First-line chemotherapy improves the resection rate and long-term survival of locally advanced (T4, any N, M0) squamous cell carcinoma of the thoracic esophagus: final report on 163 consecutive patients with 5-year follow-up.

OBJECTIVE: The objective of this prospective, nonrandomized study was to evaluate the immediate and long-term results of first-line chemotherapy and possible surgery in locally advanced, presumably T4 squamous cell esophageal cancer. SUMMARY BACKGROUND DATA: Locally advanced esophageal cancer is rarely operable and has a dismal prognosis. For this reason, neoadjuvant cytoreductive treatments are more and more frequently used with the aim of downstaging the tumor, increasing the resection rate, and possibly improving survival. Methods: From January 1983 to December 1991, 163 consecutive patients with a presumedly T4 squamous cell carcinoma of the thoracic esophagus (group A) received on average 2.5 cycles (range, 1-6) of first-line chemotherapy with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 per day, in continuous infusion from day 1 through day 5). Chemotherapy was followed by surgery when adequate downstaging of the tumor was obtained. RESULTS: Chemotherapy toxicity was WHO grade 0 to 2 in 80% of cases, but 3 toxic deaths (1.9%) occurred. Restaging suggested a downstaging of the tumor in 101 of 163 patients (62%), but only 85 patients (52%) underwent resection surgery; it was complete or R0 in 52 (32%) and incomplete or R1-2 in 33. Overall postoperative mortality was 11.7% (10 of 85), morbidity 41% (35 of 85). Complete pathologic response was documented in 6 patients, and significant downstaging to pStage I, IIA, or IIB occurred in 25 more patients. The overall 5-year survival was 11 % (median, 11 months). After resection surgery, the 5-year survival was 20% (median, 16 months); none of the nonresponders survived 4 years after palliative treatments without resection (median survival, 5 months). The 5-year survival rate of the 52 patients undergoing an R0 resection was 29% (median, 23 months). Stratifying patients according to the R, pT, pN, and pStage classifications, the survival curves were comparable to the corresponding data obtained in the 587 group B patients with "potentially resectable" esophageal cancer who underwent surgery alone during the same period. Furthermore, the results were improved in comparison with 136 previous or subsequent patients with a locally advanced tumor who did not undergo neoadjuvant treatments (group C). In these patients, the R0 resection rate was 7%, and the overall 5-year survival was 3% (median, 5 months). CONCLUSION: Although nonrandomized, these results suggest that in locally advanced esophageal carcinoma, first-line chemotherapy increases the resection rate and improves the overall long-term survival. In responding patients who undergo R0 resection surgery, the prognosis depends on the final pathologic stage and not on the initial pretreatment stage.     

Resection of lung metastases: long-term results and prognostic analysis based on 5206 cases--the International Registry of Lung Metastases

The International Registry of Lung Metastases was established in 1991 to asses the long-term results of pulmonary metastasectomy. The Registry has accrued 5206 cases of lung metastasectomy, from 18 departments of thoracic surgery in Europe (n = 13), USA (n = 4) and Canada (n = 1). Of these patients 4572 (88%) underwent complete surgical resection. The primary tumor was epithelial in 2260 (43%), sarcoma in 2173 (42%), germ cell in 363 (7%), and melanoma in 328 (6%) patients. The disease-free interval was 0 to 11 months in 1729 (33%) cases, 12 to 35 months in 1857 (36%) and more than 36 months in 1620 (31%). Single metastases accounted for 2383 (46%) cases and multiple lesions for 2726 (52%). Mean follow up was 46 months. Analysis was performed by Kaplan-Meier estimates of survival, relative risk of death and multivariate Cox model. The actuarial survival after complete metastasectomy was 36% at 5 years, 26% at 10 years and 22% at 15 years (median 35 months); the corresponding values for incomplete resection were 13% at 5 years and 7% at 10 years (median 15 months). Among complete resections, the 5-year survival was 33% for patients with a disease free-interval of 0 to 11 months and 45% for those with a disease-free interval of more than 36 months; 43% for single lesions and 27 for four or more lesions. Multivariate analysis showed a better prognosis for patients with germ cell tumors, disease-free interval of 36 months and more and single metastases. These results confirm that lung metastasectomy is a safe and potentially curative procedure.     

