Improved guideline compliance and textbook oncologic outcomes among patients undergoing multimodal treatment and minimally invasive surgery for locally advanced gastric cancer.

BACKGROUND: Although receipt of neoadjuvant chemotherapy has been identified to improve unfavorable survival outcomes among patients with locally advanced gastric cancer (LAGC), several randomized controlled trials have not demonstrated a difference in oncological outcomes/overall survival (OS) among patients undergoing minimally invasive surgery (MIS) versus open gastrectomy. This study aimed to investigate National Comprehensive Cancer Network (NCCN) guideline adherence and textbook oncological outcome (TOO) among patients undergoing MIS versus open surgery for LAGC. METHODS: In this cross-sectional study, patients with stage II/III LAGC (cT2-T4N0-3M0) who underwent curative-intent treatment between 2013 and 2019 were evaluated using the National Cancer Database. Multivariable analysis was performed to assess the association between surgical approach, NCCN guideline adherence, TOO, and OS. The study was registered on the International Standard Randomised Controlled Trial Number registry (registration number: ISRCTN53410429) and conducted according to the Strengthening The Reporting Of Cohort Studies in Surgery and Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Among 13,885 patients, median age at diagnosis was 68 years (IQR, 59-76); most patients were male (n = 9887, 71.2%) and identified as White (n = 10,295, 74.1%). Patients who underwent MIS (n = 4692, 33.8%) had improved NCCN guideline adherence and TOO compared with patients who underwent open surgery (51.3% vs 43.5% and 36.7% vs 27.3%, respectively; both P < .001). Adherence to NCCN guidelines and likelihood to achieve TOO increased from 2013 to 2019 (35.6% vs 50.9% and 31.4% vs 46.4%, respectively; both P < .001). Moreover, improved median OS was observed among patients with NCCN guideline adherence and TOO undergoing MIS versus open surgery (57.3 vs 49.8 months [P = .041] and 68.4 vs 60.6 months [P = .025], respectively). CONCLUSIONS: An overall increase in guideline-adherent treatment and achievement of TOO among patients with LAGC undergoing multimodal and curative-intent treatment in the United States was observed. Adoption of minimally invasive gastrectomy may result in improved short- and long-term outcomes.

Hepatectomy for metachronous colorectal liver metastases following complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases: a report of three cases.

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis (PM) from colorectal cancer (CRC) has been reported to substantially improve the prognosis and the quality of life of patients in comparison to systemic chemotherapy or palliative approaches. This study aimed to demonstrate the safety and feasibility of hepatectomy for metachronous liver metastases from CRC following CRS and HIPEC for PM on the basis of three case reports. CASE PRESENTATION: We describe three cases involving patients who underwent hepatectomy for metachronous liver metastases from CRC after CRS and HIPEC for PM. All patients underwent CRS and HIPEC after primary tumor resection, and hepatectomy was performed for the metachronous liver metastases after CRS and HIPEC. The hepatectomy procedures for cases 1, 2, and 3 were left hemihepatectomy and partial resection of S5, posterior sectionectomy, and left-lateral sectionectomy and partial resection of S5 and S8, respectively. Although adhesion of surrounding organs to the liver surface was observed on a broad level, dissections and hepatectomy could be performed safely. No recurrence was detected in cases 1 and 2 after hepatectomy. In case 3, liver metastases were detected from the time of the initial diagnosis of the primary tumor, and complete remission was achieved once with systemic chemotherapy. Although we performed hepatectomy for the recurrence of liver metastases after complete remission, early re-recurrence was observed after hepatectomy. CONCLUSIONS: Hepatectomy for metachronous liver metastases after CRS and HIPEC for PM could be a multi-modality treatment option for CRC recurrence.

Capecitabine-cisplatin versus 5-fluorouracil/leucovorin in combination with radiotherapy for adjuvant therapy of lymph node positive locally advanced gastric cancer.

