Risk Factors for Lymph Node Metastasis in a Western Series of Patients with Distal Early Gastric Cancer.

Background: Assessment of potential lymph node metastasis is mandatory in the appropriate treatment of early gastric cancers. This study analysed factors associated with lymph node metastasis to identify differences between node-negative and node-positive patients and between T1a and T1b cancers. Methods: The clinicopathological features of 129 early gastric cancer patients who had undergone radical gastrectomy were analysed to identify predictive factors for lymph node metastasis. Results: Lymph node metastasis was detected in 76 (59.0%) patients. Node-positive patients were younger (58.1 ± 11.3 years) than those without metastasis (61.9 ± 9.6 years, p = 0.02). Greater tumour sizes were observed in patients with lymph node metastasis (3.6 ± 1.0 cm) compared to node-negative patients (1.9 ± 0.5 cm, p = 0.00001). Depressed form, ulceration, diffuse histological type, and undifferentiated lesions were more frequent in node-positive patients than in the node-negative group. Tumour size > 3.0 cm showed a correlation with lymph node metastasis in both T1a (p = 0.0001) and T1b (p = 0.006) cancer. The male sex (p = 0.006) had a significant correlation with lymph node metastasis in T1a cancer. Depressed appearance (p = 0.02), ulceration (p = 0.03), differentiation (p = 0.0001), diffuse type (p = 0.0002), and lower third location (p = 0.005) were associated with lymph node metastasis in T1b cancer. Conclusions: Tumour size > 3 cm, undifferentiated lesions, ulceration, diffuse type, lower third location, and submucosal invasion are risk factors for lymph node metastasis in early gastric cancer.

Survival predictors of radioiodine-refractory differentiated thyroid cancer treated with lenvatinib in the real-life.

CONTEXT: Lenvatinib is approved for the treatment of radioiodine-refractory differentiated thyroid cancer (RR-DTC). The definition of predictive factors of survival is incomplete. OBJECTIVE: To identify pre- and post- treatment survival predictors in a real-life cohort of RR-DTC treated with lenvatinib. DESIGN: Multicenter, retrospective, cohort study. SETTING: Three Italian thyroid cancer referral centers. PARTECIPANTS: 55 RR-DTC treated with lenvatinib. MAIN OUTCOME MEASURES: Progression-free survival (PFS) and overall survival (OS). RESULTS: Lenvatinib was the first-line kinase-inhibitor in 96.4% of subjects. Median follow-up was 48 months. Median PFS and OS were 26 (95% CI 19.06-32.93) and 70 months (95% CI 36-111.99), respectively. Pre-treatment setting: Eastern Cooperative Oncology Group (ECOG) performance status was independently related to PFS (p < 0.001; HR 18.82; 95% CI 3.65-97.08: score 0-1 as reference) and OS (p = 0.001; HR 6.20; 95% CI 2.11-18.20; score 0-1 as reference); radioactive iodine (RAI)-avidity was independently related to PFS (p = 0.047; HR 3.74; 95% CI 1.01-13.76; avid disease as reference). Patients with good ECOG status (0-1) and RAI-avid disease obtained objective response in 100% of cases and achieved a median PFS of 45 months without any death upon a median follow-up of 81 months. Post-treatment setting: best radiological response independently predicted PFS (p = 0.001; HR 4.6; 95% CI 1.89-11.18; partial/complete response as reference) and OS (p = 0.013; HR 2.94; 95% CI 1.25-6.89; partial/complete response as reference). CONCLUSIONS: RR-DTC with good performance status and RAI-avid disease obtain the highest clinical benefit from lenvatinib. After treatment initiation, objective response was the only independent survival predictor.

Pattern of Distribution of Lymph Node Metastases in Individual Stations in Middle and Lower Gastric Carcinoma.

