高龄食管癌患者术后胸膜腔胃与胸骨后胃对肺功能影响的临床观察

目的探讨高龄食管癌患者术后胸膜腔胃与胸骨后胃对肺功能的影响。方法选取沈阳医学院附属奉天医院2009年2月至2011年5月收治的62岁以上中上段食管癌患者40例,根据手术方式不同分成胸膜腔胃组和胸骨后胃组。胸膜腔胃组20例,男16例、女4例,年龄62~79（64.70±11.47）岁,胃从胸膜腔路径行颈部吻合;胸骨后胃组20例,男17例、女3例,年龄63~77（65.90±12.72）岁,胃从胸骨后路径行颈部吻合。两组患者术前、术后15 d及术后30 d进行肺功能测定,比较呼吸功能变化情况。结果两组患者术前肺功能水平差异无统计学意义（P〉0.05）。胸膜腔胃组术后15 d及30 d肺功能较术前显著下降（P〈0.05）,胸骨后胃组术后15 d及30 d肺功能水平与术前比较差异无统计学意义（P〉0.05）。胸骨后胃组术后15 d及30 d肺功能水平显著高于胸膜腔胃组（P〈0.05）。术后并发症包括胸膜腔组吻合口瘘1例,吻合口狭窄1例,肺内感染5例,肺不张1例,胸骨后胃组出现吻合口瘘1例,吻合口狭窄1例,幽门梗阻1例,肺部感染3例。随访1年两组患者呼吸方面症状与术后30 d比较无明显变化（P〉0.05）。结论胸膜腔胃对肺功能有明显影响,而胸骨后胃对肺功能影响较小,适合高龄及肺功能差的患者,可以减少术后并发症的发生,提高患者的生活质量。     

Letter to the Editor: Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis Following Esophagectomy

World Journal of Surgery -     

Clinicopathological Features and Prognostic Factors of Adenocarcinoma of the Esophagogastric Junction According to Siewert Classification: Experiences at a Single Institution in Japan

Background

Treatment strategy for adenocarcinoma of the esophagogastric junction (AEG) remains controversial. The aims of this study are to evaluate results of surgery for AEG, to clarify clinicopathological differences according to the Siewert classification, and to define prognostic factors.

Methods

We retrospectively analyzed 179 consecutive patients with Siewert type I, II, and III AEG who underwent curative (R0) resection at the National Cancer Center Hospital East between January 1993 and December 2008.

Results

Patients with AEG were divided according to tumor: 10 type I (5.6%), 107 type II (59.8%), and 62 type III (34.6%). Larger, deeper tumors and nodal metastasis were more common in type III than type II tumors. No significant differences were seen in 5-year survival rates among the three types: type I (51.4%), type II (51.8%), and type III (62.6%). Multivariate analysis showed that depth of tumor and mediastinal lymph node metastasis were independent prognostic indicators. The recurrence rate for patients with mediastinal lymph node metastasis was 87.5%. The risk factors for mediastinal lymph node metastasis were length of esophageal invasion and histopathological grade.

Conclusions

Mediastinal lymph node metastasis and tumor depth were significant and independent factors for poor prognosis after R0 resection for AEG. Esophageal invasion and histopathological grade were significant and independent factors for mediastinal lymph node metastasis.     

Clinicopathological Characteristics and Prognostic Factors of Patients with Siewert Type II Esophagogastric Junction Carcinoma: A Retrospective Multicenter Study

Background

The incidence of esophagogastric junction (EGJ) carcinoma is increasing, but its optimal surgical management remains controversial.

Methods

We retrospectively reviewed the database of 400 patients with Siewert type II EGJ carcinoma who were treated surgically at 7 institutions between March 1986 and October 2010. We examined the clinicopathological characteristics, prognostic factors, and risk factors associated with each recurrence pattern.

