Parasternal Lymph Node Metastasis of Malignant Peritoneal Mesothelioma: Report of a Case

We report a case of malignant peritoneal mesothelioma with parasternal lymph node metastasis. The patient was a 34-year-old man who presented with a history of several years of abdominal pain and ascites of unknown origin. Exploratory laparoscopic biopsies yielded histological findings of malignancy, but a final diagnosis was not able to be made. A chest computed tomographic scan done the following year showed a parasternal nodule, and thoracoscopically obtained biopsied material was positive for calretinin. These findings led to a pathological diagnosis of metastasis to the parasternal lymph node from peritoneal mesothelioma.     

Laparoscopy and Primary Diffuse Malignant Peritoneal Mesothelioma: a Diagnostic Challenge

Primary diffuse malignant peritoneal mesothelioma is a rare malignancy with an estimated incidence of 200 to 400 new cases annually in the USA. We describe a case of diffuse malignant peritoneal mesothelioma arising in a 65-year old man who presented ascites of unknown origin. The importance of laparoscopy with subsequent histology of biopsy specimens in the diagnosis of this disease is emphasized. Because of his poor general condition, the patient had no further treatment. Update of treatment is briefly described with particular attention to multimodality approach.     

Diffuse,Mixed Malignant Pleural Mesothelioma

Forty-six patients with diffuse, mixed malignant pleural mesothelioma were treated between January, 1970, and May, 1979. All had a history of exposure to asbestos. The diagnosis was established by thoracentesis in 3 patients, thoracoscopy in 28, thoracotomy in 5, and minithoracotomy in 9. Mediastinoscopy was performed in 31 patients and bronchoscopy in 32. Mediastinoscopy was positive in only 1 patient, and in no patient was bronchoscopy positive.Ten patients received no definitive therapy and survived an average of 9.1 months (1 lived for 16 months). Thirty-one patients received chemotherapy and survived an average of 9.6 months, the 2 longest survivors each lived for 24 months. Five patients appeared to have early disease and therefore underwent thoracotomy. In only 2 of these patients did resection of all gross disease appear possible. One patient with incomplete removal is still alive after 9 months. The other 4 are all dead, having survived an average of only 6.75 months.We believe that pleural mesothelioma should be considered an unresectable neoplasm because of its multicentric origin and its diffusely invasive nature, and that attempts at partial or complete resection are not indicated. Until prospective, controlled studies demonstrate otherwise, patients with diffuse, mixed malignant mesothelioma should have the most benign surgical procedure necessary to establish a diagnosis.     

Current Management and Future Opportunities for Peritoneal Metastases: Peritoneal Mesothelioma

Purpose

Diffuse malignant peritoneal mesothelioma (MPM) is a rare and ultimately fatal cancer that was first described just over a century ago. It is a diffuse malignancy arising from the mesothelial lining of the peritoneum; morbidity and mortality from MPM is due to its propensity to progress locoregionally within the abdominal cavity.

Methods

The purpose of this article is to review the current state-of-the-science related to the diagnosis, staging, and treatment of MPM.

Results

The condition afflicts men and women equally and the peak incidence is between 55 and 60 years of age although it can arise in the young and elderly. Patients afflicted with MPM most commonly present with nonspecific abdominal symptoms that usually lead to diagnosis when the condition is relatively advanced. Historically, median overall survival for MPM patients without treatment is < 1 year. The couplet of systemic pemetrexed and cisplatin has an overall response rate of approximately 25% and a median overall survival of approximately 1 year.

Conclusion

The available data, almost all retrospective in nature, have shown that in selected patients, operative cytoreduction (CRS) and regional chemotherapy administered as hyperthermic intraoperative peritoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) is associated with long-term survival. Studies on the molecular biology of MPM have yielded new insights relating to the potentially important role of the phosphoinsitide-3-kinase/mammalian target of rapamycin (PI3 K/mTOR) pathways and immune checkpoint inhibitors that may translate into new therapeutic options for patients with diffuse MPM.

