Two-stage cytoreductive surgery for 'extensive' pseudomyxoma peritonei: A legitimate alternative or salvage strategy?

BACKGROUND AND AIM: Two-stage cytoreductive surgery (CRS) has been proposed as an alternative to one-stage surgery in patients who have 'extensive' pseudomyxoma peritonei (PMP) and/or are unfit for very extensive surgery, to reduce morbidity. We review current evidence on two-stage CRS focusing on patient selection, interval between procedures, extent of surgery, use of HIPEC, perioperative and oncological outcomes. METHODS: This is a narrative review. A literature search on PubMed and Embase was performed using keywords- 'Two-stage cytoreductive surgery', 'pseudomyxoma peritonei', 'high-volume PMP', 'huge PMP', 'cytoreductive surgery', 'HIPEC', 'staged surgery' and 'extensive pseudomyxoma peritonei'. RESULTS: Five studies reported outcomes in a total of 114 patients. The indications for two-stage CRS were: in two studies, patients undergoing an incomplete cytoreduction due to undue surgical risk were reevaluated for a second surgery during routine surveillance; severe comorbidities in one; extensive disease with PCI>28 in another and in one, only HIPEC was performed as a second procedure due to intraoperative hemodynamic instability (the two-stage procedure was performed in interest of patient's safety). Major morbidity ranged from 0 to 37.5 % (first-stage) and 25%-38.9 % (second-stage). Short term follow-up demonstrated equivalent short-term oncological outcomes compared to historical data. Long term follow-up and quality-of-life data were not available. CONCLUSIONS: The published studies showed different interpretations and applications of the two-stage CRS concept. The reported morbidity was similar to that after single-stage CRS for extensive PMP. Though short-term survival outcomes are acceptable, long-term follow-up is needed. Planned two-stage CRS should currently be reserved for highly selected clinical situations.

Optimizing local control in anorectal melanoma.

BACKGROUND: Wide local excision (WLE) of anorectal melanoma is associated with a high incidence of local recurrence. There is a paucity of literature on adjuvant radiation in this malignancy. AIM: To identify the optimal method of local treatment in anorectal melanoma. SETTINGS AND DESIGN: Retrospective study in a tertiary cancer centre. MATERIALS AND METHODS: Records of 63 patients who presented between 1980 and 2004 were reviewed. RESULTS: Of the 63 patients, 18 were treated by either surgery with or without adjuvant radiation, or by radiation alone. The remaining had advanced disease and were offered only symptomatic treatment. The median overall survival in stage I patients was 12 months, while it was seven and four months in those with stage II and III disease respectively. The median survival in patients treated by WLE with adjuvant radiation (RT), WLE alone or Abdominoperineal resection (APR) was 34, 12 and 10 months respectively. Patients in whom the disease was confined to the mucosa had a better median overall survival than those in whom it had infiltrated beyond the mucosa (102 vs 11 months). The pattern of recurrence following WLE with adjuvant RT or APR was similar. None of the patients who received adjuvant RT after wide excision had a local or nodal recurrence. CONCLUSION: Local treatment of anorectal melanoma should be individualized. WLE with adjuvant radiation seems to offer good locoregional control without reducing the survival and may be an option of treatment for patients with small, superficial anorectal melanoma. However, APR should be offered for patients with locally advanced disease or as a salvage following recurrence.

Effectiveness of noise barriers on an interstate highway: a subjective and objective evaluation.

The objective of this study was to determine the actual and perceived effectiveness of noise barriers along interstate highways. Using a 5-mile section of Interstate 71 in the greater Cincinnati area as the study area, traffic noise readings and opinions of residents living along the sections of the highway were recorded. Noise readings were taken before and after the noise barriers were erected. A questionnaire was designed to elicit noise-related annoyance of the residents in the areas adjoining the highway. The results indicated that, in general, noise barriers were effective as indicated by a reduction in noise levels by as much as 11 dBA. The barriers, however, failed to bring noise levels for locations closer to the highway within the levels desired by the government (67 dBA). Most residents living right next to the highway were very satisfied with the installation of noise barriers. In general, these individuals felt that the quality of life improved with the noise barrier installation. The same, however, was not true of residents living a few blocks away from the highway--they felt the noise barriers were a waste of money. There was no significant difference in traffic noise pattern during the weekdays or weekends. Noise readings taken in two different locations were observed to be similar.