Pleural and pulmonary dissemination patterns from gastric adenocarcinoma among patients with treated primary disease in Latin America.

Purpose: Latin America is one of the regions with the highest incidence of gastric cancer. Even though, there are not reports about the patterns of pleuro-pulmonary metastases in patients with gastric adenocarcinoma treated with curative intent and the prognosis according to each dissemination pattern. Material and methods: We conducted a retrospective analysis of patients with gastric adenocarcinoma treated with curative intent at the National Cancer Institute (INC) between 2010 and 2017. Demographic variables, variables associated with the primary disease and variables associated with the presence of pleuro-pulmonary opacities and metastases were collected. A univariate and multivariate logistic regression analysis was performed and survival curves were presented using the Kaplan Meier method and compared using the log-rank test. A Cox regression model was performed for multivariate analysis for overall survival. Results: The study included 450 patients, 51.3% were male and the median age was 63 years. Intestinal adenocarcinoma was the most frequent histological subtype, in 261 cases (58.0%). Gastric cancer initial pathological stage was stage I in 23.3% of the patients, stage II in 19.3% and stage III in 53.6%. During a median follow-up of 31.9 months, 37 (8.2%) patients developed pleuro-pulmonary opacities; among those, 14 (3.1%) met the criteria for pleuro-pulmonary metastases: 6 (1.3%) had lymphangitic metastasis, 4 (0.9%) had a mixed pattern of pleural and lung nodules, 3 (0.7%) had pleural metastasis, and only one (0.2%) had hematogenous metastasis. The median OS was 114.5 months for the entire cohort and 38.2 (95%CI, 19.2-57.2) months for patients with pleuro-pulmonary metastases. Patients with pleural metastasis and lymphangitic carcinomatosis had median survival of 24.3 (95%CI, 0.01-51.0) and 26.4 (95%CI, 18.2-34.7) months, respectively. Conclusions: incidence of pleuro-pulmonary metastases in patients with gastric adenocarcinoma treated with curative intention was low. In our series, lymphangitic carcinomatosis was the main pattern of dissemination; meanwhile, hematogenous metastasis was rare and patients with pleural carcinomatosis had the lowest median survival.

Lung Metastasectomy from Colorectal Cancer, 10-year Experience in a South American Cancer Center.

Purpose: This study aimed to describe the survival outcomes and factors associated with prognosis in patients undergoing pulmonary metastasectomy with colorectal cancer (CRC) in a cancer center in South America. Material and methods: A retrospective analysis of patients that underwent lung metastasectomy due to CRC at National Cancer Institute (INC), Colombia between 2007 and 2017 was performed and Kaplan-Meier survival analysis along with log-rank test and Cox regression multivariate analysis were completed. Results: Seventy-five patients with colorectal adenocarcinoma were included in the study. Of them, 57.3% were women with a median age of 62 years [interquartile ranges (IQR): 18.5]. For 45.3% the adenocarcinoma was located in the rectum and 29.3% had stage IV at diagnosis. 56% had a history of controlled extrapulmonary metastasis and 20% of the cases had a history of the metastasis of the liver. The median follow-up was 36.8 months (IQR: 27.4). Three-year and five-year overall survival (OS) was 57.5% [95% confidence interval (CI), 47.0-70.4] and 33.2% (95% CI, 23.4-47.2), respectively. Patients with bilateral, more than one pulmonary metastasis, abnormal postmetastasectomy carcinoembryonic antigen (CEA), history of liver metastasis, and disease-free interval (DFI) ≤12 months had worse OS. Three-year and five-year disease-free survival (DFS) was 30.1% (95% CI, 20.8-43.6) and 21.6% (95% CI, 13.0-35.9), respectively. Bilateral, more than one pulmonary metastasis, and patients with stage IV at diagnosis had the worst DFS. Multivariate analysis in the Cox regression model showed that abnormal postmetastasectomy CEA [Hazard Ratio (HR):1.97, 95% CI, 1.01-3.86, p = 0.045] and DFI ≤ 12 months (HR: 3.08, 95% CI, 1.26-7.53, p = 0.014) were independent factors for worst OS. Conclusions: The OS found falls within the wide range described in the world literature but interestingly it falls at the bottom end of this range. The factors associated with worst survival were identified as bilateral, more than one pulmonary metastasis, abnormal postmetastasectomy CEA, history of liver metastasis, and DFI ≤12 months. Contribution to the field: Pulmonary metastasectomy is the standard of care in patients with metastatic CRC. However, the literature supporting this conduct is based on retrospective studies and the only randomized controlled trial conducted to date was stopped due to poor recruitment. Limited information is available in South America about survival and factors associated with prognosis in patients with metastatic CRC. While this study is another series that adds to the many studies across the world that describe the use of pulmonary metastasectomy in CRC, it presents critical data as it is one of the few studies carried out in South America. As described in a wide range of world literature, OS found falls in patients that underwent lung metastasectomy due to CRC however; interestingly, in the South American population analyzed here it falls at the bottom end of this range. This may be explained by a large number of patients included with a history of extrapulmonary metastasis as well as may reflect inadequate patient access to reference cancer centers in Colombia. Factors associated with worst survival in our population were bilateral, more than one pulmonary metastasis, abnormal postmetastasectomy CEA, history of liver metastasis, and interval from diagnosis to development of pulmonary metastasis ≤12 months.