Results

The 5-year overall survival rate of all patients with Siewert type II EGJ carcinoma was 58.4 %. Multivariate analysis showed that T and N stages were independent prognostic factors. We also found that the incidence of lower mediastinal lymph node metastasis (17.7 %) and para-aortic lymph node metastasis (16.1 %) was relatively high. In addition, the para-aortic lymph nodes (N = 39, 9.8 %) were the most frequent node recurrence site, followed by the mediastinal lymph nodes (N = 23, 5.8 %). Lung recurrence was more common than was peritoneal recurrence. Considering each type of recurrence, multivariate analysis showed that the differentiated type was associated with a higher risk of lung recurrence than was the undifferentiated type, and N stage (pN2–3) and positive venous invasion were independent risk factors for liver recurrence.

Conclusions

This study is one of the largest retrospective studies to evaluate patients with Siewert type II EGJ carcinoma. Para-aortic and mediastinal lymph node metastasis and recurrence rates were relatively high. During the postoperative follow-up of patients with differentiated Siewert type II EGJ carcinoma, patients should be monitored for lung recurrence more closely than that for peritoneal recurrence.

     

Prognostic Factors of Patients with Spinal Chondrosarcoma: A Retrospective Analysis of 98 Consecutive Patients in a Single Center

Purpose

Chondrosarcoma (CHS) in the spine is relatively rare and minimal information has been published in the literature regarding this subject. The objective of our study was to discuss the factors that may affect outcomes of patients with spinal CHS.

Methods

Univariate and multivariate analyses were performed to identify prognostic factors for recurrence, distant metastasis, and survival of spinal CHS. T test, χ ² test and rank sum test were used to analyze a single factor for recurrence and metastasis, while survival rate was estimated using the Kaplan–Meier method. Factors with p values of ≤0.1 were subjected to multivariate analyses by binary logistic regression analyses or Cox regression analyses. p Values of ≤0.05 were considered statistically significant.

Results

A total of 98 patients with spinal CHS were included in the study. The mean follow-up period was 49.7 months (range 6–178). Recurrence was detected in 42 patients after initial surgery in our center, while distant metastasis and death occurred in 24 and 32 cases, respectively. The statistical analyses suggested that pathology grade III was closely related with distant metastasis which was an independent prognostic factor for overall survival. Total en bloc spondylectomy could significantly decrease the risk of recurrence, distant metastasis, and death of patients with spinal CHS.

Conclusions

Total en bloc spondylectomy could significantly decrease the risk of recurrence and distant metastasis, and meanwhile improve overall survival of spinal CHS. Distant metastasis which was closely associated with pathology grade III was an adverse prognostic factor for overall survival of spinal CHS.     

A Systematic Review of the Predictive Value of 18FDG-PET in Esophageal and Esophagogastric Junction Cancer After Neoadjuvant Chemoradiation on the Survival Outcome Stratification

Purpose

We studied the predictive value of [¹⁸?F]fluorodeoxyglucose-positron emission tomography (¹⁸FDG-PET) for assessing disease-free (DFS) and overall survival (OS) in esophageal and esophagogastric junction cancer.

Materials and methods

A literature search (PUBMED/MEDLINE, EMBASE, Cochrane) was performed to identify full papers with ¹⁸FDG-PET and survival data, using indexing terms and free text words. Studies with >10 patients with locally advanced esophageal cancer, presenting sequential or at least one post-adjuvant treatment ¹⁸FDG-PET data and Kaplan–Meier survival curves with >6 months median follow-up period were included. We performed a meta-analysis for DFS and OS using the hazard ratio (HRs) as outcome measure. Sources of heterogeneity study were also explored.

Results

We identified 26 eligible studies including a total of 1,544 patients (average age 62 years, 82 % males). The TNM distribution was as follows: stage I 7 %, II 24 %, III 53 % and IV 15 %. The pooled HRs for complete metabolic response versus no response were 0.51 for OS (95 % CI, 0.4–0.64; P?<?0.00001) and 0.47 for DFS (95 % CI, 0.38–0.57; P?<?0.00001), respectively. No statistical heterogeneity was present. To explore sources of clinical heterogeneity, we also realised subgroup and regression analyses. Taken into account the moderate correlation between OS and DFS (ρ?=?0.54), we used joint bivariate random regression model. These analyses did not show a statistically significant impact of study characteristics and PET modalities on the pooled outcome estimates.

