Laparoscopy alone is superior to peritoneal cytology in staging gastric and esophageal carcinoma.

BACKGROUND: Laparoscopy identifies metastatic disease in patients with upper gastrointestinal malignancies; however, it has been suggested that cytological examination of peritoneal washings may increase the diagnostic yield. We hypothesize that the addition of cytologic washings to a standardized staging laparoscopy is unnecessary for the identification of intraabdominal metastasis in patients with gastric/esophageal cancer. METHODS: Forty patients with gastric/esophageal cancer were prospectively evaluated. Patients successfully underwent a diagnostic laparoscopy protocol (with biopsies) during which peritoneal washings were obtained and processed for cytologic analysis. Laparoscopic versus cytologic identification of intraabdominal metastasis were compared. RESULTS: Forty patients successfully completed laparoscopy with collection of peritoneal washings. Laparoscopic examination of the peritoneal cavity upstaged 21 (52.5%) patients. Laparoscopic examination consistently identified a statistically significant higher number of positive patients than cytologic examination of peritoneal washings (p = 0.001) and examination of cytologic washings alone failed to identify 45% of patients with positive findings and laparoscopy. The addition of cytologic examination added no additional stage IV patients to the laparoscopy-negative group. CONCLUSION: A standardized laparoscopic examination alone is sufficient for the identification of intraabdominal metastatic disease in patients with gastric and esophageal cancer.

Peritoneovenous shunting for nongynecologic malignant ascites.

BACKGROUND: The development of malignant ascites has been associated with a poor prognosis. Previous reports have documented high morbidity rates associated with placement of palliative peritoneovenous shunts (PVS). Most study series have included gynecologic malignancies in their analysis, and wide variations in survival time have been reported. Reported data from nongynecologic malignancies and identification of preoperative factors associated with improved outcome were the concerns of the current study, which attempted to identify patients with malignant ascites who might have benefitted from PVS. METHODS: A retrospective chart review was performed and data including age, gender, weight, preoperative laboratory values, cytology on peritoneal fluid aspirates, and complications within 30 days of the operative procedure were obtained and recorded. Discharge date and follow-up status were obtained for all patients. Statistical analysis was done for categorical values by comparing survival times from date of procedure with follow-up times using the log rank test. Significance for numeric values was determined with Cox regression analysis. Multivariate analysis using Cox regression was performed for those values found to be significant on univariate analysis. RESULTS: Fifty- five patients who had undergone PVS from 1980-1996 for ascites on the Gastric and Mixed Tumor service at the Memorial Sloan-Kettering Cancer Center were identified. Two patients with benign disease and two patients with ovarian malignancies were excluded. The remaining 51 patients underwent placement of 53 PVSs for palliation. Median survival time for the entire group was 52 days. Univariate analysis identified preoperative blood urea nitrogen (BUN), creatinine (Cr), BUN to Cr ratio, and diagnosis as significant factors. Preoperative BUN emerged as an independent predictor of survival by multivariate analysis, and those patients who had a BUN value of < = 17 demonstrated a survival advantage over those with a BUN of > 17. The assessable palliation factors were hospital discharge (80% of patients) and weight loss after shunting (68% of patients lost > 1 kg). Ninety-six percent of patients (24 of 25) with a preoperative BUN of < or = 17 were discharged. CONCLUSIONS: The development of nongynecologic malignant ascites is an end stage event for most patients. The placement of PVS for those patients with nongastrointestinal tumor etiologies, a BUN of < 17, a Cr of < or = 1.1, and a BUN to Cr ratio of < 19 yielded the best results. In the current study, palliation was difficult to assess accurately, although most patients were discharged or lost > 1kg of weight after shunting.

Cutaneous angiosarcoma complicating morbid obesity.