     

Malignant Peritoneal Mesothelioma: a Case Report

In this paper we report a case of malignant peritoneal mesothelioma, a rare abdominal tumour. A 72-year-old male with a medical history of heart disease presented to our Clinic because of pain in the right half of the abdomen. Diagnostic procedures, including clinical and laboratory examination, X-ray, ultrasonography and computed tomography, revealed a tumour in the right lower quadrant of the abdomen. The approximate size of the tumour size at initial detection was 7 cm. During the pre-operative procedure an evident growth of the tumour was noticed, indicating exploratory laparotomy. Intra-operative findings revealed a large tumour of the anterolateral abdominal wall, involving the greater omentum. Tumour resection was performed, as well as resection of the portion of the anterolateral abdominal wall and omentectomy. Postoperative immunohistochemical analysis revealed malignant peritoneal mesothelioma.     

Diffuse Malignant Peritoneal Mesothelioma: Failure Analysis Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Improved survival has been reported for diffuse malignant peritoneal mesothelioma (DMPM) treated by cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). The issue of treatment failure has never been extensively addressed. The present study assessed the failure pattern, management, and outcome of progressive DMPM following comprehensive treatment. Clinical data on 70 patients with DMPM undergoing cytoreduction and HIPEC were prospectively collected; after a median follow-up of 43 months, disease progression occurred in 38 patients. Progressive disease distribution in 13 abdominopelvic regions was analyzed. In 28 patients undergoing adequate cytoreduction (residual tumor ≤2.5 mm), clinicopathological factors correlating to disease progression in each region were investigated. Median time to progression was 9 months [95% confidence interval (CI) 1.6–35.9]. Median survival from progression was 8 months (95% CI 4–16.2). The failure pattern was categorized as peritoneal progression (n = 31), liver metastases (n = 1), abdominal lymph-node involvement (n = 2), pleural seeding (n = 4). Small bowel was the single site most commonly involved (n = 27). Residual tumor ≤2.5 mm (versus no visible) was the only independent risk factor for disease progression in epigastric region (P = 0.047), upper ileum (P = 0.029), upper jejunum (P = 0.034), and lower jejunum (P = 0.002). Progressive disease was treated with second HIPEC in 3 patients, debulking in 4, systemic chemotherapy in 16, and supportive care in 15. At multivariate analysis, time to progression <9 months (P = 0.009), poor performance status (P = 0.005), and supportive care (P = 0.003) correlated to reduced survival from progression. We conclude that minimal residual disease, compared with macroscopically complete cytoreduction, correlated to failure in critical anatomical areas, suggesting the need for maximal cytoreductive surgical efforts. In selected patients, aggressive management of progressive disease seems worthwhile.     

Current Trends in the Management of Malignant Peritoneal Mesothelioma

Background

Historically, malignant peritoneal mesothelioma (MPM) has been considered an aggressive and lethal neoplasm. However, contemporary series have demonstrated improved outcomes following a combination of cytoreductive surgery and intraperitoneal chemotherapy. We sought to assess the trends in management and survival of patients with MPM in the United States.

Methods

The Surveillance, Epidemiology, and End Results database was used to identify all patients diagnosed with malignant peritoneal mesothelioma from 1973 to 2010. Overall survival (OS) was studied with Kaplan–Meier curves and Cox regression analyses.

Results

We identified 1,591 patients with MPM. Median age at diagnosis was 64 years (IQR 53–74 years) with the majority of patients presenting with metastatic disease (n = 962, 60.5 %). A total of 980 patients (61.6 %) did not receive surgical therapy. Receipt of radical cytoreduction for patients with metastatic MPM demonstrated a significant improvement in OS compared with patients not receiving surgery (20 vs. 4 months, p < 0.01). A temporal increase was observed in OS for patients receiving surgery (1991–1995: 15 vs. 2006–2010: 38 months, p = 0.1). In multivariate models, limited (HR 0.55; 95 % CI 0.48–0.63; p < 0.01) and radical (HR 0.66; 95 % CI 0.54–0.80; p < 0.01) surgery were independently associated with improved survival.