Conclusion

Despite methodological and clinical heterogeneity, metabolic response on ¹⁸FDG-PET is a significant predictor of long-term survival data.     

Influence of Surgical Margins on the Outcome of Breast Cancer Patients: A Retrospective Analysis

Objective

Breast-conserving surgery has become the preferred treatment for early breast cancer. Yet the question of what constitutes a ‘safe margin’, in terms of impact on patient outcome, remains unanswered. Our aim was to address this knowledge gap by determining the prevalence of positive and narrow margins after breast-conserving surgery, and evaluating how margin status impacted local recurrence and overall survival.

Materials and Methods

We collected data about all women who underwent breast-conserving cancer surgery in our department between 2002 and 2011, focusing on patient and tumor characteristics, the distance from the tumor to the surgical margin, therapies administered, and outcome (measured in terms of local recurrence and overall survival). Data were analyzed by R (version 3.0.1), considering p < 0.05 as significant. Multivariate analyses were also performed.

Results

Of 1,192 women who received breast-conserving surgery, 264 were considered for widening; 111 of these patients had positive margins and 153 narrow (where narrow was defined as less than 5 mm). Widening was performed for 38 % of these patients (99/264) and mastectomy for 27 % (70/264), while 36 % (95/264) had no further surgery and were simply followed-up. Our multivariate analysis confirmed that local tumor recurrence and overall survival were not significantly influenced by margin status, either at initial surgery, or (for those patients with initially positive margins) at secondary margin-widening surgery. However, the following were found to be significantly correlated with local recurrence: tumor multifocality, high expression of Ki-67/Mib-1, comedo-like necrosis, and non-axillary lymph node positivity (p < 0.05).

Conclusions

We found the status of resection margins and the management of infiltrated or narrow margins to have no significant influence on local tumor recurrence rates or on overall patient survival. Instead, biological factors connected with tumor aggressiveness seem to play the most important role in breast cancer prognosis, independent of surgical radicality.     

Early Results of Laparoscopic Biliopancreatic Diversion with Duodenal Switch: A Case Series of 40 Consecutive Patients

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure.We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity. Methods: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months. Results: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 ± 1 years (± SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 ± 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3- 210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% ± 2% excess weight loss (EWL) and at 9 months 58% ± 3% EWL. Conclusion: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.     

Outcome of Patients Surgically Treated for Various Forms of Hyperthyroidism with Differentiated Thyroid Cancer: Experience at an Endocrine Center in Italy

Purpose The incidence and aggressiveness of thyroid cancer associated with hyperthyroidism remains a subject of much controversy. The aim of this study was to analyze the frequency of coexisting hyperthyroidism and thyroid cancer, and to determine whether cancer becomes more aggressive with different forms of hyperthyroidism. Methods We retrospectively studied 2 449 patients assessed for hyperthyroidism between 1985 and 2001. All patients with a “cold” nodule on scintigraphy, such as those with Graves' disease and a concomitant solid nodule, underwent fine-needle aspiration biopsy (FNAB). Criteria for surgery were cytological findings indicative of malignancy, goiter with signs of tracheal or esophageal compression, side effects of antithyroid drug therapy, or Graves' disease with multiple relapses after therapy withdrawal or responsiveness to antithyroid drugs. Results Thyroid cancer was diagnosed more frequently in patients with Graves' disease (6.5%) than in those with uninodular toxic goiter (UTG) (4.4%) or multinodular toxic goiter (MTG) (3.9%). Lymph node involvement was found in 56% of the patients with Graves' disease, in 23% of those with MTG, and in none of those with UTG. Distant metastases were found in one patient with Graves' disease. Conclusions Cancers associated with Graves' disease seems to be more aggressive than those associated with MTG or UTG. Thus, we suggest that patients with Graves' disease be carefully monitored for the detection of thyroid nodules. Ultrasonography seems to be the best modality to detect such nodules.     

