Gastric cancer surgery: Billroth I or Billroth II for distal gastrectomy?

Background  

The selection of an anastomosis method after a distal gastrectomy is a highly debatable topic; however, the available documentation lacks the necessary research based on a comparison of early postoperative complications. This study was conducted to investigate the difference of early postoperative complications between Billroth I and Billroth II types of anastomosis for distal gastrectomies.     

Does the addition of glutamine to total parenteral nutrition have beneficial effect on the healing of colon anastomosis and bacterial translocation after preoperative radiotherapy?

Glutamine administration stimulates mucosal growth and preserves the morphology of the intestine. Theoretically, it could improve colonic anastomotic healing after radiotherapy (RT)-induced epithelial damage and mucosal atrophy induced by total parenteral nutrition (TPN). To investigate this issue, the rectosigmoid colon in male Wistar rats was irradiated to a total dose of 25 Gy. Five days after the end of RT, side-to-side anastomosis was constructed between the irradiated rectosigmoid and the nonirradiated caecum. Postoperatively, animals were divided in three groups: group I, normal diet orally; group II, TPN; group III, TPN enriched with 2% glutamine (Gln-TPN). All animals decreased in weight during RT and after surgery. Weight regain postoperatively was better in the orally fed animals in comparison with the parenterally fed animals (I vs. II and III; p < 0.01). Colonic anastomotic bursting pressure (BP) and bursting wall tension (BWT) were significantly less in group II in comparison with groups I and III (II vs. I and III; p < 0.01). BP and BWT were comparable in groups I and III. No significant differences were found between all the groups in gut bacterial translocation to the blood or to the mesenterical lymph nodes. Conclusively, Gln-TPN can play a role in counteracting the negative effect of food deprivation on the healing of irradiated colonic anastomoses. Postoperative Gln-TPN does not influence gut bacterial translocation in this rat model.     

Is there evidence that chemotherapy is of benefit to patients with carcinoma of the prostate?

Most patients with metastatic carcinoma of the prostate have osteoblastic bone metastases and nonmeasurable pelvic disease. These features cause patients to be at high risk for myelosuppression after cytotoxic chemotherapy and make it difficult to evaluate response to treatment. A critical review of larger trials that have sought to assess the role of chemotherapy in treatment of carcinoma of the prostate leads to the following conclusions: (1) Although the aim of treatment is palliation, most trials have tried to evaluate tumor response rather than the more appropriate endpoints of quality and quantity of survival for all treated patients. (2) Criteria that have been used for tumor response are variable and contain large inherent errors; most patients who are labeled as "responders" are described as being "objectively stable," but this category may be a manifestation of slowly progressive disease rather than a response to treatment. (3) There is no evidence that chemotherapy causes a meaningful prolongation of survival. (4) Chemotherapy adds considerable toxicity, and reported trials have not adequately assessed its overall impact on quality of life. Because of these factors there is little evidence that chemotherapy provides palliation for patients with prostatic carcinoma, and it should not be regarded as part of standard management. Selected patients who are symptomatic and no longer responding to hormones may be considered for trials of chemotherapy. Future trials should randomize patients to chemotherapy or supportive care, with assessment of quality and quantity of survival for all randomized patients by an observer who is unaware of the treatment.     

Viewpoint on the impact of interferon in the treatment of multiple myeloma: benefit for a small proportion of patients?

