Trends and predictors of resection of the primary tumor for patients with stage IV colorectal cancer.

BACKGROUND AND OBJECTIVES: Over 130,000 patients are diagnosed with colorectal cancer annually, with approximately 20% presenting with unresectable metastatic disease. Recent consensus guidelines recommend against primary tumor resection for asymptomatic patients with unresectable metastases. Our goal was to examine the trends and predictors of surgical resection. METHODS: Cases of colorectal cancer with synchronous metastases diagnosed between 1988-2010 were identified using the Surveillance, Epidemiology and End Results (SEER) Database. Associations between resection and clinicopathologic variables were sought using univariate and multivariate logistic regression. RESULTS: Overall, 68% of patients with synchronous metastatic colorectal cancer underwent primary tumor resection. Resection rates were as high as 76% in the earliest time period (1988-1992) and steadily dropped to 60% in the most recent period (2008-2010). Socioeconomic factors associated with resection on univariate analysis included age, race, gender, marital status, insurance status, and geographic region. Clinicopathologic characteristics associated with resection included tumor location, grade, size, and CEA level. In the multivariate model, gender, geographic region, insurance status, tumor location, grade and CEA level were independent predictors of primary tumor resection. CONCLUSIONS: Surgical resection of the primary site remains common practice for patients with synchronous metastatic colorectal cancer. Treatment disparities are associated with socioeconomic as well as clinicopathologic factors.

Population-based outcome of stage IA-IIA resected gastric adenocarcinoma: who should get adjuvant treatment?

BACKGROUND: The benefit of adjuvant treatment in gastric adenocarcinoma was demonstrated by randomized, controlled trials of patients with locally advanced tumors. Thus, its role for stage IIB-IIIC disease is widely accepted. We aimed to identify patients with stage IA-IIA gastric adenocarcinoma who have a poor prognosis and thus may benefit from adjuvant treatment. METHODS: Patients with gastric adenocarcinoma who underwent surgical resection with pathological evaluation of ≥15 lymph nodes and had available disease-specific survival (DSS) data were identified from the Surveillance Epidemiology and End Results Registry. Survival differences were evaluated with the log-rank test and Cox multivariate analysis. RESULTS: Stage and TN grouping strongly predicted DSS (P < 0.001, P < 0.001). Stage IA tumors had an excellent outcome: 91 ± 1.2 % 5-year DSS. The TN groupings of stages IB and IIA had the next best outcomes with 5-year DSS from 66 ± 4.6 % to 81 ± 2.3 %. Older age (P < 0.001), higher grade (P = 0.004), larger tumor size (P < 0.001), and proximal tumor location (P < 0.001) were independent predictors of worse DSS in stage IB-IIA tumors. We devised a risk stratification scheme for stage IB-IIA tumors where 1 point was assigned for age >60 years, tumor size >5 cm, proximal tumor location, and grade other than well-differentiated. Five-year DSS was 100 % for patients with 0 points; 86 ± 4.3 %, 1 point; 76 ± 3 %, 2 points; 72 ± 2.8 %, 3 points; and 48 ± 4.9 %, 4 points (P < 0.001). CONCLUSIONS: Patients with stage IB-IIA gastric adenocarcinoma and ≥2 adverse features (age >60 years, tumor size >5 cm, proximal location, and high-grade) have 5-year DSS ≤76 %. Adjuvant therapy may be warranted for these patients.

Tumor size and depth predict rate of lymph node metastasis and utilization of lymph node sampling in surgically managed gastric carcinoids.

