The value of restaging CT following neoadjuvant chemotherapy for resectable gastric cancer. A population-based study.

BACKGROUND: Response evaluation following neoadjuvant chemotherapy (NAC) in gastric cancer is debated. The aim of this study was to investigate the value of UICC-downstaging as mode of response evaluation following a MAGIC-style regimen of NAC. METHODS: Retrospective, population-based study on consecutive patients with resectable gastric adenocarcinoma receiving NAC from 2007 to 2016. CT-scan was obtained at diagnosis (rTNM) and repeated following NAC (yrTNM) to evaluate response in terms of downstaging. Further, yrTNM stage was crosstabulated to pathologic stage (ypTNM) to depict correlation between radiologic and pathologic assessment. RESULTS: Of 171 patients receiving NAC, 169 were available for response evaluation. For TNM-stages, 43% responded, 50% had stable disease and 7% progressed at CT. Crosstabulating yrTNM stage to ypTNM stage, 24% had concordant stages, with CT overstaging 38% and understaging 38% of the tumours, Cohen kappa ƙ = 0,06 (95%CI 0.004-0.12). Similar patterns of discordance were found for T-stages and N-stages separately. For M-category, restaging CT detected 12 patients with carcinomatosis, with an additional 14 diagnosed with carcinomatosis only at operation. No patient developed parenchymal or extra abdominal metastases, and none developed locally non-resectable tumour during delivery of NAC. Restaging CT with response evaluation was not able to stratify patients into groups of different long-term survival rates based on response mode. CONCLUSIONS: Routine CT-scan following NAC is of limited value. Accuracy of CT staging compared to final pathologic stage is poor, and radiologic downstaging as measure of response evaluation is unreliable and unable to discriminate long-term survival rates based on response mode.

Survival Trends in Patients with Small Intestinal Neuroendocrine Tumours-A Cohort Study in Central Norway.

Improved surgical resection and oncological treatment, or an earlier diagnosis may increase survival in small intestinal neuroendocrine tumours (SI-NETs), but only few studies have examined survival trends. We aimed to examine the trend in overall survival and associated factors in SI-NET patients. All patients with SI-NETs at a regional hospital from June 2005 to December 2021 (n = 242) were identified, and the cohort was divided in half, constituting a first period (until November 2012) and a second period (from November 2012). Disease and treatment characteristics, including European Neuroendocrine Tumour Society (ENETS) stage, surgery, oncological treatment and survival, were recorded. The majority (n = 205 (84.7%)) were treated surgically and surgery was considered curative in 137 (66.8%) patients. Median survival was longer in the second period (9.0 years 95% CI 6.4-11.7 in the first period vs. median not reached in the second period, p = 0.014), with 5-year survival rates of 63.5% and 83.5%, respectively. ENETS stage and oncological treatment did not differ between the periods, but factors associated with surgical quality, such as lymph node harvest and resection of multiple SI-NETs, were significantly higher in the second period. Age, ENETS stage, time period and tumour resection were independently associated with survival in a multivariate analysis.

Response Evaluation after Neoadjuvant Chemotherapy for Resectable Gastric Cancer.