Conclusions

In the current era, approximately three of every five patients do not receive surgery when diagnosed with MPM, although a significant survival benefit is noted in select patients. The opportunity to improve patient survival with surgical therapy is lost in a significant number of MPM patients.     

Japanese D3 Lymph Node Dissection in Low Rectal Cancer with Inferior Mesenteric Lymph Node Metastases

Background

There is currently no consensus on the significance of Japanese D3 lymph node dissection in low rectal cancer with inferior mesenteric lymph node (IMLN) metastasis. This is partly because, despite a number of studies on the subject, cases of IMLN metastasis are relatively rare, and there are few cases of curative resection because of metastasis to other organs. A retrospective study involving a large number of patients was conducted.

Methods

The subjects were 2,743 patients registered in the national registry of the Japanese Society for Cancer of the Colon and Rectum. The data were analyzed for (1) prognostic factors for IMLN metastasis, and (2) outcomes in R0 cases with IMLN metastasis.

Results

In the control group, 67 patients (2.7 %) were considered positive for IMLN metastasis. The outcomes in the 35 R0 cases with IMLN metastasis were 50.8 % for 5-year relapse-free survival (RFS) and 61.9 % for 5-year overall survival (OS), which were each better than for R1+R2 cases (5-year RFS 16.1 %, p = 0.0001; 5-year OS 26.7 %, p = 0.0002). The outcomes for R0 cases (total metastatic lymph nodes ≥7) with IMLN metastasis (5-year RFS 53.9 %, 5-year OS 68.8 %) did not differ significantly from those for IMLN(?) cases (5-year RFS 54.6 %, 5-year OS 57.1 %) (RFS: p = 0.9515, OS: p = 0.4621).

Conclusions

It was confirmed that cases of IMLN metastasis in low rectal cancer tend to have a large total number of metastatic lymph nodes, but if curative resection can be performed, a good prognosis can be expected. These results demonstrate the value of radical Japanese D3 lymph node dissection in low rectal cancer with IMLN metastasis.     

Predicting Non-sentinel Lymph Node Metastases in Patients with a Positive Sentinel Lymph Node After Neoadjuvant Chemotherapy

Background

The standard of care for breast cancer patients treated with neoadjuvant chemotherapy (NAC) who have a positive sentinel lymph node (+SLN) after NAC is completion axillary lymph node dissection (ALND). This study aimed to develop a nomogram to predict additional nodal disease in patients with +SLN after NAC.

Methods

The study reviewed patients 18 years of age or older who had invasive breast cancer treated with NAC followed by SLN surgery with +SLN and ALND between 2006 and 2017 at the authors’ institution. Factors predictive of positive non-SLNs were analyzed using uni- and multivariable logistic regression.

Results

The study identified 120 patients with +SLN after NAC and ALND. Of these patients, 30.8% were clinically node-negative (cN?), and 69.2% were clinically node-positive (cN+) before NAC. Tumor biology was human epidermal growth factor receptor 2-positive (HER2+) for 20%, hormone receptor-positive (HR+)/HER2? for 66.7%, and triple-negative breast cancer (TNBC) for 13.3% of the patients. Additional nodal disease was found on ALND for 63.3% of the patients. In the univariate analysis, the factors predictive of positive non-SLNs were biologic subtype (TNBC and HR+/HER2? vs HER2+; p?<?0.001), higher grade (p?=?0.047), higher pT category (p?=?0.02), SLN extranodal extension (p?=?0.03), larger SLN metastasis size (p?<?0.001), and higher number of +SLNs (p?=?0.02). The factors significant in the multivariable analysis included number of +SLNs, grade 3 vs grade 1 or 2, HER2+ versus HER2?, cN+ versus cN?, and larger SLN metastasis size. The resulting model showed excellent discrimination (area under the curve, 0.82; 95% confidence interval, 0.74–0.90) and good calibration (p?=?0.54, Hosmer–Lemeshow).