The role of adjuvant therapy after resection of T1 N1 M0 and T2 N1 M0 non-small cell lung cancer

Thirty-four consecutive patients with non-small cell lung cancer plus N1 nodal metastases (eight with T1 N1 M0 and 26 with T2 N1 M0) were retrospectively reviewed. Nineteen had adenocarcinoma, 11 had squamous disease, and four had large cell carcinoma. Eleven patients had surgical resection alone (32.3%), with a median survival of 13 months. Seven patients (20.6%) had resection followed by radiation therapy, with a median survival of 19.2 months. Sixteen patients (47.1%) had resection followed by radiation therapy and chemotherapy, consisting of cyclophosphamide, doxorubicin, methotrexate, and procarbazine. Median survival for the latter group was 45.5 months, significantly greater than for those treated with resection alone (p less than 0.005). We did not observe any relationship between survival and age, cell type, number or location of diseased hilar nodes, distance of tumor from the resected bronchial margin, tumor size, the presence or absence of visceral pleural involvement, or the type of resection performed. Resection in combination with adjuvant radiation therapy and chemotherapy offers improved median survival over resection alone in patients with T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.     

What is the optimal distal resection margin for esophageal carcinoma?

BACKGROUND: Whereas a proximal resection margin of 12 cm is recommended for complete resection of esophageal cancer, the extent of distal resection is unclear. METHODS: We examined distal resection margins in a consecutive series of patients who underwent esophagectomy for squamous cell carcinomas (n = 50), primary esophageal adenocarcinomas (n = 100), and adenocarcinomas of the cardia (n = 39), in whom all macroscopic tumor was judged to be completely resected. RESULTS: Microscopic tumor was found at a 3-cm distal resection margin for one multifocal squamous cell carcinoma. Positive distal resection margins were seen in 12% (12 of 100 patients) of primary esophageal adenocarcinomas (median, 2 cm versus 4 cm if negative; p = 0.002, Wilcoxon) and 28% (11 of 39 patients) of cardia adenocarcinomas (median, 1 cm versus 3 cm if negative; p = 0.02, Wilcoxon). Although pathologic stage was shown to be the only significant predictor of overall survival (Hazard ratio [HR] 1.8; 95% confidence interval 1.2 to 2.6; p = 0.007), there was a trend toward reduced postoperative survival for patients with histologically positive distal resection margins, in particular for patients with cardia adenocarcinomas (median, 15.4 months versus 5.7 months if negative; p = 0.0001). CONCLUSIONS: To achieve consistently negative distal resection margins, we recommend resection of at least 5 cm of macroscopically normal foregut below the distal margin of the primary tumor.     

Surgical treatment of primary small cell carcinoma of the esophagus. Clinical analysis of 11 cases]

545 cases of esophageal carcinoma were confirmed histologically and by esophagoscopic biopsy between Jan. 1982 and May 1990. Primary small cell carcinoma was identified in 19 cases. Of 11 patients confirmed operatively, 5 had oat cell carcinoma, 4 combined oat cell carcinoma and 2 intermediate cell carcinoma. The mean overall survival period was 13.9 months. The longest survival period was 27 months. The prognosis of primary small cell carcinoma was poorer than that of squamous carcinoma of the esophagus because of its propensity of spread and metastasis. Once the diagnosis of small cell carcinoma was established, surgery was undertaken as early as possible. For patients who had lymph node metastasis at the time of diagnosis, we recommended surgical treatment plus systemic chemotherapy after operation. To increase the resection rate, it is important to do chest CT scan, bronchiofiberscopy and B-type ultrasonography before operation.     

Bronchogenic carcinoma located in the aortic window. The importance of the primary lesion as a determinant of survival