(1) Background: Lymph node (LN) dissection is the cornerstone of curative treatment of GC. The pattern of distribution of LN metastases is closely related to several factors. The aim of this study is to evaluate the factors determining the distribution of nodal metastases in a population of N+ distal GC patients undergoing gastrectomy and D2 lymphadenectomy. (2) Methods: The medical charts of 162 N+ GC patients who underwent surgical resection over a 15-year period were retrospectively analyzed. Clinical, pathological and anatomical characteristics were evaluated to identify the factors affecting the patterns and prevalence of metastases in individual LN stations. (3) Results: LN metastasis is correlated with the depth of the tumor and to diffuse-type tumors. A higher number of metastatic nodes was documented in patients with middle-third tumors (8.2 ± 7.3 vs. 4.5 ± 5.0 in lower-third tumors, p = 0.0001) and in patients with tumors located on the lesser curve. Station 4 showed the highest rate of metastases (53.1%). Concerning stations 7 to 12, station 8 showed the highest metastasis rate (28.4%). Metastases at stations 1, 2, 4 and 7 to 11 were dominant in middle-third cancer, whereas stations 5 and 6 were dominant in lower-third cancers. Station 4, 5, 6, 10 and 11 metastases were dominant when the cancer was located on the greater curve, whereas stations 1, 2, 7, 8 and 12 were dominant in lesser-curve cancers. (4) Conclusions: The study documented that in patients with distal GC, the distribution of nodal metastases at individual stations is closely related to primary tumor location.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer: A retrospective cohort study.

BACKGROUND: Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory. Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant. AIM: To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer. METHODS: A retrospective analysis of clinical data and pathological characteristics (age, sex, primary site of the tumor, Lauren histotype, number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion as defined by the standard nomenclature) was conducted in patients with gastric cancer. For each patient we calculated the Kattan's score. We arbitrarily divided the study population of patients into two groups based on the nomogram score (< 100 points or ≥ 100 points). Prespecified subgroups in these analyses were defined according to age (≤ 65 years or > 65 years), and number of lymph nodes retrieved (≤ 35 lymph nodes or > 35 lymph nodes). Uni- and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity. RESULTS: One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy. Perioperative mortality rate was 3.8% (7 patients); a higher mortality rate was observed in patients aged > 65 years (P = 0.002) and in N+ patients (P = 0.04). Following univariate analysis, mortality was related to a Kattan's score ≥ 100 points (P = 0.04) and the presence of advanced gastric cancer (P = 0.03). Morbidity rate was 21.0% (40 patients). Surgical complications were observed in 17 patients (9.1%). A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested (P = 0.0005). CONCLUSION: Mortality and morbidity rate are higher in N+ and advanced gastric cancer patients. The removal of more than 35 lymph nodes does not lead to an increase in mortality.

Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing.

PURPOSE: Anal fissure is caused by a pathological contraction of the internal anal sphincter. Lateral internal sphincterotomy remains the gold standard for the treatment of fissure. Botulinum toxin injections have been proposed to treat this condition without any risk of permanent injury of the internal sphincter. We investigate clinical and pathological variables and the effects of different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure. METHODS: This is a retrospective study at a single center. The patients underwent a pre-treatment evaluation that included clinical inspection of the fissure and anorectal manometry. We collected and analyzed demographic data, pathological variables, associated pathological conditions, and treatment variables. Success was defined as healing of the fissure, and improvement of symptoms was defined as asymptomatic persistent fissure. RESULTS: The findings of 1003 patients treated with botulinum toxin injections were reported. At 2 months evaluation, complete healing was evident in 780 patients (77.7%). Resting anal tone (77.1 ± 18.9 mmHg) was significantly lower from baseline (P < 0.0001) and from 1-month value (P = 0.0008). Thirty-nine not healed patients underwent lateral internal sphincterotomy, and 184 were re-treated with 50 UI of botulinum toxin. In these patients, the healing rate was 93.9% (171 patients). Dose and injection site of toxin correlates with healing rate. There were no relapses during an average of about 71 months. CONCLUSION: Our data show that injection of botulinum toxin into the internal anal sphincter is a safe and effective alternative to surgery in patients with chronic anal fissure.

An Intrapancreatic accessory spleen presenting as a neuroendocrine tumor.

Although the second most common site of the accessory spleen is the tail of the pancreas, intrapancreatic accessory spleens (IPAS) are rarely recognized radiologically. When an accessory spleen is located in the pancreas, it may mimic a hypervascular pancreatic tumor. We report a case of intrapancreatic accessory spleen which radiologically (on TC) mimicked a neuroendocrine pancreatic tumor (PNET). It was not possible to be sure that the pancreatic nodule had no malignant potential; because of the close proximity to splenic vessel we performed en bloc resection of the spleen and distal pancreas. Postoperative course was uneventful. IPAS must be considered in the differential diagnosis of pancreatic tail tumors, particulary an asymptomatic small PNET; new and adequate diagnostic studies have demonstrated utility in defining these lesions. We review pertinent literature. KEY WORD: Intrapancreatic accessory spleen, Pancreatic neuroendocrine tumor.

Open versus laparoscopic colorectal surgery in the era of multimodality treatment of cancer.