BACKGROUND: Radical resection with regional lymphadenectomy is recommended for all sporadic gastric carcinoids. Local resection, however, is accepted for some carcinoids from other gastrointestinal sites (i.e., appendix and rectum). We sought to examine the relation of tumor size and depth to lymph node metastasis to determine whether gastric carcinoids can be selected for endoscopic resection. We also sought to quantify the utilization of lymph node sampling. METHODS: 984 patients with localized gastric carcinoids who underwent cancer-directed surgery between 1983 and 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) registry database. RESULTS: Tumor size and depth predicted probability of lymph node metastasis. Lymph node metastasis was not seen in intraepithelial (IE) tumors <2 cm. Of tumors <1 cm invading into the lamina propria or submucosa (LP/SM), 3.4% had lymph node metastasis. Excluding IE tumors <2 cm and LP/SM tumors <1 cm, all other subgroups based on size and depth had rates of lymph node metastasis ≥ 8%. Tumor size and depth predicted probability of lymph node sampling. Overall, only 21% of tumors had lymph node sampling. Excluding IE tumors <2 cm and LP/SM tumors <1 cm, only 43% of tumors had lymph node sampling. CONCLUSIONS: Tumor size and depth predict lymph node metastasis for gastric carcinoids. Endoscopic resection may be appropriate for intraepithelial (IE) tumors <2 cm and perhaps tumors <1 cm invading into the lamina propria or submucosa. Lymph node sampling is underused for gastric carcinoids at high risk for lymph node metastasis.

Associations of Socioeconomic Variables With Resection, Stage, and Survival in Patients With Early-Stage Pancreatic Cancer.

IMPORTANCE: Socioeconomic variables including sex, race, ethnicity, marital status, and insurance status are associated with survival in pancreatic cancer. It remains unknown exactly how these variables influence survival, including whether they affect stage at presentation or receipt of treatment or are independently associated with outcomes. OBJECTIVES: To investigate the relationship between socioeconomic factors and odds of resection in early-stage, resectable pancreatic adenocarcinoma and to determine whether these same factors were independently associated with survival in patients who underwent resection. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of patients diagnosed as having T1 through T3 M0 pancreatic adenocarcinoma between January 1, 2004, and December 31, 2011, identified from the Surveillance, Epidemiology, and End Results database. MAIN OUTCOMES AND MEASURES: Socioeconomic and geographic variables associated with utilization of resection and disease-specific survival. RESULTS: A total of 17,530 patients with localized, nonmetastatic pancreatic cancer were identified. The resection rate among these patients was 45.4% and did not change over time. Utilization of resection was independently associated with white vs African American race (odds ratio [OR] = 0.76; 95% CI, 0.65-0.88; P < .001), non-Hispanic ethnicity (for Hispanic, OR = 0.72; 95% CI, 0.60-0.85; P < .001), married status (OR = 1.42; 95% CI, 1.30-1.57; P < .001), insurance coverage (OR = 1.63; 95% CI, 1.22-2.18; P = .001), and the Northeast region (vs Southeast, OR = 1.67; 95% CI, 1.44-1.94; P < .001). Stage at presentation correlated with sex, race, ethnicity, marital status, and geographic region (ethnicity, P = .003; all others, P < .001); however, the factors associated with increased resection correlated with more advanced stage. Patients who underwent resection had significantly improved disease-specific survival compared with those who did not undergo resection (median, 21 vs 6 months; hazard ratio [HR] for disease-specific death = 0.32; 95% CI, 0.31-0.33; P < .001). Disease-specific survival among the patients who underwent surgical resection was independently associated with geographic region, with patients in the Pacific West (HR for death = 0.706; 95% CI, 0.628-0.793), Northeast (HR for death = 0.766; 95% CI, 0.667-0.879), and Midwest (HR for death = 0.765; 95% CI, 0.640-0.913) having improved survival in comparison with those in the Southeast (all P < .001). CONCLUSIONS AND RELEVANCE: Disparities in the utilization of surgical resection for patients with early-stage, resectable pancreatic cancer are associated with socioeconomic variables including race, ethnicity, marital status, insurance status, and geographic location. Of these factors, only geographic location is independently associated with survival in patients undergoing resection.

Tumor size and depth predict rate of lymph node metastasis in colon carcinoids and can be used to select patients for endoscopic resection.