Thirty-four patients with an aortic window lesion were carefully staged with gallium scans and mediastinoscopy according to the TNM classification system for carcinoma of the lung. All were in Stage III. Twenty-five patients had non-oat cell carcinomas (15 squamous cell, eight adeno-, two large cell) and nine had oat cell carcinomas. Quantitative ventilation-perfusion lung scans were particularly helpful in verifying the subaortic location of the tumor by showing a less than 20% interference with pulmonary blood flow or ventilation secondary to left mainstem bronchus or pulmonary artery invasion. Decision for resectability in 13 Stage III M0 patients was based on the length of the uninvolved proximal left main pulmonary artery seen on pulmonary arteriogram. Eight patients (seven non-oat cell and one oat cell) had resection after radiation and prior to chemotherapy (after two cycles of chemotherapy and prior to radiation therapy for the oat cell) with a resultant survival rate better than those of M0 and M1 non-oat cell or oat cell patients without resection. The survival rates of nine non-oat cell M0 patients, nine non-oat cell M1 patients, and eight oat cell patients, all without resection, were not statistically different. This similarity in survival rates is explained by the observation that 38% of the non-oat cell M1, 71% of the non-oat cell M0, and 63% of the oat cell patients died from complications of their primary tumor. Patients with aortic window lesions, irrespective of their histology, have an extremely poor prognosis due to the high incidence of lethal complications of their primary tumor. Complete resection when feasible, as judged by pulmonary arteriography, provides the best control of the primary tumor and, as a consequence, gives longer survival.     

Treatment of modified Stage II (T1 N1 M0, T2 N1 M0) non-small cell bronchogenic carcinoma. A combined modality approach

Twenty patients with postsurgical, modified Stage II (T2 N1 M0, T1 N1 M0) non-small cell bronchogenic carcinoma were seen between 1974 and 1981 and were evaluated in a retrospective manner. Fifteen patients had T2 N1 M0 lesions, while 5 patients had T1 N1 M0 disease. Eight patients were treated with surgical resection alone, of whom seven had died, with a median survival of 12.0 months. Four patients received surgical resection and postoperative radiation therapy, of whom two have died, with a median survival not reached at 37 months. Eight patients were treated with surgical resection, radiation therapy, and adjuvant chemotherapy including cyclophosphamide (C), doxorubicin (A), methotrexate (M), and procarbazine (P). Six patients are alive and free of disease, with a median survival not yet reached at 72 months. There is a significant survival advantage for the 12 patients treated with combined modality therapy (surgical resection + radiation therapy; surgical resection + radiation therapy + chemotherapy) compared to the eight patients treated with SR alone (p less than 0.01), and for the eight patients receiving chemotherapy versus the 12 patients who did not (p less than 0.01). In spite of thorough clinical and surgical staging, patients with T1 and T2 primary tumors with N1 disease have a high relapse rate, predominantly in metastatic sites. Adjuvant radiation therapy and chemotherapy appear to benefit these patients with modified Stage II non-small cell bronchogenic carcinoma.     

Management of primary and recurrent soft-tissue sarcoma of the retroperitoneum.

From 1982 to 1987, 114 patients underwent operation at Memorial Sloan-Kettering Cancer Center for soft-tissue sarcoma of the retroperitoneum. A retrospective analysis of these patients defines the biologic behavior, surgical management of primary and recurrent disease, predictive factors for outcome, and impact of multimodality therapy. Complete resection was possible in 65% of primary retroperitoneal sarcomas and strongly predicts outcome (p less than 0.001). The rate of complete resection was not altered by histologic type, size, or grade of tumor. These patients had a median survival of 60 months compared to 24 months for those undergoing partial resection and 12 months for those with unresectable tumors. Forty-nine per cent of completely resected patients have had local recurrence. This is the site of first recurrence in 75% of patients. These patients undergo reoperation when feasible. Complete resection of recurrent disease was performed in 39 of 88 (44%) operations, with a 41-month median survival time after reoperation. Tumor grade was a significant predictor of outcome (p less than 0.001). High-grade tumors (n = 65) were associated with a 20-month median survival time compared to 80 months for low-grade tumors (n = 49). Gender, histologic type, size, previous biopsy, and partial resection versus unresectable tumors did not predict outcome by univariate analysis. Adjuvant radiation therapy and chemotherapy could not be shown to have significant impact on survival. Concerted attempt at complete resection of both primary and recurrent retroperitoneal soft-tissue sarcoma is indicated.     