AIM OF THE STUDY: Although surgery is considered to be curative treatment, recurrence rates are high in gastric cancer. Adjuvant 5-fluorouracil (5-FU) based chemoradiotherapy has been shown to improve the prognosis. We compared tolerability and efficacy of the two different chemotherapy regimens; 5-FU/leucovorin (LV) versus cisplatin with capecitabine (XP) combined with radiotherapy (RT) in the adjuvant therapy of the lymph node positive locally advanced gastric cancer. MATERIALS AND METHODS: Totally, 104 patients who underwent curative surgery with lymph node resection were evaluated, respectively. Patients were stratified two group based on the adjuvant chemoradiotherapy regimen. Group 1 (n = 46) received XP followed capecitabine with RT (XRT) then XP. Group 2 (n = 58) received 5-FU/LV combined with RT postoperatively. Two groups were compared based on clinicopathological parameters. Factors related with disease-free survival (DFS) and overall survival (OS) were analyzed. RESULTS: Totally, 32 patients had recurrent disease, and there was no difference between two groups. While peritoneal metastasis was more common in XP arm, distant metastasis was commonly seen in 5-FU/LV arm. There was no significant difference between two groups in regard of Grade 3/4 toxicitis; hematologic toxicities were more in 5-FU/LV group than XP arm. In addition, dose modification because of toxicities were more frequent in 5-FU/LV arm (P = 0.003). For all groups, lymph node dissection type was related with DFS, surgical margin and recurrence were important for OS. CONCLUSION: XP-XRT regimen is well tolerated with lower toxicity compared the standard 5-FU/LV-RT. Although there is no difference with respect to outcome, patients with XP arm without the necessity of intravenous catheter admitted hospital less frequent than bolus5-FU/LV arm.

Stereotactic body radiotherapy for early stage lung cancer: History and updated role.

Stereotactic Body Radiotherapy (SBRT) represents a consolidated treatment option for patients with medically inoperable early stage non-small cell lung cancer (NSCLC). The clinical evidence accumulated over the past decade supports its use as an alternative to surgery with comparable survival outcomes. Due to its limited toxicity, SBRT is also applicable to elderly patients with very poor baseline pulmonary function or other severe comorbidities. Recent comparative studies in operable patients raised the issue of the possible use of SBRT also for this subgroup, with quite promising results that still should be fully confirmed by prospective trials with long-term follow up. In early stage lung cancer, clinicians are now faced with a decision-making process that should take into account different factors. The need of pathological diagnosis and accurate nodal staging still represents a challenge, as well as the interpretation of radiological findings after SBRT, often confusing du to the difficulties in distinguishing between radiation-induced changes and local relapse. Aim of this review is to summarize and discuss the major studies on SBRT for early stage lung cancer, providing data on its efficacy and toxicity and discussing the still open issues on its role. Quality of life, pulmonary function and risk of secondary cancers are also discussed, as well as future perspectives and current research topics.

[Percutaneous ablation of hepatocellular carcinoma in older patients in clinical practice]. / Tratamiento percutáneo del carcinoma hepatocelular en pacientes con edad avanzada en la práctica clínica.

INTRODUCTION: A high percentage of older patients with early-stage hepatocellular carcinoma (HCC) are potential candidates for percutaneous ablation. MATERIAL AND METHODS: We prospectively assessed data from patients older than 70 years with HCC. We determined their demographic and clinical characteristics, the treatment provided and the response, complications and survival among those treated with radiofrequency ablation (RFA) and/or percutaneous ethanol injection (PEI). RESULTS: Of 194 patients with HCC, 84 were older than 70 years (43.3%). The mean age was 76.8 ± 4.5 years. Seventy-five percent were male and 91.7% had cirrhosis. Cancer was initially identified by a surveillance program in 61.9%. According to the Barcelona Clinic Liver Cancer staging system, 60.7% were classified as having early stage cancer (0-A), 19% as stage B, 12% as stage C, and 8.3% as stage D. Potentially curative initial treatment was provided in 38.2% (surgical resection in 4.8%, PEI in 22.6%, RFA in 4.8%, PEI+RFA in 6%), transarterial chemoembolization in 20.2%, and sorafenib in 3.6%. Twenty-five percent of patients were not treatment candidates and 13% refused the recommended treatment. The median follow-up after percutaneous ablation was 23 months (IQR 14.2-40.6). The mean number of sessions was 3.5 ± 2.2 for PEI and 1.8 ± 1.6 for RFA. The complications rate per session was 4%. Remission was achieved in 35.7%. The overall median survival was 45.7 months (95% CI 20.8-70.6). CONCLUSIONS: Almost half of the patients with HCC in our sample were elderly and more than half were diagnosed at an early stage. Percutaneous ablation was performed in one-third of the sample, achieving remission in 37.5%. There were few complications. Therefore, these patients should be assessed for percutaneous ablation.