AIM: To compares the efficacy and safety of laparoscopic surgery (LS) and open surgery (OS). To analyze early results of a single institution experience using adjuvant intraoperative radiation therapy (IORT) presacral boost in locally advanced cancer. MATERIAL OF STUDY: 264 patients with curable colorectal cancer undergoing laparoscopic (97) or open colorectal resection (167). In 41 patients (31 open and 10 laparoscopic resection) with locally advanced rectal cancer we performed IORT. Primary endpoints were the evaluation of postoperative clinical and oncologic results. RESULTS: Twenty (21%) patients underwent conversion from laparoscopic to open surgery. The overall morbidity rates were 17.5% in the LS group and 20.9% in the OS group (P= 0.5). Average operative time was shorter in the OS than in the LS series (P= 0.01). Use of parenteral narcotics was shorter in LS than in OS group (P <0.001), but there were more stoma creations in LS group than in OS group (P= 0.001). All patients are alive at different followup periods. DISCUSSION: Colorectal cancer is the second leading cause of death from malignancy in the industrialized world. The risk of local recurrence after treatment increases with tumor stage. The roles of radiochemotherapy and surgical procedures have been investigated extensively in the last decades, especially in locally advanced rectal cancer. CONCLUSIONS: Laparoscopic techniques can be applied to colorectal malignancies without sacrificing oncologic results. Multimodality treatment with LS and IORT is safe and feasible.

Left-sided IVC in left renal cell carcinoma.

AIM: Congenital anomalies of the inferior vena cava (IVC) are very rare and extremely diverse, reflecting the complexity of the embryological development of these structures. The variants must be differentiated from pathology, particularly lymphadenopathy, on imaging studies as their presence can affect surgical and interventional procedures in retroperitoneum. We describe two patients with renal cell carcinoma of left kidney and left IVC. CASE REPORT: First patient was taken up for left radical nephroureterectomy. During surgery the existence of a transposed left IVC was demonstrated. The second case is a fifty-four-year-old man; abdomen and pelvic CT-scan with coronal maximum intensity projection reconstruction showed a 7 cm heterogeneously enhancing neoformation involving the left kidney with intraparenchymal hematoma and a transposed left IVC. CONCLUSIONS: Preoperative detection of congenital IVC anomalies can prevent morbidity. Once diagnosed, appropriate care must be taken during the operation to expose and define the anatomic anomaly and protect it from injury.

Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity.

AIM: To study the effect of botulinum toxin in patients with chronic anal fissure after biliopancreatic diversion (BPD) for severe obesity. METHODS: Fifty-nine symptomatic adults with chronic anal fissure developed after BPD were enrolled in an open label study. The outcome was evaluated clinically and by comparing the pressure of the anal sphincters before and after treatment. All data were analyzed in univariate and multivariate analysis. RESULTS: Two months after treatment, 65.4% of the patients had a healing scar. Only one patient had mild incontinence to flatus that lasted 3 wk after treatment, but this disappeared spontaneously. In the multivariate analysis of the data, two registered months after the treatment, sex (P = 0.01), baseline resting anal pressure (P = 0.02) and resting anal pressure 2 mo after treatment (P < 0.0001) were significantly related to healing rate. CONCLUSION: Botulinum toxin, despite worse results than in non-obese individuals, appears the best alternative to surgery for this group of patients with a high risk of incontinence.

Severe acute pancreatitis: advances and insights in assessment of severity and management.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Surgical prophylaxis of pouchitis in ulcerative colitis.

Ileal pouch-anal anastomosis (IPAA) is now the procedure of choice for most patients requiring proctocolectomy for ulcerative colitis. The J-shaped pouch, usually 15-20 cm in length, is easiest to construct and has functional outcomes identical to those of the more complex designs. IPAA is a complex procedure, and complications occur frequently. Despite the significant improvements this surgical advance has made on the quality of life in these patients, inflammation of the surgically created ileal pouch or pouchitis remains a major late postoperative complication that can often overshadow the benefits of this otherwise curative operation. Several inflammatory and noninflammatory complications can occur after IPAA. Pouchitis is the most common, occurring in ≈50% of patients. Whereas acute pouchitis can be treated rapidly and successfully in the majority of patients, refractory and chronic pouchitis remain therapeutic challenges to patients and physicians. The problem is believed to be caused by stasis of feces in the pouch with overgrowth of aerobic and anaerobic organisms. The size of the pouch has a significant influence on the incidence of pouchitis: a smaller pouch usually empties better than a larger pouch and so may be less susceptible to pouchitis.