Surgical Outcome of Patients with Core-Biopsy-Proven Nonpalpable Breast Carcinoma: A Large Cohort Follow-Up Study

Background  Breast-conserving surgery (BCS) is the preferred treatment for nonpalpable breast carcinoma. The outcome, however, may be disappointing. In this study surgical outcome in a large cohort of patients diagnosed with nonpalpable breast carcinoma is evaluated. Methods  In 833 patients with 841 nonpalpable breast carcinomas the number of re-excisions and type of surgical procedures was calculated and summed per patient. Subsequently, the number of conversions to mastectomy and the number of days until complete tumor removal were analyzed. In a subgroup analysis the patients with an in situ carcinoma were compared with the patients with an invasive carcinoma. Results  The initial surgery consisted of BCS for 589 tumors (70%) and of mastectomy for 242 tumors (29%). For ten tumors (1%) the initial surgery was unknown. After BCS, 158/589 tumors (27%) required a re-excision: 116/337 (34%) for the in situ carcinomas and 63/504 (13%) for the invasive carcinomas (p = 0.0001). The number of conversions from BCS to mastectomy was 106/589 (18%): 66/241 (28%) in patients diagnosed with an in situ carcinoma versus 40/348 (11%) in patients with an invasive carcinoma (p = 0.0001). The median number of days until complete tumor removal was 28, being 38 days for the in situ carcinomas and 25 days for the invasive carcinomas (p = 0.0001). Conclusions  There is room for improvement in the surgical treatment of nonpalpable breast carcinoma, especially the relatively favorable in situ carcinoma, as it requires significantly more excisions, mastectomies, conversions to mastectomy, and days for complete removal.     

Everolimus-Based Immunosuppression in Patients With Hepatocellular Carcinoma at High Risk of Recurrence After Liver Transplantation: A Case Series

BackgroundLiver transplantation offers the most effective treatment in patients with hepatocellular carcinoma (HCC). However, transplant patients outside the Milan criteria have a high risk of tumor recurrence, which has been linked to standard immunosuppression regimens. Everolimus is a mammalian target of rapamycin inhibitor that has been used for immunosuppression, but its effect on recurrence and survival in HCC patients with a high risk of tumor recurrence has not been examined. We compared long-term survival and cumulative recurrence in high-risk patients receiving everolimus-based immunosuppression after liver transplantation for HCC with an historic control group.MethodsThe everolimus group comprised 21 patients receiving a liver transplant at our center from February 2005 to December 2010. The control group comprised 31 patients receiving a liver transplant from May 1994 to January 2005. All patients received cyclosporine or tacrolimus as initial post-transplant immunosuppression. Patients in the everolimus group switched to everolimus 2 weeks later.ResultsThere were no differences between the two groups in number of rejection episodes or of infectious or surgical complications. Five-year survival was 60.2% in the everolimus group and 32.3% in the control group (P = .05). Five-year cumulative recurrence rate was 61.3% in the control group and 41.3% in the everolimus group. Treatment with everolimus was identified as an independent predictor of longer survival (hazard ratio = 0.34; P = .02).ConclusionsPatients receiving liver transplantation for HCC with a high risk of tumor recurrence may well benefit from everolimus-based immunosuppression, with no added risks of rejection or other post-transplant complications.     

A Changing Policy for the Surgical Treatment of Tetralogy of Fallot: Early and Late Results in 235 Consecutive Patients

Between February, 1969, and March, 1980, 235 consecutive patients underwent repair of tetralogy of Fallot. Of these, 94 patients were less than 4 years of age, including 40 less than 2 years of age. Previous palliative procedures had been performed in 46 patients. Conservative technique to relieve the right ventricular outflow tract (RVOT) obstruction was employed in 194 patients; transannular approach was performed in the remaining 41. There were 18 hospital deaths (7.6%) and 3 late deaths. The early and late results were significantly related to the ratio of the right ventricular to left ventricular systolic peak pressure after repair. Until 1976, the age of patients at operation constituted an operative risk factor. Since 1977, none of the 17 infants who underwent operation died after the repair. In the overall series, the transannular approach to relieve the RVOT obstruction affected the early mortality and the late results. During the last 3 years, only 1 of the 12 patients who received an aortic homograft monocusp transannular gusset died in the hospital, and the 11 survivors were completely symptom free at follow-up.     