Second primary pancreatic adenocarcinoma three years after successfully treated index esophageal cancer.

CONTEXT: Development of a second primary malignancy after an index esophageal cancer is a rare event, primarily due to short survival of patients with esophageal cancer. However, the number of long-term esophageal cancer survivors has been increasing due to advances in early detection and therapy. CASE REPORT: We report herein a case of pancreatic adenocarcinoma that developed three years after a successfully treated early-stage adenocarcinoma of the esophagus. A 70-year-old Caucasian male presented with vague complaints of nausea, vomiting and abdominal distention, with subsequent development of jaundice. A computed tomography scan of abdomen revealed a 2.9 cm soft tissue mass in the head of the pancreas and the patient underwent a Whipple's procedure, with pathology confirming the diagnosis of pancreatic adenocarcinoma. Three years previously, the patient was successfully treated for adenocarcinoma of the esophagus via minimally invasive esophagogastrectomy. Despite chemoradiotherapy for localized disease and subsequent systemic chemotherapy for metastatic pancreatic cancer, the patient eventually succumbed to his illness. CONCLUSION: We discuss the association between esophageal cancer and subsequent second malignancies, along with implications for surveillance and therapy.

Coexistence of malignant struma ovarii and cervical papillary thyroid carcinoma.

CONTEXT: Struma ovarii is an uncommon monodermal teratoma in which thyroid tissue is the predominant element. Malignant transformation of struma ovarii is an even rarer occurrence. CASE PRESENTATION: We describe a 42-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a symptomatic left pelvic mass. Histology revealed malignant struma ovarii with classical papillary thyroid carcinoma expression. Ultrasonography of the cervical neck showed thyroid micronodules and a dominant 1-cm nodule in the left thyroid lobe. As the ovarian tumor was large, the patient underwent a total thyroidectomy with the intention of administering ¹³¹I therapy in an adjuvant setting. Histology of the cervical thyroid gland revealed bilateral multifocal papillary thyroid carcinoma with extrathyroidal extension and perithyroidal lymph node metastasis. METHODS: Morphological (microscopy), immunohistochemical (Hector Battifora mesothelial cell 1, cytokeratin-19, galectin-3), and molecular (BRAF V600E, RAS, RET-PTC) characteristics and clonality analysis of the cervical thyroid and ovarian tumors were explored to distinguish them as separate malignancies. RESULTS: The thyroid-type tumors from the cervical gland and ovary were discordant in terms of tissue histology and level of cytokeratin-19 expression. The clinical features and tumor profile results supported the independent existence of these two embryologically related, although topographically distinct, malignancies. CONCLUSION: Our findings provided support for synchronous, albeit distinct, primary tumors in the ovary and cervical thyroid. "Field cancerization" and early genomic instability may explain multifocality in all thyroid-type tissue. In this regard, patients with malignant struma ovarii should undergo imaging of their thyroid gland for coexisting disease and thyroidectomy recommended for suspected malignancy or in preparation for radioiodine therapy.

[Osteosarcoma of the prostate after radiotherapy]. / Osteosarkom der Prostata nach Strahlentherapie.

Osteosarcoma of the prostate is a rare finding. These tumours usually occur years after radiotherapy for prostate cancer. We report the case of a 74-year-old man with prostate cancer who had been treated with radiotherapy and androgen deprivation therapy. The man presented with urinary retention and his prostate was transurethrally resected. The histopathological investigation showed formations of a poorly differentiated osteosarcoma in the prostate. Because of serious comorbidities we decided to withhold chemotherapy considering its potential side effects. The man died a few months after the diagnosis of osteosarcoma in the prostate with the disease in a metastatic stage. In conclusion, osteosarcoma of the prostate is a rarely reported consequence of radiotherapy in patients with prostate cancer and is characterised by poor life expectancy.