Left hepatic lobe agenesis, a rare anatomical condition.

Left hepatic lobe agenesis is a rare congenital disorder, first reported by Wakefield in 1898. Since then, less than 40 cases have been described in the literature. We present the case of a man with a left hepatic lobe agenesis diagnosed during the study of obstructive jaundice.

Cholecystectomy 7 days vs 4 weeks after mild biliary pancreatitis; looking a decrease the incidence of persistent choledocholithiasis and ERCP: A multicentric randomized clinical trial.

BACKGROUND: Mild acute biliary pancreatitis (MABP) requires definitive treatment of the cholelithiasis to avoid recurrent biliary events. Recent publications recommend performing early surgery to prevent readmissions. However, an exceedingly early cholecystectomy could imply missing the presence of persistent choledocholithiasis or requiring a significant number of preoperative endoscopic retrograde cholangiopancreatographies (ERCP). This multicentre randomized clinical trial compares early surgery performed a week after MABP with delayed surgery (at 4 weeks), to compare readmission rates for recurrent biliary events and the incidence of residual choledocholithiasis between the two groups. MATERIALS AND METHODS: A total of 198 patients with a first episode of MABP defined by the Atlanta 2012 criteria were enrolled. Randomization was done by a central study coordinator: 98 to early surgery and 100 to delayed surgery. All of them had preoperative or intraoperative imaging to exclude persistent choledocholithiasis. Laparoscopic cholecystectomy was performed by dedicated teams of experienced surgeons. RESULTS: Early surgery reduced the rate of readmissions for biliary events before cholecystectomy by half (7.2% vs 15.8%, p = 0,058). There were no differences in the type of surgery, postoperative stay, or complications compared with delayed surgery. Choledocholithiasis was observed in 9.0% of patients in the early group and 7.7% in the delayed group (p 0,719). The preoperative or intraoperative imaging study avoided unnecessary ERCP, which was performed in only 6 (3%) patients. CONCLUSIONS: Early cholecystectomy performed seven days after resolution of MABP had a low incidence of recurrent biliary events and complications, and was not associated with an increase in residual choledocholithiasis or need for unnecessary ERCP.

[Endoscopic-radiologic rendezvous for biliary obstruction management. Case report and literature review]. / Rendezvous radiológico-endoscópico para manejo de obstrucción biliar. Reporte de casos y revisión de la literatura.

Biliary obstruction of different origin is a common clinical problem, with significant impact on the patients quality of life and poses a permanent risk of cholangitis. The management of these patients has evolved over time, makes collection of various technological developments and involve clinicians, surgeons, gastroenterologists, and interventional radiologists. Were port four cases of biliary obstruction that despite the significant demographic and clinical differences between them could be successfully managed approach in the biliary tract with the technique of radiological endoscopic Rendezvous.

Rendezvous radiológico-endoscópico para manejo de obstrucción biliar: Reporte de casos y revisión de la literatura / Endoscopic-radiologic rendezvous for biliary obstruction management: Case report and literature review

La obstrucción biliar de diverso origen constituye un problema clínico frecuente, con importante impacto sobre la calidad de vida de los pacientes y que plantea el riesgo permanente de colangitis. El manejo de estos pacientes ha evolucionado en el tiempo, haciendo acopio de diversos desarrollos tecnológicos e involucrando a clínicos, cirujanos, gastroenterólogos y radiólogos intervencionistas. Reportamos aquí cuatro casos de pacientes con obstrucción biliar que, a pesar de las importantes diferencias demográficas y etiológicas, pudieron ser exitosamente manejados, abordando la vía biliar con la técnica de Rendezvous radiológico endoscópico.