Sequential thoracic metastasectomy prolongs survival by re-establishing local control within the chest

OBJECTIVE: The value of sequential thoracic metastasectomies is unknown. We evaluate repeat metastasectomy for limited recurrences within the thorax. METHODS: From July 1988 to September 1998, 54 patients underwent 2 to 6 separate sequential procedures to excise metastases after recurrence isolated to the thorax. Kaplan-Meier survival and Cox modeling determined prognostic variables. RESULTS: Thirty-three men and 21 women, 22 to 76 years underwent 2 (100%, n = 54), 3 (50%), 4 (22%), or 5 to 6 (11%) metastasectomies. Fifty-four percent of patients had carcinoma, 35% sarcoma, 9% germ cell, and 2% melanoma. There were no operative deaths; all late deaths occurred from cancer. Median follow-up was 48 months. Cumulative 5-year survival from the second procedure was 57%. After the second, third, fourth, and fifth procedures, respectively, permanent control was achieved in 15 (27%) of 54 patients, 5 (19%) of 27, 1 (8%) of 12, and 0 of 7. Recurrence amenable to additional surgery occurred in 27 (50%) of 54, 12 (44%) of 27, 6 (50%) of 12, and 1 (17%) of 6. Mean hazard for the development of unresectable recurrence increased from 0.21 after the second procedure to 0.91 after the fifth procedure. The 5-year survival for the 27 patients undergoing only 2 metastasectomies was 60% (median not yet reached), 33% for the 15 patients undergoing only 3 metastasectomies (median 34.7 months), and 38% for the 12 patients undergoing 4 or more (median 45.6 months). From the time a recurrence was declared unresectable, patients had a 19% 2-year survival (median 8 months). CONCLUSIONS: Multiple attempts to re-establish intrathoracic control of metastatic disease is justified in carefully selected patients, but the magnitude of benefit decays with each subsequent attempt.     

胸顶部肿瘤外科治疗27例临床分析

目的　探讨前径路技术在胸顶部肿瘤手术治疗中的应用及其优势。　方法　从 1995年 1月至 2 0 0 1年 1月 ,手术治疗原发性胸顶部肿瘤患者 2 7例 ,平均年龄 4 9 2岁。病理类型包括非小细胞肺癌、肉瘤、神经纤维瘤、颈段食管癌等。通过对临床表现、肿瘤类型及外侵范围、手术径路及切除程度、并发症、生存期等资料进行分析 ,评估前径路对手术安全性和彻底性的帮助以及对延长生存期的作用。　结果　 6例采用前径路半蛤壳切口 ,全部得到完全切除 ;2 1例采用后径路Paulson切口 ,其中 13例为完全切除 ,8例为姑息性切除。随访 2 3～ 4 6个月 (平均 2 9个月 ) ,总的中位生存期为2 1个月 ,其中完全切除者为 2 9个月 ,姑息切除者为 14个月 ,两者差异有显著意义 (P <0 0 1)。前径路的完全切除率明显高于后径路 (χ2 =1.6 78,P <0 0 1)。　结论　前径路切口可显著改善胸顶结构的暴露 ,尤其对于锁骨下血管、臂丛神经等结构可在直视下予以解剖 ,从而增加了手术的安全性和彻底性。     

Esophageal carcinoma: surgery without preoperative adjuvant chemotherapy

Our experience with 100 consecutive patients with esophageal carcinoma treated with surgical intervention as the primary method of therapy between 1967 and 1987 was reviewed. Preoperative chemotherapy was not administered by us. Follow-up was complete for all 100 patients. Twelve percent of tumors were in the proximal third of the esophagus, 21% were in the middle third, and 67% were in the distal third. Adenocarcinoma accounted for 44% of all tumors, squamous cell for 55%, and adenosquamous for 1%. Six patients were in stage I, 14 were in stage II, and 80 were in stage III; no patient was in stage IV. Surgical procedures included 85 esophagogastrectomies with primary anastomoses, 11 with colon interposition, and 4 with Roux-en-Y small-bowel interposition. Six patients had radical laryngopharyngo-esophagectomy with gastric or colopharyngeal anastomosis. Operative mortality was 3%. The mean survival of stage I patients was 182 months; stage II patients, 25 months; and stage III patients, 18 months. Our data show that surgical resection without preoperative adjuvant chemotherapy remains the cornerstone of therapy for patients with carcinoma of the esophagus.     

