Merkel cell carcinoma metastasis to the pancreas: report of a rare case and a review of the literature.

CONTEXT: Merkel cell carcinoma is a rare skin tumour which can metastasise to regional lymph nodes and occasionally to distant organs. Merkel cell carcinoma metastasis to the pancreas has been rarely reported. CASE REPORT: We describe the case of Merkel cell carcinoma metastasis to the pancreas and review the literature on this rare phenomenon. CONCLUSION: Merkel cell carcinomas metastasis should be considered as a differential in patients who present with a pancreatic mass with a previous history of Merkel cell carcinomas.

Can pressurised intraperitoneal aerosol chemotherapy with oxaliplatin (PIPAC-O+) be added to standard treatment for resectable high-risk gastric cancer patients? A study protocol.

OBJECTIVES: Gastric cancer remains one of the most fatal cancers, despite an intensive treatment regime of chemotherapy-surgery-chemotherapy. Peritoneal metastatic disease is commonly diagnosed post treatment regime and once established, patients are likely to die in 3-9 months. Systemic chemotherapy does not increase survival for these patients due to the poor vascularisation of this area. We are proposing the addition of pressurised intraperitoneal aerosol chemotherapy (PIPAC) to the treatment regime for curative patients as a preventive measure to reduce the risk of peritoneal metastases occurring. METHODS: This is a prospective, single centre, non-randomised, open-label pilot trial evaluating the addition of PIPAC to the standard multimodal treatment pathway. Patients will undergo standard neoadjuvant chemotherapy with four cycles of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT), then PIPAC, followed by gastrectomy. Four cycles of FLOT will be administered post-surgery. Primary outcome is safety and feasibility, assessed by perioperative morbidity and possible interruptions of the standard multimodal treatment pathway.

Liver resection for non-colorectal non-neuroendocrine metastases.

OBJECTIVE: Liver resections for non-colorectal non-neuroendocrine liver metastases (NCNELM) are gaining popularity. This study examines the outcomes of liver resections in patients with NCNELM in an Australian hospital. METHOD: A database search identified 21 attempted liver resections on 20 patients (12 men, eight women, mean age: 63.1) from 1998 to 2013. A retrospective analysis considered patient demographics and primary malignancy details. Complication rates were compared to those for colorectal metastases at the same institution. Kaplan-Meier curves were used to plot overall survival. RESULTS: Complete resection was achieved in 16 of the 21 operations with 13 cases having proven metastases (three cases were benign lesions on final histology). Primary cancers were gastric (n = 4), gall bladder/bile duct (n = 3), renal (n = 3), soft tissue sarcoma (n = 3), melanoma (n = 2), pancreatic (n = 2), anal (n = 2), breast (n = 1) and unknown (n = 1). Primary histology types were adenocarcinoma (n = 10), sarcoma (n = 3), renal cell (n = 3), squamous cell (n = 2), melanoma (n = 2) and gastrointestinal stromal tumour (n = 1). There was no peri-operative mortality. Significant post-operative complications (Clavien-Dindo Grade III or more) occurred in six patients (28.5%). Overall survival at 2 and 5 years was 46.2% and 30.8%, respectively, for all 21 cases of attempted resection, and 51.9% and 34.6%, respectively, for the 13 cases of complete resection of malignant metastases. CONCLUSIONS: This study produced comparable 5-year survival rates to those reported after liver resection for colorectal metastases and in other studies on NCNELM. Complication rates were comparable to those for colorectal liver metastasis resection at the same institution.

Liver resection in octogenarians: are the outcomes worth the risk?