Biliary obstruction of different origin is a common clinical problem, with significant impact on the patients´ quality of life and poses a permanent risk of cholangitis. The management of these patients has evolved over time, makes collection of various technological developments and involve clinicians, surgeons, gastroenterologists, and interventional radiologists. Were port four cases of biliary obstruction that despite the significant demographic and clinical differences between them could be successfully managed approach in the biliary tract with the technique of radiological endoscopic Rendezvous.

Terapia de conversión en cáncer gástrico estadio IV: a propósito de un caso / Case Report of Conversion Therapy in Stage IV Gastric Cancer

Resumen Se reporta el caso de una paciente de 47 años, con diagnóstico inicial de un tumor de Krukenberg por una lesión anexial de 10 cm de diámetro y una lesión corporal gástrica de 3 cm. La biopsia mostró un adenocarcinoma pobremente diferenciado con células en anillo de sello. Una laparoscopia inicial mostró un índice de carcinomatosis peritoneal (ICP) de 24, por lo cual se le indica a la paciente quimioterapia con intención paliativa (cisplatino y capecitabina). Con mejoría clínica importante, respuesta adecuada y favorable a la quimioterapia, la paciente se remitió a una salpingo-ooforectomía bilateral. Continúa con quimioterapia evidenciándose mejoría de las imágenes tomográficas y una excelente respuesta clínica. Por este motivo, se decide en conjunto con la familia llevarla a cirugía. Se le practica una gastrectomía total con linfadenectomía D2 con intención curativa. La paciente recibe quimioterapia con capecitabina y cisplatino por 3 meses más, hasta cuando se evidencia compromiso ganglionar paraaórtico, por lo que es necesario reiniciar la quimioterapia con un nuevo esquema, entonces se le formula irinotecán. La paciente completa 22 meses desde el diagnóstico inicial, la condición clínica es muy buena y está asintomática.

Abstract We report the case of a 47-year-old patient initially diagnosed with a Krukenberg tumor, an adnexal lesion 10 cm in diameter and a 3 cm lesion in the gastric corpus. A biopsy showed a poorly differentiated adenocarcinoma with signet ring cells. Initial laparoscopy showed an index of peritoneal carcinomatosis of 24 which indicated chemotherapy with palliative intent (cisplatin and capecitabine). The patient improved significantly and underwent a total hysterectomy with salpingo-oophorectomy. Chemotherapy continued with excellent clinical response as evidenced in CT scans. Together with the patient's family, it was decided that she should undergo surgery. A total gastrectomy with D2 lymphadenectomy with curative intent was performed. The patient continued to receive capecitabine and cisplatin for three more months until para-aortic lymph node involvement was demonstrated and it became necessary to restart chemotherapy with a new scheme using iriniotecan. The patient has completed 22 months after the initial diagnosis in very good and clinical condition without symptoms.

Factores asociados con carcinomatosis por Cáncer Gástrico: ¿A quiénes hacemos laparoscopia? / Factors associated with peritoneal carcinomatosis due to gastric cancer: On whom do we perform laparoscopy?

