Intensified neoadjuvant multimodal approach in synchronous liver metastases from gastric cancer: a single institutional experience

Background. Synchronous liver metastases (LM) from gastric (GC) or esophagogastric junction (EGJ) adenocarcinoma are a rare events. Several trials have evaluated the role of liver surgery in this setting, but the impact of preoperative therapy remains undetermined. Methods. Patients with synchronous LM from GC/EGJ adenocarcinoma who achieved disease control after induction chemotherapy (ICT) and were subsequently scheduled to chemoradiotherapy (CRT) to the primary tumor and surgery assessment were retrospectively analyzed. Pathological response, patterns of relapse, progression-free survival (PFS), and overall survival (OS) were calculated. From July 2002 to September 2012, 16 patients fulfilling the inclusion criteria were identified. Results. Primary tumor site was GC (nine patients) or EGJ (seven patients). LM were considered technically unresectable in nine patients. Radiological response to the whole neoadjuvant program was achieved in 13 patients. Eight patients underwent surgical resection of the primary tumor; in five of these LM were resected. A complete pathological response in the primary or in the LM was found in four and three patients, respectively. The most frequent site of relapse/progression was systemic (eight patients). Local and liver-only relapses were observed in two patients each. After a median follow-up of 91 months, the median OS and PFS were 23.0 (95% CI 13.2-32.8) and 17.0 months (95% CI 11.7-22.3). 5-year actuarial PFS is 17.6%. Conclusion. Our results suggest that an intensified approach using ICT followed by CRT in synchronous LM from GC/EGJ adenocarcinoma is feasible and may translate into prolonged survival times in selected patients

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Mid-term oncologic outcome of a novel approach for locally advanced colon cancer with neoadjuvant chemotherapy and surgery

Purpose. Neoadjuvant chemotherapy is being actively tested as an emerging alternative for the treatment of locally advanced colon cancer (LACC) patients, resembling its use in other gastrointestinal tumors. This study assesses the mid-term oncologic outcome of LACC patients treated with oxaliplatin and fluoropyrimidines-based preoperative chemotherapy followed by surgery. Methods and patients. Patients with radiologically resectable LACC treated with neoadjuvant therapy between 2009 and 2014 were retrospectively analyzed. Radiological, metabolic, and pathological tumor response was assessed. Both postoperative complications, relapse-free survival (RFS), and overall survival (OS) were studied. Results. Sixty-five LACC patients who received treatment were included. Planned treatment was completed by 93.8 % of patients. All patients underwent surgery without delay. The median time between the start of chemotherapy and surgery was 71 days (65-82). No progressive disease was observed during preoperative treatment. A statistically significant tumor volume reduction of 62.5 % was achieved by CT scan (39.8-79.8) (p < 0.001). It was also observed a median reduction of 40.5 % (24.2-63.7 %) (p < 0.005) of SUVmax (Standard Uptake Value) by PET-CT scan. Complete pathologic response was achieved in 4.6 % of patients. Postoperative complications were observed in 15.4 % of patients, with no cases of mortality. After a median follow-up of 40.1 months, (p25-p75: 27.3-57.8) 3-5 year actuarial RFS was 88.9-85.6 %, respectively. Five-year actuarial OS was 95.3 %. Conclusion. Preoperative chemotherapy in LACC patients is safe and able to induce major tumor regression. Survival times are encouraging, and further research seems warranted (AU)

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Patterns and management of distant failure in locally advanced rectal cancer: a cohort study

PURPOSE: To determine the long-term outcomes of locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiation (CRT) and surgery, and to analyze the management and survival once distant failure has developed. METHODS: Data from LARC patients treated from 2000 to 2010 were retrospectively reviewed. CRT protocols were based on fluoropirimidines ± oxaliplatin. Follow-up consisted of physical examination, carcinoembryonic antigen levels, and chest-abdominal-pelvic CT scan. RESULTS: The study included 228 patients with a mean age of 59 years. Forty-eight (21.1 %) patients had distant recurrence and 6 patients (2.6 %) had local recurrence. Median follow-up was 49 months. The 5- and 10-year actuarial disease free survival was 75.3 and 65.0 %, respectively. The 5- and 10-year actuarial overall survival (OS) was 89.6 and 71.2 %, respectively. Patients were classified as having liver (14 patients) or lung (27 patients) relapse according to the organ firstly metastasized. The variables significantly associated by univariate Cox analysis to survival were the achievement of an R0 metastases resection and the Köhne risk index, while the metastatic site showed a statistical trend. By multivariate Cox analysis, the only variable associated with survival was a R0 resection (HR = 16.3, p\0.001). Median OS for patients undergoing a R0 resection was 73 months (95 % CI 67.8-78.2) compared to 25 months (95 % CI 5.47-44.5) in those non-operated patients (p\0.001). CONCLUSIONS: Combined treatment for LARC obtains a 5-year OS rounding 90 %. Follow-up based on thoracic abdominal CT scan allows an early diagnosis of metastatic lesions. Surgical resection of metastases, regardless of their location, greatly increases the patient's survival rate

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Clinical significance of cellular and acellular mucin pools in rectal carcinoma following preoperative chemoradiotherapy

