Treatment of peritoneal carcinomatosis by cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion (IHCP): postoperative outcome and risk factors for morbidity.

BACKGROUND: Cytoreductive surgery with limited or extended peritonectomy associated with intraperitoneal hyperthermic chemoperfusion (IHCP) has been proposed for treatment of peritoneal carcinomatosis (PC) from abdominal neoplasms. METHODS: Fifty-nine patients with PC from abdominal neoplasms underwent 61 treatments using this technique from January 2000 to August 2005. Surgical debulking, completed by partial or total peritonectomy, was performed in most cases. In 16 patients with positive peritoneal cytology without macroscopic peritoneal disease, IHCP was performed in order to prevent peritoneal recurrence. IHCP was carried out throughout the abdominopelvic cavity for 60 minutes using a closed abdomen technique. Intra-abdominal temperature ranged between 41 degrees C and 43 degrees C; mitomycin C (25 mg/mq) and cisplatin (100 mg/mq) were the anticancer drugs generally used, and they were administered with a flow rate of 700-800 ml/minute. RESULTS: Mean hospital stay was 13 +/- 7 (range 7-49) days. Postoperative complications occurred in 27 patients (44.3%); of these, major morbidity was observed in 17 (27.9%). The most frequent complications were wound infection (9 cases), grade 2 or greater hematological toxicity (5 cases), intestinal fistula (5 cases), and pleural effusion requiring drainage (5 cases). Reoperation was necessary in 5 patients (8.2%). One patient with multiorgan failure died in the postoperative period (mortality rate: 1.6%). Multivariate analysis of several variables identified completeness of cancer resection (CCR-2/3 vs. CCR-0/1, relative risk: 9.27) and age (relative risk: 1.06 per year) as independent predictors of postoperative morbidity. Preliminary follow-up data indicate that survival probability may be high in patients with ovarian or colorectal cancer and low in patients with gastric cancer. CONCLUSIONS: IHCP combined with cytoreductive surgery involves a high risk of morbidity, but postoperative complications could be resolved favorably in most cases with correct patient selection and adequate postoperative care. Tumor residual and advanced age significantly increase the risk of morbidity after this procedure.

Folinic acid, 5-fluorouracil and etoposide after curative resection for gastric cancer.

BACKGROUND/AIMS: The aim of this study was to evaluate the survival benefit of adjuvant chemotherapy with etoposide, leucovorin and 5-fluorouracil (ELF) in gastric cancer patients undergoing previous surgery with a curative intent. METHODOLOGY: The clinical outcome of 49 patients with resected gastric cancer treated with adjuvant chemotherapy was compared with that of 85 surgically treated historical controls who did not receive any adjuvant treatment. The chemotherapy regimen consisted of six cycles of daily 1-hour intravenous infusions of folinic acid 100 mg/m2 and 5-FU 400 mg/ m2, and a 2-hour infusion of etoposide 100 mg/m2, for three days every 28 days. RESULTS: The 5-year relapse-free survival was 32% in the adjuvant arm and 27% in the control arm (p = 0.6). At the last follow-up, there were 32 deaths in the adjuvant arm and 60 in the control arm. The median duration of survival was respectively 23 and 19 months, and the 5-year survival rates were 34% and 29% (p = 0.4). The chemotherapy was well tolerated. CONCLUSIONS: Our data suggest that ELF adjuvant treatment is a safe and well tolerable combination chemotherapy in patients with resected gastric cancer, but it does not seem to improve prognosis in comparison with historical controls.

A clinical case of duodenal gastrointestinal stromal tumor with a peculiarity in the surgical approach.

We describe a case of duodenal, third portion, segmental resection for gastrointestinal stromal tumor. A 76-year-old man was referred for gastrointestinal bleeding, dyspnea and asthenia. Esophagogastroduodenoscopy showed a duodenal bleeding fistula. Computerized tomography demonstrated a retroperitoneal mass that compressed and displaced forward the third duodenal tract. Segmental resection of the third portion of the duodenum with a subtotal gastrectomy was performed. The patient was reconstructed with a termino-terminal duodenal anastomosis of the second and the fourth tract and with a Roux-en-Y gastrojejunum anastomosis. There were no postoperative complications. This duodenectomy procedure could be useful as a less extensive resection for duodenal gastrointestinal stromal tumor located in the third portion of the duodenum when the tumor is well capsulated, when the surrounding structures are not infiltrated and when there are no vascular difficulties. The technique reduces the morbidity and mortality correlated with duodenocefalopancreasectomy and improves postsurgical quality of life without worsening the risk of recurrence.

[Benefits of extended lymphadenectomy in patients with gastric carcinoma with metastasis to second level lymph nodes. An Italian multicenter study]. / Benefit della linfoadenectomia estesa in pazienti affetti da carcinoma gastrico con metastasi ai linfonodi di secondo livello. Studio italiano multicentrico.