Patterns of failure in anorectal melanoma. A guide to surgical therapy

Anorectal melanoma is an aggressive tumor with a reported 5-year survival rate of 6%. Recommendations for local surgical therapy vary from local excision to abdominoperineal resection. Therapy, patterns of failure, and survival were retrospectively examined in 32 patients with anorectal melanoma. Twenty-six patients were treated surgically, 14 with abdominoperineal resection and 12 with local excision. Local recurrence occurred less frequently in patients undergoing abdominoperineal resection (4 [29%] of 14) compared with patients undergoing local excision (7 [58%] of 12) but developed concomitantly with distant or regional metastasis in all but 2 of the 11 patients whose operations failed locally. Inguinal nodal disease developed in 15 patients (47%). Pelvic nodal disease became apparent in only 2 patients (7%). There was no difference in overall survival between the two surgically treated groups (median survival, 19.5 months for patients treated with abdominoperineal resection vs 18.9 months for patients treated with local excision). Therefore, local excision is recommended when technically feasible since these patients eventually succumb to metastasis regardless of surgical therapy.     

Benefit of postoperative adjuvant chemoradiotherapy in locoregionally advanced esophageal carcinoma

OBJECTIVE: We sought to determine whether chemoradiotherapy after esophagectomy improves survival. METHODS: From 1994 to 2000, 31 patients with locoregionally advanced esophageal carcinoma (90% pT3, 81% pN1, and 13% pM1a) received postoperative adjuvant chemoradiotherapy. Concurrently, 52 patients with advanced carcinoma underwent esophagectomy alone and survived at least 10 weeks, the time frame for adjuvant therapy. A propensity score based on demographic, tumor, and surgical factors was used to identify matched pairs to determine the association of adjuvant therapy with outcomes. RESULTS: For patients receiving adjuvant therapy versus esophagectomy alone, risk-unadjusted median, 1-year, and 4-year survivals were 28 versus 14 months, 68% +/- 8.4% versus 60% +/- 6.8%, and 44% +/- 9.0% versus 17% +/- 5.6%, respectively (P =.05). Similarly, risk-unadjusted median time to recurrence was 25 versus 13 months (P =.15), and median recurrence-free survival was 22 versus 11 months (P =.04). Among propensity-matched patients, median, 1-year, and 4-year survivals for those receiving adjuvant therapy versus esophagectomy were 28 versus 15 months, 60% +/- 11.0% versus 65% +/- 10.7%, and 44% +/- 11.3% versus 0% (P =.05). Median time to recurrence was 25 versus 13 months (P =.04), and recurrence-free survival was 22 versus 10 months (P =.02). CONCLUSION: In patients with locoregionally advanced esophageal carcinoma, addition of postoperative adjuvant chemoradiotherapy to esophagectomy alone doubled survival time, time to recurrence, and recurrence-free survival. Patients with locoregionally advanced carcinoma after esophagectomy should be considered for adjuvant therapy.     

Pancreatic resection for locally advanced primary and metastatic nonpancreatic neoplasms

We conducted a retrospective review of our single-institution experience with pancreas resection for locally advanced primary malignancy or metastases from other organs. From January 1989 through April 2001 35 patients underwent pancreatic resection for locally advanced primary (17) and recurrent nonpancreatic (18) tumors. Patient records were examined for recurrence and survival. Seventeen patients with locally advanced primary tumors presented with pancreatic extension either into the head/body (six) or tail (11). Pancreatic resections were completed as en bloc procedures with the primary disease of stomach (five), colon (four), sarcoma (five), adrenal gland (one), or spleen (one). Procedures performed included pancreaticoduodenectomy for proximal lesions and distal pancreatectomy for disease limited to the pancreatic tail. Median overall survival was 56 months. Fourteen of 17 patients remain alive: three with disease and 11 without evidence of recurrence. Eighteen patients presented with recurrent tumor from a previously resected right upper quadrant tumor (nine) or metastases from an intra-abdominal source (nine). The primary source was colon (eight), biliary (three), sarcoma (three), melanoma (two), ovary (one), and unknown primary (one). Patients underwent pancreaticoduodenectomy, distal pancreatectomy, or resection of residual pancreas. Overall median survival was 46 months. In this group of 18 patients there was no increased survival in those patients with a time to recurrence from their primary tumor resection greater than 2 years. We conclude that pancreatic resection for locally advanced nonpancreatic or recurrent intra-abdominal malignancies is possible in properly selected patients. The ability to obtain disease-free margins through en bloc resection is a key component of therapy.     