BACKGROUND: The method of response evaluation following neoadjuvant chemotherapy (NAC) in resectable gastric cancer has been widely debated. An essential prerequisite is the ability to stratify patients into subsets of different long-term survival rates based on the response mode. Histopathological measures of regression have their limitations, and interest resides in CT-based methods that can be used in everyday settings. METHODS: We conducted a population-based study (2007-2016) on 171 consecutive patients with gastric adenocarcinoma who were receiving NAC. Two methods of response evaluation were investigated: a strict radiological procedure using RECIST (downsizing), and a composite radiological/pathological procedure comparing the initial radiological TNM stage to the pathological ypTNM stage (downstaging). Clinicopathological variables that could predict the response were searched for, and correlations between the response mode and long-term survival rates were assessed. RESULTS: RECIST failed to identify half of the patients progressing to metastatic disease, and it was unable to assign patients to subsets with different long-term survival rates based on the response mode. However, the TNM stage response mode did achieve this objective. Following re-staging, 48% (78/164) were downstaged, 15% (25/164) had an unchanged stage, and 37% (61/164) were upstaged. A total of 9% (15/164) showed a histopathological complete response. The 5-year overall survival rate was 65.3% (95% CI 54.7-75.9%) for TNM downstaged cases, 40.0% (95% CI 20.8-59.2%) for stable disease, and 14.8% (95% CI 6.0-23.6%) for patients with TNM progression, p < 0.001. In a multivariable ordinal regression model, the Lauren classification and tumor site were the only significant determinants of the response mode. CONCLUSIONS: Downsizing, as a method for evaluating the response to NAC in gastric cancer, is discouraged. TNM re-staging by comparing the baseline radiological CT stage to the pathological stage following NAC is suggested as a useful method that may be used in everyday situations.

Gastric neuroendocrine carcinoma after long-term use of proton pump inhibitor.

We present a case of a gastric neuroendocrine carcinoma in a patient with a history of long-term proton pump inhibitor (PPI) use. A 49-year-old man using PPI for the last 15 years due to gastroesophageal reflux disease developed progressive dysphagia, dyspepsia and weight loss. Upper gastrointestinal endoscopy, endoscopic ultrasonography and abdominal CT diagnosed a malignant tumor localized to a hiatal hernia. Fasting serum chromogranin A and gastrin concentrations were elevated (32 nmol/l and 159 pmol/l, respectively). Helicobacter pylori PCR analysis of antral biopsies was negative. Biopsies from endoscopically normal oxyntic mucosa showed enterochromaffin-like (ECL) cell hyperplasia. Tumor biopsies revealed a poorly differentiated neuroendocrine carcinoma. Sevier-Munger staining, immunohistochemistry and electron microscopy indicated ECL cell as origin of the tumor cells. Concerns have previously been raised about the safety of long-term PPI use due to a possible increased risk of cancer. This case illustrates a patient with a poorly differentiated neuroendocrine carcinoma with ECL cell characteristics probably induced by hypergastrinemia secondary to long-term PPI use.

[Eosinophilic gastroenteritis]. / Eosinofil gastroenteritt.

BACKGROUND: Eosinophilic gastroenteritis is a disease that presents with nonspecific symptoms such as abdominal pain, nausea and diarrhoea. We here present an overview of the disease with an emphasis on practical management. MATERIAL AND METHODS: The basis for the review is literature retrieved through a search in PubMed and on our own experience treating patients with this disease. A case is reported. RESULTS: Eosinophilic gastroenteritis is a rare chronic inflammatory disease of the gastrointestinal tract that mainly affects the stomach and upper small bowel. Young middle-aged adults (most men) are most frequently affected. Abdominal pain and diarrhoea are the most common symptoms. The etiology and pathogenesis is unknown. Correct diagnosis may be difficult and is based on gastrointestinal symptoms, eosinophilic infiltration of the bowel wall and exclusion of other causes of eosinophilia. Treatment is symptomatic with different doses of corticosteroids. Long-term prognosis seems good. INTERPRETATION: The clinical presentation of eosinophilic gastroenteritis varies and underdiagnosing is therefore likely. Many patients have normal levels of eosinophils in blood and normal findings with endoscopy. Correct diagnosis therefore depends on awareness of the disease.

Survival and Disease Recurrence in Patients with Duodenal Neuroendocrine Tumours-A Single Centre Cohort.