Pathologic characteristics of second breast cancers after breast conservation for ductal carcinoma in situ.

BACKGROUND: The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. Although many eventually develop a second breast cancer (SBC), little is known about the characteristics of SBCs. The authors described the characteristics of SBC and examined associations between the pathologic features of SBC and index DCIS cases. METHODS: Women were identified in the National Comprehensive Cancer Network Outcomes Database who were diagnosed with DCIS from 1997 to 2008 and underwent lumpectomy and who subsequently developed SBC (including DCIS or invasive disease that occurred in the ipsilateral or contralateral breast). The Fisher exact test and the Spearman test were used to examine associations between the pathologic characteristics of SBC and index DCIS cases. RESULTS: Among 2636 women who underwent lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow-up. Of these 150 women, 105 (70%) received adjuvant radiotherapy, and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of women and invasive in 50.7% of women. Among the index DCIS cases, 60.6% were estrogen receptor (ER)-positive, and 54% were high grade, whereas 77.5% of SBCs were ER-positive, and 48.2% were high grade. Tumor grade (P = .003) and ER status (P = .02) were associated significantly between index DCIS and SBC, whereas tumor size was not (P = .87). CONCLUSIONS: After breast conservation for DCIS, SBC in either breast exhibited pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype.

Transperitoneal laparoscopic radical nephrectomy after multiple previous abdominal surgeries and intraperitoneal hyperthermic chemotherapy: a case report.

Laparoscopic indications are still growing due to the acquisition and development of new skills and expertise in the laparoscopic field. We report the first case of a successful transperitoneal right radical nephrectomy after intraperitoneal hyperthermic chemotherapy in a 56-year-old female who previously underwent multiple abdominal surgeries for appendicular adenocarcinoma with pseudomyxoma peritonei. In patients with multiples previous abdominal surgeries and intraperitoneal chemotherapy, transperitoneal laparoscopic surgeries are feasible in experienced hands. However, patient safety is paramount and conversion to open surgery should always be considered in case of complications.

A novel method of auricular reconstruction.

Seven male patients and 8 total ears underwent composite excision for neoplasm of the auricular helix. Defect size ranged from 2.5 to 4.5 cm exceeding the conventional limit of l.5 cm for wedge excision with primary closure. An incision at the root of the helix released the superior auricular muscle and a portion of the strong supporting anterior auricular tendon. An inferior incision allowed for the advancement of the lobule. The combined release permitted chondrocutaneous mobilization and closure without tension. The cupping deformity was avoided by trimming the concha in a wedge excision. Notching was eliminated with a step cut and close approximation on closure. The superior auriculocephalic sulcus was preserved by altering the fulcrum point of rotation.Ears were reconstructed with favorable esthetic outcome with over 1 year of follow-up in 5 of 7 patients. This technique represents an alternative method of single stage reconstruction of the auricular helix.

Tumor diverticular que imita una enfermedad neoplásica en un paciente VIH-positivo / Diverticular tumor imitating neoplastic disease in an HIV positive patient

Introducción: A pesar de que en la era de la terapia antirretroviral de alta eficacia (HAART) la incidencia de los tumores malignos en la población VIH/SIDA está en creciente aumento y es actualmente su mayor causa de muerte, estos pacientes también pueden presentar lesiones tumorales de origen inflamatorio, micótico, parasitario, o bacteriano, que en algunos casos puede resultar muy difícil diferenciar de una neoplasia antes de la exéresis quirúrgica completa de la lesión. Objetivo: Comunicar el caso de un paciente VIH-positivo con un tumor inflamatorio de origen diverticular y discutir los posibles diagnósticos diferenciales. Paciente y método: Paciente masculino de 42 años, drogadependiente y VIH positivo (estadio AI), en tratamiento con HAART, con constipación y mucorrea de 4 años de evolución y proctorragia postevacuatoria y dolor abdominal a predominio de FII intermitentes desde hace un año. Examen fisico, laboratorio de rutina, CEA y perfil inmunológico normales. La videocolonoscopía y el colon por enema mostraron una estenosis sigmoidea infranqueable con mucosa conservada. La tomografia computada abdominopelviana evidenció engrosamiento parietal del colon sigmoides y múltiples ganglios no adenomegálicos. Resultados: Se indicó el tratamiento quirúrgico con el diagnóstico de un probable tumor extramucoso benigno, o de bajo grado de malignidad. Se encontró un tumor sigmoideo duro-elástico de 9 x 7 cm, con la serosa congestiva y adherencias laxas a la cara posterior de la vejiga, acompañado por varias adenopatías mesentéricas. Se realizó una resección anterior con carácter oncológico. Abierta la pieza se constató un gran engrosamiento parietal con mucosa edematosa. No tuvo complicaciones postoperatorias. La anatomia patológica informó una enfermedad diverticular del colon con peridiverticulitis y marcada fibrosis parietal. (TRUNCADO) (AU)...