Herein, we report a case of cutaneous angiosarcoma in a 35-year-old, morbidly obese woman. The tumor arose in the most dependent portion of the lower abdominal panniculus and showed typical changes of chronic lymphedema. The patient underwent a radical resection of her lower abdominal wall panniculus, which showed a multicentric, high-grade angiosarcoma with bilateral superficial inguinal lymph node metastases. Histologically, conventional vasoformative areas were admixed with poorly differentiated sheets of spindle and epithelioid cells. Factor VIII was focally positive (membranous), whereas CD31 showed robust, diffuse positivity (membranous and cytoplasmic). The initial margins of resection were negative, and no follow-up radiation or chemotherapy was given. Following a recurrence at the previous excision site, the patient died 7 months after the surgery. Postmortem examination revealed a widely metastatic tumor that involved multiple organ systems. We believe this is the second report of cutaneous angiosarcoma occurring in a chronically lymphedematous abdominal panniculus due to morbid obesity.

Primary colonic lymphoma.

BACKGROUND AND OBJECTIVES: The colon is a rare location for gastrointestinal non-Hodgkin's lymphoma (NHL). This study was undertaken to identify risk factors, presentation, treatment, and prognosis for primary colonic lymphoma (PCL) through review of a large tertiary care hospital system experience. METHODS: A retrospective review of all patients with colonic malignancy and NHL was performed using pathology and cancer registry databases from January 1989 to December 1998. Criteria for inclusion were no evidence of extraperitoneal disease, no leukemic or lymphomatous abnormalities in the blood, and disease confined to the colon. RESULTS: Seven patients met the inclusion criteria (4 male, 3 female; 33-72 years). They represented 1.4% of all NHL, 14% of gastrointestinal NHL and 0.9% of all colonic malignancies diagnosed during this period. Three of the patients had positive serology for human immunodeficiency virus; one was taking steroids chronically for Addison disease. The most common presentation was nonspecific abdominal pain. The lack of specific symptoms delayed diagnosis from 1-12 months. All patients underwent laparotomy with resection. The most common tumor location was the cecum (5/7, 71%). Regional lymph nodes were affected in all but 1 patient. All tumors were B-cell lymphomas (5 small noncleaved cell, 2 large cell). Six of 7 patients received adjuvant chemotherapy. Of the 6 patients available for follow-up four remain alive (12, 19, 23, and 25 months after diagnosis). In both patients who died the disease recurred diffusely. CONCLUSIONS: The colon is a rare location for NHL. Immunosuppression is the most common risk factor. Patients' frequently present with non-specific abdominal pain, this leads to lengthy delays in diagnosis. Most of these tumors are located in the cecal area. Surgery is the most widely utilized form of therapy. Although adjuvant therapy is frequently utilized, its' impact on survival is unclear.

Detection of tyrosinase mRNA by reverse transcription-polymerase chain reaction in melanoma sentinel nodes.

BACKGROUND: Sentinel lymph node (SLN) biopsy is an alternative to elective dissection or observation for management of lymph node basins in patients with cutaneous melanomas. The detection of tyrosinase mRNA in melanoma SLN specimens by reverse transcription-polymerase chain reaction (RT-PCR) has been reported to be a more sensitive method to detect subclinical metastases, compared with histological analysis. The aims of this study were to (1) define the yield of RT-PCR in assessing SLNs, compared with histological analysis, (2) identify the incidence of false-positive results in SLNs, and (3) report the rate of actin PCR negativity (i.e., samples with degraded RNA) in SLNs. METHODS: Twenty-eight patients with 1.2-9.6-mm cutaneous melanomas underwent SLN biopsy (between October 1996 and March 1997). One half of each SLN was analyzed by nested RT-PCR for tyrosinase mRNA. The other half of the SLN was examined by routine microscopy. Twenty-one lymph nodes from patients without melanoma were evaluated as controls. RESULTS: Two of the 28 patients with melanoma were excluded because of RNA degradation, as indicated by actin negativity. Six of the remaining 26 patients exhibited melanoma metastases in routine histological examinations. All histologically positive lymph nodes were RT-PCR-positive. Thirteen of the 20 (65%) histologically negative cases were RT-PCR-positive. Of 21 control lymph nodes, 3 were actin-negative and were not assessable for tyrosinase mRNA. Two of the remaining 18 (11%) negative-control nodes were RT-PCR-positive. CONCLUSIONS: Among patients undergoing SLN biopsy, tyrosinase mRNA was detectable in 73% of SLNs from patients at risk for regional nodal metastases, including all of those with histologically positive SLNs. There is a definable false-positive rate for tyrosinase mRNA detection in the lymph nodes of patients who do not have melanoma. Actin verification of RNA integrity is necessary to ensure the accuracy of this test in detecting tyrosinase mRNA. Ongoing follow-up monitoring will define the prognostic value of this assay.