Background and objectives: The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Pathological findings remain the most significant prognostic factor. The presence of mucin pools and their prognostic significance is a controversial issue. The aim of this study was to analyze the incidence of cellular and acellular mucin pools and their clinical significance. Methods: Four-hundred and forty-six consecutive prospectively collected specimens from patients with LARC treated with long-course preoperative CRT and surgery were analyzed. Kaplan-Meier analysis was performed. Results: Mucin pools were present in 182 specimens (40.8 %); 66 (14.7 %) were acellular, and viable tumor cells were identified in 116 (26 %). The complete pathological response rate was 13.5 % (60 of 446). With a median follow-up of 79.0 months, the 5- and 10-year disease-free survivals for patients with acellular and cellular mucin pools were 81.5, 78.1, 63.7 and 61.2 %, respectively (p B 0.026). The presence of cells in the colloid response to treatment was associated with a 17.8 and 16.9 % decrease in 5- and 10-year disease survival vs. acellular colloid response. Conclusions: Our results suggest that cellular mucin pools are an indicator of an aggressive phenotype and harbingers of a worse prognosis (AU)

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Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease (AU)

Peutz-Jeghers syndrome and duodeno-jejunal adenocarcinoma – therapeutic implications

The Peutz-Jeghers syndrome (PJS) is an autosomal dominant hamartomatous poliposis describred in 1921. Hemminki in 1997 described the presence of LKB-1 mutation tumor-suppressor gen. The patients with PJS develop a higher cumulative incidence of gastrointestinal, pancreas and extraintestinal tumors, being occasion of a renew interest on hamartomatous polyposis syndromes regarding the clinical care, cancer surveillance treatment and long term follow-up. We report the case of a 38 years old male, diagnosed of PJS who developed a multiple adenocarcinoma in duodenum and yeyunum. Surgically treated and with a long-term free disease survival of 11 years represents the sixth case reported in the spanish literature of PJS associated with a gastrointestinal tumor. A critical review, molecular alterations and the established criteria of tumor screening and surveillance are reviewed(AU)

Lipomas submucosos de colon / Submucous large-bowel lipomas

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Risk factors related to operative morbidity in patients undergoing gastrectomy for gastric cancer

Introduction. The purpose of this study is to analyzepostoperative morbidity and mortality of patientsoperated on for gastric cancer in a single institutionduring the last twenty years, and to definerisk factors for complications.Material and methods. A retrospective study wascarried out on 434 patients who underwent gastrectomyfor gastric cancer between January 1983 andDecember 2002. Analysis of main medical and surgicalcomplications and analysis of morbidity riskfactors.Results. Overall morbidity and mortality rates were38.4% and 2.7% respectively. The most frequentcomplications were pneumonia (13%) and intra-abdominalabcesses (12%). The main cause of deathwas anastomotic dehiscence with abdominal sepsis.The last ten years mortality rate dropped from 4.7%to 0.8%. Risk factors for complications were gender(male, p = 0.01) and resection of spleen (p = 0.02) orpancreas (p = 0.002). A significantly lesser rate ofcomplications was found in patients who had underwentgastrectomy during the previous five years(p = 0.001) or with tumors located in the lower thirdof the stomach (p = 0,01).Conclusion. Morbidity of gastrectomy for gastriccancer in our institution is still high but mortalityhas decreased significantly over the last ten yearsdue to the specialization of the hospital and the surgicalteam. The main risk factor for complicationswas pancreatosplenectomy in the multivariate analysis

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Adenoma velloso hipersecretor de recto. Diagnóstico y tratamiento / Secreting villous adenoma. Diagnosis and treatment

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Estado actual de la cirugía laparoscópica esofágica / The present state of esophageal laparoscopic surgery

La cirugía laparoscópica ha cambiado el abordaje terapéutico de las enfermedades esofágicas más frecuentes. Con los excelentes resultados en el control de síntomas y con la baja morbilidad asociada el tratamiento quirúrgico se indica cada vez más en la patología esofágica benigna como una alternativa superior a un tratamiento médico crónico y menos eficaz. Para la hernia de hiato y el reflujo gastroesofágico la funduplicatura de Nissen por laparoscopia es la técnica de elección. Los mejores resultados en el tratamiento de la acalasia se consiguen con la miotomia de Heller laparoscópica. Esta experiencia creciente incluye la resección de tumores de esófago combinando toracoscopia y laparoscopia con resultados similares a los de cirugía abierta

Laparoscopic surgery has changed the therapeutic approach in the most frequent esophageal diseases. With the excellent results in the control of symptoms and the low associated morbidity, surgical treatment is increasingly indicated in benign esophageal pathology as a superior alternative to a chronic and less efficient medical treatment. For the hiatus hernia and gastroesophageal reflux, Nissen’s fundoplication by laparoscopy is the technique of choice. The best results in the treatment of acalasia are obtained with Heller’s laparoscopic myotomy. This growing experience includes the resection of tumours of the esophagus combining thorascopy and laparoscopy with similar results to those of open surgery

Papel de la cirugía en el tratamiento del linfomagástrico primario / Surgery´s role in management of primary gastric lymphoma

El Linfoma Gástrico Primario es una entidad patológica cuyo manejo óptimo está en discusión. Se estudian retrospectivamente 23 pacientes tratados en nuestro Centro por Linfoma Gástrico entre 1976 y 1998 con resección quirúrgica como terapia principal. En diez pacientes la cirugía fue el único tratamiento realizado, en el resto se asoció quimio y/o radioterapia según criterio del oncólogo-hematólogo responsable. No hubo diferencias en cuanto a morbimortalidad entre los diferentes tratamientos. Se analizan las características clínicas e histológicas y la evolución de los pacientes. Ninguno de los pacientes ha fallecido a consecuencia del linfoma, no habiéndose presentado tampoco ningún caso de recurrencia local ni a distancia. Opinamos que la cirugía es una opción válida en el tratamiento del Linfoma Gástrico Primario. La asociación de tratamientos complementarios dependerá del estadio definitivo, las características histológicas del tumor y la posibilidad de realizar o no una resección radical (AU)