Introduction: Despite the fact that in the highly active antiretroviral therapy (HAART) era the incidence of malignant tumors in HIV/AIDS population is increasing, and is currently the major cause of death, these patients can also present tumoral lesions of inflammatory, fungal, parasitic, or bacterial origin in some cases very difficult to differentiate from a neoplasia before complete surgical resection. Objective: Report on a HIV positive patient with an inflammatory diverticular tumor, and discuss the possible differential diagnosis. Patient and methods: Male, 42 years old, intravenous drug abuser, and HIV-positive (AI stage), on HAART, complaining of constipation and mucous discharge the last 4 years, and intermittent rectal bleeding and abdominal pain (predominantly in the right iliac fossae) the last year. Physical examination, blood tests, CEA, and immune status were normal. Colonoscopy and barium enema showed a not negotiable sigmoid stenosis with normal mucosa. The computed tomography of the abdomen and pelvis showed parietal thickening of the sigmoid colon and multiple not enlarged lymphoid nodes. Results: Surgical treatment, with the diagnosis of probable extramucosal benign or low-grade malignant tumor, was indicated. A 9 x 7 cm, rubber consistency sigmoid tumor was found. It had congestive serosa and smooth adhesions to the posterior aspect of the bladder, associated with several mesenteric nodes. An oncologíc anterior resection was carried out. The opened specimen showed a 4 cm thickening of the intestinal wall, with edematous, non tumoral mucosa. The postoperative course was uneventful. The histopathology report was diverticular colonic disease with peridiverticulitis, and marked parietal fibrosis. Conclusion: Currently, in the HIV-positive population the incidence of malignant tumors related or not to AIDS has increased, due to better management of opportunistic infections, and the best life expectancy... (TRUNCADO)

Subtotal hepatectomy following neoadjuvant chemotherapy for a previously unresectable hepatocellular carcinoma.

An awareness of variant hepatic vascular anatomy provides vital information in the preoperative evaluation of patients with hepatocellular carcinoma. The authors present a patient with unresectable hepatocellular carcinoma who responded to combination systemic and regional chemotherapy. Because of the presence of an enlarged inferior right hepatic vein, the patient subsequently underwent successful subtotal hepatectomy with resection of all three main hepatic veins. This case illustrates that the combination of innovative neoadjuvant chemotherapy and well-planned surgical approaches may benefit a small number of patients previously deemed unresectable.

Incidental and concurrent malignant lymphomas discovered at the time of prostatectomy and prostate biopsy: a study of 29 cases.