Resumen Introducción: Varios estudios han demostrado la efectividad de la laparoscopia en la evaluación de los pacientes con tumores avanzados. Sin embargo, no hay uniformidad con respecto a lo sistemático de su uso y diferentes autores han reportado indicaciones y resultados variables. Métodos: Estudio observacional, analítico, de corte transversal en el que se evaluó un modelo con un grupo de variables asociadas con el diagnóstico laparoscópico de carcinomatosis. Se incluyeron todos los pacientes con adenocarcinoma gástrico que fueron llevados a laparoscopia de estadificación desde enero de 2008 y hasta completar la muestra, que fue estimada en 153 casos. Las variables evaluadas fueron edad, género, pérdida de peso, valor de albúmina sérica, localización endoscópica del tumor, tipo histológico según la clasificación de Lauren, descripción tomográfica del tumor (T), presencia de adenopatías (N) y ascitis. La presencia de carcinomatosis fue definida por observación laparoscópica. Resultados: Fueron analizados 153 pacientes; 102 hombres (66%) y 51 mujeres (33%) con edades entre 28 y 86 años. Los factores asociados de manera estadísticamente significativa con presencia de carcino matosis peritoneal fueron edad menor de 65 anos (OR=2,0; IC95%:1 a 4,2), género femenino (OR=2,2; IC95%: 1,06 a 4,7), localización cardial del tumor (OR=2,6; IC95%: 1,25 a 5,2), pre sencia de ascitis (OR=4,3; IC95%: 1,3 a 15,9) e histología del tipo difuso (OR=3,0; IC95%: 1,5 a 5,8). Conclusiones: La laparoscopia de estadificación es una herramienta valiosa en el abordaje ini cial de los pacientes con cáncer gástrico avanzado y los estudios de imagen no la reemplazan. Las mujeres, menores de 65 años, con tumores cardiales del tipo histológico difuso y con ascitis documentada en TAC tienen mayor riesgo de cursar con carcinomatosis peritoneal en el momento del diagnóstico, por lo que proponemos el uso sistemático de la laparoscopia de estadificación en los pacientes que cumplan una o más de estas características. © 2017 Instituto Nacional de Cancerología. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Abstract Introduction: Several studies have demonstrated the effectiveness of laparoscopy in the eva luation of patients with advanced tumours. However, there is no uniformity with respect to its systematic use, with different authors having reported variable indications and outcomes. Methods: An observational, analytical, cross-sectional study in which a model was evaluated with a group of variables associated with the laparoscopic diagnosis of peritoneal carcino-matosis. The study included all patients with gastric adenocarcinoma who were submitted to staging laparoscopy from January 2008 until the sample was completed, which was estimated in 153 cases. The variables evaluated were age, gender, weight loss, serum albumin value, endoscopic tumour location, histological type, according to Lauren classification and tumour tomography (T), presence of lymphadenopathy (N), and ascites. The presence of peritoneal carcinomatosis was defined by laparoscopic observation. Results: A total of 153 cases of gastric adenocarcinoma patients submitted to staging laparos-copy were analysed in the Gastrointestinal Surgery Department of the National Cancer Institute. They included 102 men (66%) and 51 women (33%), aged between 28 and 86 years. Statistically significant factors associated with the presence of peritoneal carcinomatosis were, age less than 65 years (OR = 2.0, 95% cI: 1 - 4.2), female gender (OR 2.2, 95% CI: 1.06 (OR = 2.6, 95% CI: 1.25 - 5.2), presence of ascites (OR = 4.3, 95% CI: 1.3 - 15.9), and histology of the diffuse type (OR 3.0; 95% CI: 1.5 - 5.8). Conclusions: Staging laparoscopy is a valuable tool in the initial approach of patients with advanced gastric cancer, and imaging studies do not replace it. Women, younger than 65 years, with gastroesophageal junction (GEJ) tumours, of the diffuse histological type, and with docu mented ascites in computed tomography scan, are at greater risk of peritoneal carcinomatosis at the time of diagnosis. Thus, the systematic use of staging laparoscopy is proposed in patients who meet one or more of these characteristics.

Tres cánceres primarios simultáneos: reporte de caso y revisión de la literatura / Three simultaneous primary cancers: Case report and literature review

Resumen La presencia de un segundo o tercer cáncer primario después del diagnóstico inicial de malignidad es un evento cada vez más frecuente asociado con la mejor sobrevida y seguimiento de pacientes con cáncer a nivel mundial. Sin embargo, la presencia de tres neoplasias primarias simultáneas sigue siendo un evento singular. Presentamos el caso de una mujer de 76 años con tumor neuroendocrino del intestino delgado, adenocarcinoma de colon sigmoide y adenocarcinoma mucinoso de ovario de manera simultánea, manejada quirúrgicamente. Reali zamos una revisión de la literatura.

Abstract The presence of a second or third primary cancer after the initial diagnosis of malig nancy is an increasingly frequent event associated with the improved survival and monitoring of cancer patients worldwide. However, the presence of three simultaneous primary neoplasms remains a singular event. The case is presented of a 76-year-old woman with a neuroendo crine tumour of the small intestine, sigmoid colon adenocarcinoma, and a mucinous ovarian adenocarcinoma, simultaneously surgically managed. A literature review on the topic was also conducted.

Neoplasia mucinosa quística del mesenterio: presentación de caso y revisión de la literatura / Mucinous cystic neoplasms of the mesentery: Case presentation and literature review

Las neoplasias quísticas mucinosas del mesenterio son infrecuentes, carecen de hallazgos clínicos específicos y usualmente se diagnostican incidentalmente como otros quistes mesentéricos. Presentamos el caso de una mujer de 67 años con un quiste mesentérico erroneamente clasificado en el preoperatorio como un tumor ovárico. Fue extraído completamente y la revisión histológica mostró un cistadenoma mucinoso. Revisamos la literatura y los casos reportados hasta la fecha.

Mucinous cystic neoplasms of the mesentery are rare, have a lack of specific clinical findings, and are usually diagnosed incidentally as other mesenteric cysts. The case is reported on a 67 year-old woman with a mesenteric cyst erroneously classified preoperatively as an ovarian tumor. It was completely resected and histological review showed a mucinous cystadenoma. A review is performed on the literature and cases reported to date.