BACKGROUND: Australian life expectancy is high by world standards, largely because of advanced health care. It is therefore important to determine safety and oncological benefits of major surgical procedures in the elderly. This retrospective review examines outcomes of liver resection in octogenarians. METHODS: Data on all liver resections performed at The Queen Elizabeth Hospital were collected in a prospective database. The primary aim was to determine overall and disease-free survival, and secondary aim to assess perioperative quality of life (QoL) and functionality outcomes using surrogate markers. RESULTS: Twenty-four octogenarians underwent 26 liver resections for colorectal liver metastases (n = 20), hepatocellular carcinoma (n = 4), cholangiocarcinoma (n = 1) and benign lesion (n = 1). Median hospital stay was 11 days. There were no major post-operative complications and only one patient experienced a decline in QoL. There was no 90-day mortality. Five-year overall survival and 5-year disease-free survival were 47% and 37%, respectively. Median duration of follow-up was 34 months. CONCLUSION: Liver resection can be performed safely in octogenarians with low morbidity, excellent overall survival and good QoL outcomes.

Mycobacterial infection of the gallbladder masquerading as gallbladder cancer with a false positive pet scan.

Isolated mycobacterial infection of gall bladder is an extremely rare entity. Only anecdotal reports are evident in the literature. A preoperative diagnosis of mycobacterial infection of gallbladder is therefore very difficult. The case of a 72-year-old male who underwent surgery for suspected gallbladder cancer is presented. The diagnosis of cancer was based on radiological findings and an abnormal uptake of fluorine-18-fluoro-2-deoxy-D-glucose (FDG) on positron emission tomography (PET) scan whilst being followed up for colorectal cancer. He underwent cholecystectomy and gallbladder bed resection. Histopathology was consistent with mycobacterial infection of the gallbladder.

Atypical mycobacterial infection mimicking metastatic cholangiocarcinoma.

Mycobacterial infections are rare in developed countries. Isolated involvement of the liver and biliary tree by mycobacterial infection is extremely rare. We report a case of a 45-year-old Caucasian female presenting with obstructive jaundice with a common bile duct stricture and multiple hypodense liver lesions raising suspicion of a metastatic cholangiocarcinoma. Percutaneous core biopsies of the liver lesions however suggested granulomatous process and histology at surgical excision confirmed this finding. Atypical mycobacteria (M. abcessus) sensitive to Amikacin were cultured from the surgical specimen proving the diagnosis. With the resurgence of tubercular and atypical mycobacterial infections in the developed world, it is important not to overlook these in differential diagnosis of various malignancies.

Does patient volume affect clinical outcomes in adult intensive care units?

PURPOSE: This systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume. METHODS: A systematic search strategy was used to identify studies reporting on volume-outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms. RESULTS: A total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies. CONCLUSIONS: The results indicate that outcomes of certain subsets of ICU patients--especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis--are better in high volume centres within the constraints of risk adjustments.

Treatment of unresectable hepatocellular carcinoma with radiolabelled lipiodol.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common solid organ tumours, with approximately 500,000 new cases being reported each year. It has a very high prevalence in Asia, and almost two-thirds of all cases occur in this region. The incidence of this tumour in Australia has nearly doubled in the past decade. Surgical resection is the mainstay of treatment, but only 10-30% of HCC are amenable to surgical resection at the time of diagnosis. The prognosis for patients with unresectable HCC remains dismal. Internal radiotherapy with radiolabelled lipiodol has been used with some success in treatment of HCC. Several studies have validated its usefulness in an adjuvant setting, but it also appears to have a role in treating unresectable tumours. METHODS: Twenty-two patients with proven HCC, not amenable to or having failed surgical treatment, were evaluated for radiolabelled lipiodol treatment. Of these, 10 patients were excluded after initial evaluation and 12 patients underwent treatment. Patients were followed up every 3 months with physical examination, computed tomography scan and alpha-fetoprotein levels. Overall survival, change in tumour size and alpha-fetoprotein levels were used to evaluate the efficacy of treatment. RESULTS: The median overall survival in patients undergoing lipiodol therapy was 15 months. Tumour size was stabilized in most patients and very few side-effects of the treatment were observed. CONCLUSION: This study has shown that radiolabelled lipiodol is an effective method for the treatment of unresectable locally advanced HCC.