BACKGROUND: Duodenal neuroendocrine tumours (D-NETs) are rare but increasingly diagnosed. This study aimed to assess the overall survival and recurrence rate among patients treated for D-NETs. METHODS: Patients with D-NETs were retrospectively reviewed with a median follow-up time of 4.8 years (range 0.0-17.2 years). RESULTS: A total of 32 patients with median age 68.0 years were identified. Fifteen patients underwent surgery while ten patients underwent endoscopic treatment. Mean estimated overall survival for the entire population was 12.1 years (95% CI 9.5-14.7 years), while 5-year overall survival was 81.3%. Tumour grade G1 was associated with longer mean estimated survival compared to G2 tumours (13.2 years versus 4.4 years, p = 0.010). None of the 23 patients who underwent presumed radical endoscopic or surgical resection had disease recurrence during follow-up. Tumours <10 mm could be treated endoscopically whereas a high proportion of patients with tumours 10-20 mm should be considered for surgery. CONCLUSION: Patients with D-NETs had long overall survival, and mortality was more influenced by other diseases. Both endoscopic and surgical resections were effective as no recurrences were diagnosed during follow-up.

Survival and disease recurrence in patients operated for small intestinal neuroendocrine tumors at a referral hospital.

BACKGROUND AND OBJECTIVES: Small intestinal neuroendocrine tumors (SI-NETs) are slow growing but have frequently metastasized at the time of diagnosis. Most patients are operated with either curative intent or with intent to prolong overall survival. In the current study we have examined overall and disease-free survival in patients operated for SI-NETs. METHODS: All patients with a histological diagnosis of SI-NET at St Olav's hospital in the period 1998-2018 were reviewed retrospectively. Patient, disease and treatment characteristics including European Neuroendocrine Tumor Society (ENETS) TNM staging classification, surgery type, time to recurrence and survival were recorded. RESULTS: A total of 186 patients were identified, whereof 54.3% male, median age at operation 68 years. The majority (n = 141 (75.8%)) underwent elective surgery and surgery was considered curative (radical) in 120 (64.5%) patients. Median estimated overall survival was 9.7 years (95% CI 7.6-11.8) for the entire population. Stage of disease, carcinoid heart disease, age, elective surgery, preoperatively known SI-NET, curative surgery and synchronous cancer were associated with survival in a multivariate analysis. Thirty-six of 120 (30%) patients had disease recurrence after a median follow-up time of 5.5 years, with a median estimated recurrence-free survival of 9.1 (5.4-12.9) years. Recurrence free survival was associated with age and synchronous cancer. CONCLUSIONS: Patients with SI-NETs had long overall survival which seemed influenced by stage of disease, presence of carcinoid heart disease, an elective surgery, preoperatively known SI-NET, age and synchronous cancer. Appropriate preoperative diagnostic procedures and elective surgeries seem beneficial and should be aimed for.

[3-D navigation in laparoscopic surgery]. / Tredimensjonal navigasjon i laparoskopisk kirurgi.

BACKGROUND: The main drawback with the laparoscopic approach is that the surgeon lacks the possibility to palpate vessels, tumours and organs during surgery. Furthermore, the laparoscope only provides a surface view of organs. There is a need for more advanced visualization that enhances the view to include information below the surface of the organs when the procedure is planned and for control and guidance during treatment. MATERIAL AND METHODS: We propose 3-D navigation technology based on preoperatively acquired MR or CT data used in combination with a laparoscopic navigation pointer. The pointer has an attached position tracker which enables the surgeon to interactively control the display of images prior to and during surgery. RESULTS: We have used this technology during treatment of four patients with adrenal tumours. Preoperative registration of images of the patients was performed within two minutes with an average accuracy of 7.1 mm. 2-D and 3-D visualizations interactively controlled by the pointer were used both for planning and for guidance of the surgical procedures. INTERPRETATION: The pointer was a useful tool in image guidance of laparoscopic surgery in the reported cases both for planning the approach in detail and for guidance. We believe abdominal 3-D image guidance using a laparoscopic navigation pointer has a large potential for improving laparoscopic surgery, especially in cases where vessels and anatomical relations might be difficult to identify using only a laparoscope. Accordingly, this new technology will increase safety and facilitate successful laparoscopic surgery.