Results after pancreatic resection for metastatic lesions

Background Unlike primary pancreatic carcinoma, isolated metastatic lesions to the pancreas are uncommon. Although the value of surgical resection is poorly documented, resection may be deemed appropriate in selected cases. The aim of this study was to review our experience with the operative management of pancreatic metastases Methods Sixteen patients who underwent pancreatic resection for the treatment of metastatic disease were identified from a prospective pancreatic database. The clinical features of and results after resection were examined. Results Renal cell carcinoma was the most frequent primary histopathology (10 of 16; 62%). In the remaining patients, the primary histopathology was non-small-cell lung cancer (n=3), sarcoma (n=1), melanoma (n=1), or transitional cell carcinoma of the bladder (n=1). A prolonged disease-free interval (median, 7.5 years) was characteristic of most patients. Operative procedures performed included eight pancreaticoduodenectomies, seven distal pancreatectomies, and one total pancreatectomy. The operative mortality was 6%, and the morbidity was 25%. The overall 2- and 5-year actuarial survival rates were 62% and 25%, respectively. A trend toward improved survival was observed in the renal cell carcinoma patients, but this finding was not statistically significant. Conclusions Long-term survival after pancreatic resection for metastatic disease is achievable, and patients with primary renal cell carcinoma seem to have a more favorable prognosis. Surgical resection should thus be offered to selected patients with isolated metastatic disease to the pancreas.     

早期食管癌内镜及病理特点分析

目的 总结早期食管癌内镜及病理特点,探讨其对临床诊断的价值.方法 回顾性分析2003年1月至2007年12月西南医院收治的62例早期食管癌患者的临床资料,总结其内镜和病理特点.结果 食管上段癌8例,中段癌42例,下段癌12例.内镜分型依次为表面扩散生长型30例,双向生长型11例,腔内生长型9例,壁内生长型7例,混合生长型5例.多数肿瘤直径为1.0～2.9 cm.行外科手术治疗38例、内镜黏膜切除术治疗23例、内镜黏膜下层剥离术治疗1例.术后病理检查:原位癌13例,黏膜内癌22例,黏膜下癌27例,黏膜内癌和黏膜下癌的淋巴结转移率分别为5%(1/22)和15%(4/27).病理分型:鳞癌57例,腺癌2例,小细胞癌、肉瘤化癌、梭形细胞癌各1例.结论 早期食管癌好发于食管中段,以表面扩散生长型多见,以鳞癌为主,普通内镜联合卢戈液和美蓝检查是发现早期食管癌的重要方法.     

双侧肾上腺继发性肿瘤的临床分析

目的 了解双侧肾上腺继发性肿瘤的临床特点和发生发展规律，提高对本病的诊治效果。方法 回顾性分析1990年1月至2001年12月收治50例双侧肾上腺继发性肿瘤患者资料。男45例，女5例。中位年龄56岁（23～75）。肾上腺肿瘤直径：左侧2．0～11．0cm，中位3．7cm；右侧1．5～14．0cm，中位4．0cm。结果 50例患者原发肿瘤主要为肺癌、淋巴瘤、黑色素瘤、肾癌等，分别占64．0％、12．0％、6．0％、6．0％。肺癌中以小细胞未分化癌常见（46．9％）。肿瘤发生时间：与原发瘤同时诊断26例（52．0％），原发肿瘤治疗后发现双侧肾上腺转移24例，其中1年内18例（75．0％）。44例在诊断时即有肾上腺外转移（88．0％），单纯性肾上腺转移6例（12．0％）。50例患者总生存时间1～70个月，中位生存期6个月。3例行同期或分期切除后联合放化疗，其中1例食管黑色素瘤患者生存19个月，1例肺腺癌患者15个月，1例肾癌患者生存26个月健在。结论 双侧肾上腺继发性肿瘤的原发肿瘤以肺癌和淋巴瘤常见，大多在原发瘤发现同时或术后1年内诊断，多采用姑息性治疗，预后较差，手术切除联合化疗或化放疗可能延长患者的生存期。     

Endoscopic Management of Early Esophageal Neoplasia: an Emerging Standard

Introduction

Endoscopic mucosal resection (EMR) and ablation technologies have markedly changed the treatment of early esophageal neoplasia. We analyzed treatment and outcomes of patients undergoing multimodal endoscopic treatment of early esophageal neoplasia at our institution.