Conclusion

A clinical prediction model incorporating biologic subtype, grade, clinical node status, size of the largest SLN metastasis, and number of +SLNs can help physicians and patients estimate the likelihood of additional nodal disease and may be useful for guiding decision making regarding axillary management.

     

The Role of Perioperative Systemic Chemotherapy in Diffuse Malignant Peritoneal Mesothelioma Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

The aim of this study was to evaluate the effects of perioperative systemic chemotherapy (CT) on short-term surgical and long-term oncologic results in diffuse malignant peritoneal mesothelioma (DMPM) patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Patients and Methods

We retrospectively analyzed data obtained from an institutional prospective database at NCI of Milan. The study group comprised 116 DMPM patients treated with CRS + HIPEC from August 1995 to October 2011. A total of 60 cases underwent preoperative CT (PRECT), 30 underwent postoperative CT (POSTCT), and 26 did not undergo any CT (NOCT). Also, 55 cases used the perioperative combination of platinum and pemetrexed. We tested whether covariates related to clinical, histologic, PRECT, and surgical treatment were correlated with completeness of cytoreduction (CC), postoperative G3-5 morbidity, and progression-free survival and overall survival (OS). Univariate and multivariate analyses were performed.

Results

Factors independently associated with CC were ECOG performance status (PF) of 0, and PCI <20. Factors independently associated with postoperative G3-5 morbidity were ECOG >1, bowel anastomosis, and number of peritonectomy procedures. Preoperative platelet count >400 × 103/mm³, histological subtype (biphasic and sarcomatoid vs epithelial), CC, and G3-5 morbidity were independent prognostic factors. PRECT was not associated with CC or G3-5 morbidity. There was no significant difference in terms of survival between the PRECT, POSTCT, and NOCT groups.

Conclusions

The CC, G3-5, and OS were not influenced by aspects related to perioperative CT. The present data warrants confirmation reconducting the comparative analysis in a larger multi-institutional series preferably using matching control techniques.     

我国165例腹膜恶性间皮瘤临床特点

目的：总结我国腹膜恶性间皮瘤的临床表现及诊治方法。方法：以腹膜恶性间皮瘤为检索词,分别对中国期刊网全文数据库、维普资讯网中文科技期刊数据库在2000—2010年期间发表的中文临床报道进行检索。结果：共检出腹膜恶性间皮瘤165例,男性多于女性。临床症状以腹痛、腹胀为最常见,出现率约为77.8%及63.9%。腹水是最常见的体征,出现率约为96%。剖腹及腹腔镜下探查是确诊的最常见手段。腹膜恶性间皮瘤预后较差,综合治疗后中位生存期约1.5年。结论：腹膜恶性间皮瘤是临床罕见病,误诊率高,应充分认识其特点,提高早期诊治腹膜恶性间皮瘤的水平。积极的综合治疗可以延长病人的生存期。     

Malignant Peritoneal Mesothelioma: Prognostic Factors and Oncologic Outcome Analysis

Background

Most patients with malignant peritoneal mesothelioma (MPM) present with late-stage, unresectable disease that responds poorly to systemic chemotherapy while, at the same time, effective targeted therapies are lacking. We assessed the efficacy of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) in MPM.

Methods

We prospectively analyzed 65 patients with MPM undergoing CRS/HIPEC between 2001 and 2010. Kaplan–Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting oncologic outcomes.

Results

Adequate CRS was achieved in 56 patients (CC-0 = 35; CC-1 = 21), and median simplified peritoneal cancer index (SPCI) was 12. Pathologic assessment revealed predominantly epithelioid histology (81 %) and biphasic histology (8 %), while lymph node involvement was uncommon (8 %). Major postoperative morbidity (grade III/IV) occurred in 23 patients (35 %), and 60-day mortality rate was 6 %. With median follow-up of 37 months, median overall survival was 46.2 months, with 1-, 2-, and 5-year overall survival probability of 77, 57, and 39 %, respectively. Median progression-free survival was 13.9 months, with 1-, 2-, and 5-year disease failure probability of 47, 68, and 83 %, respectively. In a multivariate Cox-regression model, age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), aggressive histology (epithelioid, biphasic), and postoperative sepsis were joint significant predictors of poor survival (chi square = 42.8; p = 0.00001), while age at surgery, SPCI >15, incomplete cytoreduction (CC-2/3), and aggressive histology (epithelioid, biphasic) were joint significant predictors of disease progression (Chi square = 30.6; p = 0.00001).