The incidence and histologic features of malignant lymphomas discovered at the time of prostate biopsy, transurethral resection, and prostatectomy are not well documented. We searched our surgical pathology files for malignant lymphomas identified from prostate surgical specimens from 1989 to 2004. Of 4,831 cases of prostate specimens (3,405 biopsies, 266 transurethral resections, 1,160 prostatectomies) examined at the City of Hope during this period, 29 cases of malignant lymphomas involving the prostate and pelvic lymph nodes were identified (0.6%). These malignant lymphomas can be divided into two groups: 1) 18 incidental cases (0.37%) without prior history of malignant lymphoma; and 2) 11 cases (0.23%) with concurrent known malignant lymphoma. For the first group, the patients with pelvic node involvement ranged in age from 59 to 78 years (mean, 69.2 years; median, 70 years), and the patients with prostate involvement ranged in age from 45 to 78 years (mean, 64.6 years; median, 67.5 years). For the second group, the patients ranged in age from 53 to 80 years (mean, 66.8 years; median, 69 years). Diagnoses of all cases were confirmed by immunohistochemistry or molecular analysis. Ten of 18 cases in the first group involved pelvic nodes only, and the other 8 cases were primary prostatic lymphoma. Of 18 cases in the first group, 13 were small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL), 3 were marginal zone B-cell lymphoma, and 1 was mantle cell lymphoma. These lymphomas were not readily apparent in most cases by histologic examination, and may be confused with chronic prostatitis when the prostate was involved or with reactive lymphoid hyperplasia when pelvic nodes were involved. Immunohistochemistry and molecular studies may be necessary to confirm the diagnosis. For the second group, prostate and pelvic lymph nodes were involved as part of systemic dissemination of concurrent malignant lymphoma. The diagnosis was usually easily established in these cases. Of 11 cases, 4 were SLL/CLL, 4 were follicular lymphoma, 2 were mantle cell lymphoma, and 1 was diffuse large B-cell lymphoma.

Multiple deep-seated cavernomas in the third ventricle, hypothalamus and thalamus.

BACKGROUND: Cavernomas are rarely located in the third ventricle, hypothalamus, or thalamus. In this report, we present our experience managing a patient with three cavernomas, one each in the floor of the third ventricle, hypothalamus, and left thalamus. CASE PRESENTATION: This 62-year-old woman had had an unsteady gait and weakness of both legs for six months. Magnetic resonance imaging (MRI) revealed multiple intracranial tumours in the third ventricle, hypothalamus, and left thalamus. The third ventricle tumour was found to be a cavernoma by intra-operative endoscopic examination and then was excised via a transcortical, transventricular approach. Pathology revealed a cavernoma. The other two tumours were assumed to be cavernomas because of their MRI features. Three days after surgery, the patient developed right hemiparesis and disturbance of consciousness. Computed tomography revealed a left thalamic haemorrhage. After conservative treatment, her conscious level gradually recovered and she could walk with support seven months after surgery. INTERPRETATION: Our experience with this rare case of multiple, deep-seated cavernomas suggests that management of such patients requires specific consideration of the clinical manifestations, location, size, and previous bleeding history.

[Mucoepidermoid carcinoma of the salivary glands after high dosage radiotherapy]. / Mukoepidermoid-Karzinom der Speicheldrüsen nach hochdosierter Radioiodtherapie.

BACKGROUND: High-dose radioiodine therapy following total thyroidectomy is standard for patients suffering from differentiated thyroid carcinoma and contributes significantly to their favourable prognosis. Due to active iodine accumulation, high focal radiation doses are received by the salivary glands. PATIENTS/RESULT: Report on two patients, who received multiple high-dose radioiodine treatments because of a differentiated metastatic thyroid carcinoma. A few years later, they developed a mucoepidermoid carcinoma of the salivary glands. Due to the high cumulative radiation dose, radiation-induced secondary malignancies following radiation-induced sialadenitis appears likely, although no causal connection could be proven. CONCLUSION: Consistent protection of the salivary glands during radioiodine therapy as well as the follow-up of the many long-term survivors of differentiated thyroid carcinomas is desirable to further lower the salivary gland-related side effects and to detect secondary malignancies as early as possible.

Retroperitoneal malignant fibrous histiocytoma causing variegated colonic lesions.

A 68-year-old man visited our hospital because of heartburn. A firm mass was palpated in the left upper abdominal quadrant. Ultrasonography and computed tomography revealed a large left sided retroperitoneal tumor. A barium enema examination showed shallow irregularly depressed or elevated lesions. Colonoscopy revealed an irregularly shaped ulcer and multiple submucosal masses suggesting invasion by an extrinsic malignant tumor. Although colonoscopic biopsy was negative, a resected tumor was histologically diagnosed as a malignant fibrous histiocytoma (MFH). When such varigated lesions are detected in the colon, MFH should be considered, and an attempt to sample the submucosal layer may be necessary.