The actual benefit of extended lymphadenectomy in terms of survival in the surgical treatment of gastric cancer is still a debated issue. The aim of this non-randomized prospective multicentre study was to evaluate long-term survival in a group of patients with involvement of the second level lymph nodes, which would not have been removed with a limited lymphadenectomy. From 1991 to 1997, 451 patients with primary gastric cancer underwent curative resection with extended lymphadenectomy in three italian surgical departments. Lymph node stations were removed and classified according to the rules of the Japanese Research Society for Gastric Cancer; in all cases, retrieval of the lymph nodes was performed by the surgeon on the fresh specimen. Metastases to lymph node stations 7-12 were found in 126 patients out of 451 (27.9%). A mean number of 13 +/- 9 positive lymph nodes (range: 1-42) was found in these cases. Lymph node stations 7 and 8 showed the highest incidence of metastases (61.1% and 44.4%, respectively). Morbidity and mortality rates were 17.1% and 2% in 451 cases treated by extended lymphadenectomy, and 21.4% and 3.2%, respectively, in 126 cases with involvement of second level lymph nodes. In this group of patients, the five-year survival rate was 32 +/- 4%. Multivariate analysis, identified depth of invasion (P < 0.0001, relative risk (RR) 2.4) and the number of positive lymph nodes (P < 0.001, RR 1.6) as significant predictors of a poor prognosis. Japanese-type extended lymphadenectomy is associated with low morbidity and mortality rates if performed in specialised centres. The incidence of metastases in lymph node stations removed with this technique is by no means negligible. This procedure could be beneficial as regards long-term survival even in patients with involvement of regional lymph nodes.

[Primary ano-rectal melanoma: considerations on a clinical case and review of the literature]. / Il melanoma primitivo ano-rettale: considerazioni su un caso clinico e revisione della letteratura.

Anorectal melanoma is a rare disease (1% of all anorectal malignancies). It is characterised by aspecific symptoms and the differential diagnosis versus other lesions of the rectum and anus is often difficult. The prognosis is very poor: mean survival is about 24 months, and at diagnosis most patients present distant metastases. Surgery is suggested as being the best treatment for this disease, since radio- and chemotherapy are generally only used for palliative purposes. Long-term survival depends on the stage of the melanoma at diagnosis. The possible surgical treatments available consist in local resection, which is considered the first therapeutic choice, and abdominoperineal amputation when local resection cannot be performed, or as a palliative operation. Inguinal lymphadenectomy is indicated when the inguinal lymph nodes are involved. In this report we describe a case of anorectal melanoma in a 73-year-old woman who underwent abdominoperineal amputation as surgical palliative treatment, because of infiltration of the puborectal muscle. The case report is followed by a review of the literature.

[Cystadenoma of the pancreas: 4 cases in our clinical experience]. / Cistoadenomi del pancreas: 4 casi nella nostra esperienza clinica.

Cystic neoplasms account for about 10% of all cystic lesions of the pancreas and less than 1% of all exocrine pancreatic neoplasms. The authors report 4 cases of pancreatic cystadenoma (3 women and 1 man; mean age 59 years; range: 41-72), 2 serous and 2 mucinous, treated over the period from 1999 to 2002. The main symptoms were hypochondrial pain in two patients and diffuse abdominal pain in one while the fourth patient was asymptomatic. The patients were studied clinically by CT, echotomography and angiography. In three cases the tumours were located in the pancreatic body-tail, and in one case in the head. Serum amylase, lipase and tumour markers were all in the normal range. Only in one case was there an accurate preoperative diagnosis of tumour; in the other cases, a histological diagnosis was possible after surgical resection. Surgical treatment depended on tumour localisation: duodeno-cephalopancreatectomy for tumours in the head and distal pancreatectomy with splenectomy for tumours located in the body-tail, Lymphadenectomy at levels I and II was performed in all cases. There was no postoperative mortality and only one female patient developed postoperative acute pancreatitis. During the follow-up CT scans showed no recurrence of the pancreatic tumours. In agreement with the international literature, we hold that all cystic tumours of the pancreas should be treated by surgical therapy, above all because of the major differential diagnosis problems they continue to present. Conservative treatment is justified only for well documented asymptomatic serous cystadenomas.

[Pancreatic metastasis from clear cell renal carcinoma: a clinical case]. / Metastasi pancreatiche da carcinoma renale a cellule chiare (RCC): un caso clinico.

Renal cell carcinoma rarely metastasizes to the pancreas. In this report we describe a case of late pancreatic metastases in a seventy-year-old woman, surgically treated 21 years before for renal clear-cell carcinoma. Preoperative staging revealed the presence of four pancreatic lesions. A distal pancreatectomy and splenectomy were performed, and the postoperative period was complication-free. Histopathological analysis revealed metastases from renal clear-cell carcinoma. This case shows that in patients operated on for renal clear-cell carcinoma we have to consider the possibility of late metastases to the pancreas. Therefore, these patients should be submitted to long-term follow-up. In keeping with the current literature, we advocate aggressive surgical treatment in pancreatic metastases from renal clear-cell carcinoma.