Patient characteristics, treatment, and outcome of unknown primary melanoma in the United States for the years 1981 and 1987.

The American College of Surgeons performed a patient care and evaluation study of malignant melanoma for years 1981 and 1987 to determine the presenting symptoms, methods of evaluation, clinical management, and disease outcome. Previous reports on malignant melanoma of the skin, mucous membrane, and eye have been published. This report details the findings for 58 patients with malignant melanoma of an unknown primary diagnosed in 1981 and 87 patients diagnosed in 1987. The total number of patients was relatively small in comparison to all malignant melanoma patients. These patients were younger than the skin, ocular, and mucous membrane melanoma patients. There were significantly more males than females. When the anatomical site of a pathological positive node was known, it most frequently was in the axilla. Surgery, radiation therapy, and chemotherapy were frequently used in treatment of these patients. Although the overall prognosis is poor, some patients will have long term survival, and aggressive therapy should be considered for at least some of these patients.

Islet cell tumors of the pancreas.

Pancreatic endocrine neoplasms are a heterogeneous group of tumors that produce active hormones and result in distinct clinical syndromes. For the most part, they are malignant and require sophisticated diagnostic and localization techniques in order to identify their presence. Delays in diagnosis are the rule rather than the exception. Improvements in the diagnosis of gastrinomas and insulinomas appear to result in an increase in resectability rates. The widespread availability of intraoperative ultrasonography, as well as improved knowledge of the location of these tumors, has also had an impact on improved cure rates. With heightened awareness of these syndromes, increasing numbers of patients can be identified and more effective treatments developed for the refractory and recurrent tumors.

Lymphokine mRNA expression by transplantable murine B lymphocytic malignancies. Tumor-derived IL-10 as a possible mechanism for modulating the anti-tumor response.

In vitro and in vivo expressions of cytokine mRNAs by four transplantable murine B lymphocytic malignancies designated A20, MOPC 315, 2PK-3, and RAW 8.1 were determined using sensitive reverse-transcribed (RT)-PCR. Despite significant differences in both the stage of B cell differentiation represented by each cell line and the method used to induce the original B lymphocytic tumors, IL-6 and IL-10 mRNAs were detected in each of the cultured cell lines. Whereas IL-2, IL-4, IL-5, and IL-12 mRNAs were not detected in cultured cells, expression of cytokine mRNAs in solid tumor tissue was quite different. RT-PCR of poly(A)+ RNA isolated from each of the four solid tumors demonstrated the presence of IL-4, IL-5, IL-6, IL-10, TGF-beta 1, and TNF-alpha mRNAs. There was a noticeable lack of significant IL-2 mRNA expression in any of the solid tumors. Using RT-PCR, it was clear that each of the malignant B lymphocytes expressed IL-6, IL-10, TGF-beta 1, and TNF-alpha, with limited expression of IL-4 and IL-5. To explore the mechanisms that might contribute to the lack of IL-2 mRNA in these solid tumors, quantitative competitive (QC)-RT-PCR was used to quantify expression of IL-10 mRNA. MOPC 315 tumor expressed the most IL-10 mRNA (23.2 pg/micrograms of poly(A)+ RNA), whereas 2PK-3, A20, and RAW 8.1 tumors expressed 7.4, 2.6, and 0.6 pg/micrograms of poly(A)+ RNA, respectively. Secretion of IL-10 into culture supernatants or into sera and ascitic fluid of tumor-bearing animals correlated with mRNA expression. This dysregulated IL-10 production in animals with B lymphocytic tumors suggested a mechanism that may account for the lack of IL-2 mRNA expression in solid tumors, and suggested a possible mechanism by which malignant B lymphocytes may limit cell-mediated antitumor responses.