Interferon-α (IFN-α) generally inhibits myeloma cell growth. However, a growth stimulatory effect for myeloma cells has also been reported. In patients with untreated multiple myeloma (MM) IFN-α, used as a single agent, produced an objective response rate ranging from 10 to 25%. In previously untreated patients: (1) the time to response is short, (2) the median duration of response is similar to the duration of response observed in patients given chemotherapy, and (3) the patients who are more likely to benefit are those with IgA myeloma type. Concerning the results of IFN-α given as a single agent in relapsing and resistant MM, they are poor, with a response rate ranging between 10–20%. The combination of high-dose glucocorticoids and IFN-α for relapsing/resistant patients produced controversial results. Some studies showed an increased response rate and/or longer survival with chemotherapy plus IFN-α versus chemotherapy alone in previously untreated patients. In contrast, most reports did not show a significant increase in response rate or survival benefit by adding IFN-α to the initial chemotherapy. Perhaps the most encouraging role for IFN in MM is as maintenance therapy in patients responding to first line treatment (ie conventional chemotherapy followed or not by high-dose intensification/autotransplantation). In spite of that, several reports failed to show longer response duration. The majority of studies have shown a modest but significant prolongation in response duration in favour of the IFN arm. However, most of these studies have failed to show a significant survival advantage with IFN maintenance. A meta-analysis, by the Myeloma Trialists' Collaborative Group in Oxford, based on the individual data from 4012 patients included in 24 randomized trials (induction and/or maintenance) has shown that IFN produced a moderate improvement in relapse-free survival and a minor improvement in overall survival. In summary, the only role of IFN in MM is as maintenance treatment after a response is achieved. However, looking at the published data, it seems that the vast majority of patients do not benefit from IFN maintenance, while a small proportion of them, in the range of 5–10%,     

Laparoscopic assisted distal gastrectomy for early gastric cancer: Is it an alternative to the open approach?

ObjectiveThis study aims to compare short term outcomes and oncological value of laparoscopy assisted (LADG) and open distal gastrectomy (ODG) in the treatment of early gastric cancer.MethodsMeta-analysis of 12 studies, including three randomized controlled trials, published between 2000 and 2007, comparing laparoscopy assisted and open distal gastrectomy in 951 patients with early gastric cancer, was done. Outcomes of interest were operative data, lymph node clearance, postoperative recovery complications.ResultsOverall morbidity rate was significantly less with LADG (10.5% versus 20.1%, P = 0.003, OR 0.52, CI 0.34–0.8). A mean of 4.61 less number of lymph nodes dissected than ODG (CI ?5.96, ?3.26 P < 0.001) when all studies are included. There was no difference between the two groups in number of lymph nodes dissected when less than D2 lymphadenectomy was done (2.44 nodes less in LADG group, CI ?5.52, 0.63; P = 0.12). LADG patients had less operative blood loss (mean of 151 ml, P < 0.001), less time to walking, oral intake and flatus. LADG patients had less length of hospital stay (5.7 days, P < 0.001), postoperative fever and pain. ODG group showed significantly less operative time. There was no significant difference between the two groups in the incidence of anastomotic complications and wound infection.ConclusionLADG is a safe technical alternative to ODG for early gastric cancer with a lower overall complication rate and enhanced postoperative recovery. Endorsing LADG as a better alternative to ODG requires data on long term survival, quality of life and cost effectiveness.     

Does overweight impact on the prognosis of patients with renal cell carcinoma? A single center experience of 683 patients

BACKGROUND AND OBJECTIVES: An increased incidence of renal cell carcinoma (RCC) in obese patients has been reported by several authors. We investigated the association of body mass index (BMI) with prognosis of patients with RCC. METHODS: From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients were performed at our institution. Patients' BMI at operation was evaluated, overall, tumor-specific and progression-free survival was investigated using the Kaplan-Meier method, for multivariate analysis the Cox regression model was used. RESULTS: Four hundred seventeen patients were males, 266 females. Mean age was 62 years (range 16-88). BMI was available in 609 (89.2%). 371/609 (60.9%) of patients exhibited a BMI greater than 25. After a mean follow-up of 41.5 months, 86 (12.6%) patients died from metastatic RCC, and 29 (4.3%) were alive with metastatic disease. A significant advantage regarding overall (P = 0.015) and progression-free (0.017) but not tumor-specific survival (P = 0.057) was found for patients with a BMI of more than 25 compared to normal-weight patients. In multivariate analysis, BMI showed no significant association with tumor-specific survival. CONCLUSIONS: Patients with a BMI of more than 25 had a better outcome compared to patients with normal weight in univariate analysis but not multivariate analysis.     