Methods

Records of patients undergoing endoscopic treatment for esophageal low-grade intraepithelial neoplasia (LGIN, n?=?11), high-grade intraepithelial neoplasia (HGIN, n?=?24), or T1N0M0 neoplasia (n?=?10), presenting between 2007 and 2009, were reviewed. Outcomes included eradication of neoplasia/intestinal metaplasia, development of metachronous neoplasia, and progression to surgical resection.

Results

There were 45 patients, 96% male, with a mean age 67?years. The degree of neoplasia prior to intervention was intramucosal (8) or submucosal (2) carcinoma in 10, HGIN in 24, and LGIN in 11. Patients underwent a total of 166 procedures (median 3/patient, range 1?C9). These included 120 radiofrequency ablation sessions, 38 EMRs, and 8 cryoablations. Mean follow-up was 21.3?months. Neoplasia and intestinal metaplasia were eradicated in 87.2% and 56.4% of patients, respectively, while 15.4% developed metachronous neoplasia. Three patients underwent esophagectomy. No patient developed unresectable disease or died.

Conclusion

Endoscopic treatment of early esophageal neoplasia is safe and effective in the short term. A minority of treated patients developed recurrent neoplasia, which is usually amenable to further endoscopic therapy. Complications are relatively minor and uncommon. Endoscopic therapy as the initial treatment for early esophageal neoplasia is an emerging standard of care.     

Limited resection of lung cancer.

AIM: Follow-up results after a limited resection (segmentectomy, wedge resection of lung) are represented in this paper according to the TNM classification and histological type of tumour. METHODS: Since 1980 until 1997, 1173 patients (pts) with lung cancer were treated surgically. 42 (36 males and 6 females) of them underwent a limited resection of lung. Distribution of pts according to the TNM classification was: T1N0 was found in 12 pts and T2N0 in 11 pts, T2N0 in 11pts, T2N1 in 7 pts, other 12 pts had N2. Sqamous cell carcinoma was in 19 pts, Adenocarcinoma in 13 pts, Small cell carcinoma in 9 pts, one pt--Carcinosarcoma. After the operation 9 pts received radiation therapy, 9 pts--chemotherapy. RESULTS: The best follow-up results were in pts with T1-2N0 who received adjuvant therapy: median survival was 45.7 months. The pts, treated only surgically, lived 36.7 months. The pts with N2 lived only 9 months. CONCLUSION: 1. A limited resection of lung with lymph nodes dissection can be performed only in cases T1-2N0. 2. In cases with N0 of undifferentiated carcinoma (anaplastic, small cell) adjuvant therapy ought to be given after operation. 3. In cases of N1, N2 we recommend adjuvant therapy regardless of histological type of tumour.     

Partial hepatectomy for metastases from noncolorectal, nonneuroendocrine carcinoma

OBJECTIVE: To define perioperative and long-term outcome and prognostic factors in patients undergoing hepatectomy for liver metastases arising from noncolorectal and nonneuroendocrine (NCNN) carcinoma. SUMMARY BACKGROUND DATA: Hepatic resection is a well-established therapy for patients with liver metastases from colorectal or neuroendocrine carcinoma. However, for patients with liver metastases from other carcinomas, the value of resection is incompletely defined and still debated. METHODS: Between April 1981 and April 2002, 141 patients underwent hepatic resection for liver metastases from NCNN carcinoma. Patient demographics, tumor characteristics, treatment, and postoperative outcome were analyzed. RESULTS: Thirty-day postoperative mortality was 0% and 46 of 141 (33%) patients developed postoperative complications. The median follow up was 26 months (interquartile range [IQR]) 10-49 months); the median follow up for survivors was 35 months (IQR 11-68 months). There have been 24 actual 5-year survivors so far. The actuarial 3-year relapse-free survival rate was 30% (95% confidence interval [CI], 21-39%) with a median of 17 months. The actuarial 3-year cancer-specific survival rate was 57% (95% CI, 48-67%) with a median of 42 months. Primary tumor type and length of disease-free interval from the primary tumor were significant independent prognostic factors for relapse-free and cancer-specific survival. Margin status was significant for cancer-specific survival and showed a strong trend for relapse-free survival. CONCLUSIONS: Hepatic resection for metastases from NCNN carcinoma is safe and can offer long-term survival in selected patients. Hepatic resection should be considered if all gross disease can be removed, especially in patients with metastases from reproductive tract tumors or a disease-free interval greater than 2 years.