BACKGROUND: Regional lymphadenectomy is recommended for all colon carcinoids, whereas resection without lymphadenectomy is accepted for selected appendiceal and rectal carcinoids. We examined the relation of tumor size and depth to lymph node metastasis in order to determine whether colon carcinoids could be selected for endoscopic resection. METHODS: Patients were identified from the Surveillance Epidemiology and End Results Registry. The Pearson chi-square and the log rank tests were used. P < 0.05 was considered significant. RESULTS: We identified 929 patients who underwent resection of localized colon carcinoids without distant metastasis diagnosed from 1973 to 2006. The diagnosis of small and superficial tumors increased over time (p < 0.001). The presence of lymph node metastasis was adversely associated with survival (p < 0.001); however, there was only a trend toward independence on multivariate analysis (p = 0.054). Tumor size and depth were associated with lymph node metastasis (p < 0.001, p < 0.001). Tumors were subgrouped by size and depth to find cases with a low risk of lymph node metastasis. Intramucosal tumors < 1 cm had a 4% rate of lymph node metastasis, while all other subgroups had rates ≥ 14%. CONCLUSION: Tumor size and depth predict lymph node metastasis for colon carcinoids. Endoscopic resection may be appropriate for intramucosal tumors <1 cm.

Pneumatosis intestinalis and portal venous gas without bowel ischemia in a patient treated with irinotecan and cisplatin.

Pneumatosis intestinalis and gas within the portal venous system are findings predictive of bowel ischemia. The etiologies of these alarming radiographic signs are diverse and not all causes require emergent surgical intervention. The combination of pneumatosis intestinalis, portal venous gas, and acidosis typically portends bowel ischemia and inevitable necrosis. This case report is the first description of benign pneumatosis and portal venous gas secondary to irinotecan and cisplatin.

Gastrointestinal stromal tumors (GISTs).

PURPOSE OF REVIEW: Gastrointestinal stromal tumors (GISTs) have recently been the subject of considerable clinical and experimental interest. This focus is based on the recognition that GISTs characteristically have uncontrolled activation of the KIT protein, a transmembrane tyrosine kinase receptor involved in cell survival, development, and proliferation. The clinical application of imatinib mesylate, a selective inhibitor of the KIT kinase activity, has provided a novel molecularly targeted therapy for these tumors. This review summarizes publications from the last year regarding these tumors. RECENT FINDINGS: Recent studies have focused on imaging, the identification of prognostic factors and molecular events, and the role of systemic therapy in the treatment of these tumors. Emerging data suggest that the combination of endoscopic ultrasound and fine-needle aspiration analysis for KIT expression may be useful in separating these lesions from other submucosal lesions of the gastrointestinal tract. The benefits and limitations of computed tomography and positron emission tomography in identifying, staging, and evaluating the response to therapy of these lesions have been more clearly defined. Although tumor size and the number of mitoses remain the best prognostic markers, several studies reported provocative data using other markers such as Ki-67, p53, and alterations in p16. Mutational analysis of the KIT oncoprotein continues to be the subject of considerable interest in relation to both prognosis and resistance to therapy. Finally, a series of new studies have confirmed the benefits and better defined the results of therapy with imatinib mesylate. There is increasing interest in expanding the role of this agent into the adjuvant setting and in combining such therapy with reoperation for responsive disease. SUMMARY: In the past year there have been significant developments in our understanding of GISTs and their response to therapy. Many questions remain unanswered and new issues have arisen as the benefits of imatinib mesylate therapy are revealed. There is considerable optimism that the targeted molecular approach being applied to the treatment of GISTs will serve as a model for the development of similar approaches to other more common tumors.

Fate of human thyroid tissue autotransplants.

PURPOSE: We conducted this study to establish whether human thyroid tissue autografts can survive and function in the absence of their native blood supply in muscle. The benefits of this potential could be incorporated in routine surgery to reduce the incidence of post-operative hypothyroidism. METHODS: Fifteen patients with benign thyroid disorders, seven of whom had Graves' disease and eight, multinodular goiter (MNG), underwent modified subtotal thyroidectomy and the autotransplantation of thyroid tissue in the sternocleidomastoid muscle. About 3-5 g of thyroid tissue was cut and implanted into the sternocleidomastoid muscle. Postoperative clinical assessment, thyroid function tests, and technetium scans of the neck were done to assess the function of remnant and transplanted thyroid tissue. RESULTS: The transplanted tissue was functional in six of the eight patients with MNG and four of the seven with Graves' disease. All the patients with MNG and a functional transplant became euthyroid within 6 months postoperatively. Although the transplanted tissue was functional in four patients with Graves' disease, only one became euthyroid, while the other three required supplemental hormone therapy for postoperative hypothyroidism. CONCLUSIONS: These findings demonstrate the ability of autotransplanted thyroid tissue to survive, function, and grow in muscle.