially shunts food away from the obstructed duodenum or pylorus, thus reducing reflex emesis. METHODS: A retrospective review of patients undergoing PSPG for malignant obstruction from 1999 to 2011 was performed. Ability to tolerate oral intake in the postoperative period and at last follow-up was the criterion for a successful bypass. RESULTS: Fifty-five patients with locally advanced or metastatic tumors underwent PSPG. The median follow-up period was 8 months. No patient developed signs of gastric outlet obstruction after PSPG. Seventy-five percent of patients had pancreatic or duodenal and 25% had nonpancreatic cancers. Nine patients developed postoperative complications. The perioperative mortality rate was zero. Median overall survival was 9 months. All patients were tolerating an enteral diet on the day of discharge, and as of the last follow-up, 95% were tolerating their enteral diets. CONCLUSIONS: This and a previous study from the authors' institution show that PSPG is a good alternative for palliative bypass in the setting of malignant gastric outlet obstruction over classic gastrojejunostomy.