All in the family? Analyzing the impact of family history in addition to genotype on medullary thyroid carcinoma aggressiveness in MEN2A patients

Several guidelines for patients with multiple endocrine neoplasia 2A (MEN2A) take into account genotype and family history of medullary thyroid carcinoma (MTC) disease aggressiveness. We sought to determine if an association exists independent of genotype, which could provide important information for counseling MEN2A patients in management of their MTC. Pedigrees of patients with ≥5 family members with MEN2A were retrospectively reviewed. Analysis was performed among kindreds with the most frequently observed codon mutation (RET 634). Familial MTC disease aggressiveness was evaluated using: (1) mean age at diagnosis of MTC, (2) current mean age of carriers without MTC, (3) proportion of kindred with MTC with metastatic disease at diagnosis, (4) proportion of kindred with MTC with metastasis/death from MTC as worst outcome, and (5) proportion of kindred with disease progression. 170 affected patients from 12 different MEN2A kindreds met inclusion criteria. The number of affected family members available for study per kindred ranged from 8 to 43 individuals. A difference in mean age of MTC diagnosis was found in screened patients (p = 0.01); mean age of MTC-free patients did not differ (p = 0.93). No differences were noted among kindreds in disease stage at presentation, worst outcome, or progression; marked variation in these measures was noted within families. In conclusion, a difference in age of MTC diagnosis among different RET 634 kindreds was identified. In contrast, notable intra-familial variability in disease aggressiveness was observed. Based on these findings, we recommend counseling patients with codon 634 mutations that their MTC disease course cannot be predicted by that of their relatives.     

Does paraaortic lymphadenectomy have a benefit in the treatment of ovarian cancer that is apparently confined to the ovaries?

We conducted a retrospective review of all epithelial ovarian carcinoma patients with disease that is apparently confined to the ovaries who were treated in the Obstetric and Gynecologic Hospital of the University of Tours. In our hospital, no lymphadenectomies for such epithelial ovarian carcinoma patients are carried out. We studied the survival of these patients that were operated upon from 1 December 1975 until 1 August 1997. 43 epithelial ovarian carcinoma patients were studied; 22 were stage Ia, 1 was stage Ib and 20 were stage Ic. The average age was 58 years (range 27-86 years). 5% (2/43) developed recurrent disease and the rates of disease-free and overall survival after 5 years were 83% and 90.3% respectively. These results are very close to those described in literature for patients who underwent paraaortic and pelvic lymphadenectomy. As no series to date has demonstrated the benefit of paraaortic lymphadenectomy on survival and we know that paraaortic lymphadenectomy increases morbidity, we think it reasonable to propose surgery without lymphadenectomy for the treatment of early ovarian epithelial cancer patients whose disease is apparently confined to the ovaries.     

Do patients with very few brain metastases from breast cancer benefit from whole-brain radiotherapy in addition to radiosurgery?

Background

The aim of this study was to analyse the reasons for not starting or for early of radiotherapy at the Radiation Oncology Department.

Methods

All radiotherapy treatments from March 2010 to February 2012 were included. Early withdrawals from treatment those that never started recorded. Clinical, demographic and dosimetric variables were also noted.

Results

From a total of 3250 patients treated and reviewed, 121 (4%) did not start or complete the planned treatment. Of those, 63 (52%) did not receive any radiotherapy fraction and 58 (48%) did not complete the course, 74% were male and 26% were female. The mean age was 67 ± 13 years. The most common primary tumour was lung (28%), followed by rectum (16%). The aim of treatment was 62% radical and 38% palliative, 44% of patients had metastases; the most common metastatic site was bone, followed by brain. In 38% of cases (46 patients) radiotherapy was administered concomitantly with chemotherapy (10 cases (22%) were rectal cancers).

The most common reason for not beginning or for early withdrawal of treatment was clinical progression (58/121, 48%). Of those, 43% died (52/121), 35 of them because of the progression of the disease and 17 from other causes. Incomplete treatment regimens were due to toxicity (12/121 (10%), of which 10 patients underwent concomitant chemotherapy for rectal cancer).

Conclusions

The number of patients who did not complete their course of treatment is low, which shows good judgement in indications and patient selection. The most common reason for incomplete treatments was clinical progression. Rectal cancer treated with concomitant chemotherapy was the most frequent reason of the interruption of radiotherapy for toxicity.