The Improvement of Surgical Treatment for Patients with Gallbladder Cancer: Analysis of 208 Consecutive Cases Over the Past Decade

Objectives

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

Methods

A retrospective review of all patients with gallbladder cancer admitted during the past 11?years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n?=?77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n?=?131).

Results

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P?=?0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9?% vs. 19?%, P?=?0.040) and disease-free survival (P?=?0.017). Median survival in group 1 was 14.7?months, while in group 2 it was 22.3?months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P?=?0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P?=?0.108).

Conclusions

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.     

Prognostic Factors of Patients with Thymic Carcinoma After Surgery: A Retrospective Analysis of 58 Cases

Background

Thymic carcinoma is reputed to carry a poor prognosis. Although few scholars have studied the prognosis of thymic carcinoma, the prognostic factors of patients after surgery are not well established. We analyze the prognostic significance of undetermined factors to predict the survival of patients after surgery.

Methods

We reviewed 351 cases of thymic epithelial tumor treated with surgery at a single institution in China from 1992 to 2011. A total of 58 patients were histopathologically reconfirmed as having thymic carcinoma. Clinicopathological characteristics and treatment modalities were reviewed. During the follow-up, with a median of 65.8 months, survival time was analyzed using the Kaplan–Meier method. Univariate and multivariate analysis were performed to identify prognostic factors.

Results

The overall 3-, 5-, and 10-year survival rate was 69.0, 43.1, and 12.1 %, respectively. The Log-rank test revealed that Masaoka stage (p = 0.000), histology group (p = 0.000), completeness of the resection (p = 0.000), great vessel invasion (p = 0.000), and presence of symptoms (p = 0.003) were significant prognostic factors in all patients. However, tumor size (p = 0.086), age (p = 0.677), sex (p = 0.706), smoking (p = 0.065), and alcohol (p = 0.875) were not prognostic factors. A Cox proportional hazards regression model showed that Masaoka stage (hazard ratio = 15.640, p = 0.000) and completeness of the resection (hazard ratio = 18.303, p = 0.000) were the only independent prognostic factors.

Conclusions

The Masaoka stage and completeness of the resection were independent prognostic factors that predicted long-term survival of patients with thymic carcinoma treated with surgery.     

Efficacy of Anastrozole in a Consecutive Series of Advanced Breast Cancer Patients Treated with Multiple Prior Chemotherapies and Endocrine Agents: M. D. Anderson Cancer Center Experience

▪  Abstract: Anastrozole is a highly selective, nonsteroidal aromatase inhibitor approved by the U.S. Food and Drug Administration (FDA) in January 1996 for the treatment of advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy. To date, information on anastrozole's use has been limited to breast cancer patients with minimal prior therapy. The purpose of this review was to determine, in clinical practice, the benefits of anastrozole in advanced breast cancer patients treated with multiple prior cytotoxic and endocrine therapies. This was a retrospective review of a consecutive series of 117 patients who received anastrozole after marketing in January 1996. As this was not a prospective study, rigorous response criteria could not be applied. Responses were categorized as improvement in disease (ID), stable disease (SD), or progressive disease (PD). One hundred eight patients were evaluable for response with a median age of 61 years and the number of prior therapies ranging from one to nine. Response, defined as improvement of disease or stable disease 8 weeks, was seen in 59% of patients. Patients with three or more prior endocrine therapies demonstrated a 61% response (ID + SD) and patients with ER-negative tumors demonstrated 50% response. Patients with prior aminoglutethamide therapy exhibited similar response rates to the overall group. One male patient received anastrozole without benefit. This data determines the activity of anastrozole even in heavily pretreated patients and suggests that patients who have tumors that are ER-negative may also benefit from anastrozole therapy. ▪