Conclusions

Tumor histology, disease burden, and the ability to achieve adequate surgical cytoreduction are essential prognostic factors in MPM patients undergoing CRS/HIPEC.     

残胃癌淋巴结转移的相关研究

目的探讨残胃癌淋巴结转移的特点,为残胃癌术中合理的淋巴结清扫提供依据。方法回顾性分析广西壮族自治区人民医院普外-儿外科2004年6月至2012年6月期间由同一手术者进行残胃癌根治术的22例患者的临床资料,并用等距随机抽样法随机抽取同期原发性胃癌患者50例作为对照,比较2组患者的临床病理资料及术中所清扫淋巴结的转移情况。结果与原发性胃癌患者相比,残胃癌患者联合脏器切除率较高〔54.55%（12/22）比14.00%（7/50）〕,差异有统计学意义（χ2=12.929,P=0.000）。在淋巴结转移方面,残胃癌患者淋巴结总转移阳性率明显高于原发性胃癌患者〔30.56%（103/337）比22.13%（208/940）〕,差异有统计学意义（χ2=9.583,P=0.002）;微转移方面,残胃癌患者淋巴结微转移阳性率高于原发性胃癌〔2.97%（10/337）比1.49%（14/940）〕,但差异无统计学意义（χ2=2.939,P=0.086）。残胃癌患者No.10淋巴结总转移阳性率较原发性胃癌患者高〔52.17%（12/23）比17.39%（4/23）〕,差异有统计学意义（χ2=6.133,P=0.013）;残胃癌患者No.10的12个转移淋巴结中有4个微转移,原发性胃癌中未检出微转移淋巴结。残胃癌空肠系膜淋巴结转移阳性率为35.71%（5/14）。结论残胃癌有其独特的淋巴结转移规律,术中应行D2淋巴结廓清术和空肠系膜淋巴结清扫术,同时应重点对No.10淋巴结进行清扫,必要时行联合脏器切除。     

Patterns of Lymph Node Metastases in Papillary Thyroid Carcinoma: Results from Consecutive Bilateral Cervical Lymph Node Dissection

Background  

In patients with papillary thyroid carcinoma (PTC), the appropriate extent of lymph node dissection has not yet been established due to lack of accurate patterns of lymph node metastases (LNM). The aim of this study was to clarify the LNM pattern in PTC patients based on our institution’s experience with a consistent technique of bilateral neck dissection, and to consider the rational extent of lymph node dissection.     

Sentinel Lymph Node Metastases Detected by Immunohistochemistry Only Do Not Mandate Complete Axillary Lymph Node Dissection in Breast Cancer

Background: The significance of breast cancer sentinel lymph node (SLN) metastases detected only by immunohistochemistry staining (IHC) remains poorly understood. This study attempted to quantify the risk of non-SLN metastases.Methods: A prospectively collected database of 750 consecutive SLN biopsy procedures in breast cancer patients was reviewed. Medical records were reviewed to supplement the database.Results: SLNs were identified in 738 (98.4%) of these procedures in 723 patients. Of these, 151 patients (20.5%) had metastases detected by hematoxylin and eosin staining (H&E), and 33 (4.6%) of the 718 with known IHC staining results had metastases detected by IHC only. Twenty-eight (84.8%) of 33 patients with IHC-detected metastases underwent complete axillary lymph node dissection (CALND). The median primary tumor size was 2.0 cm among those undergoing CALND and 0.9 cm among the five patients treated without CALND (P = .10). Two of the 28 patients (7.1%) had additional metastases detected with CALND. These patients had a T3 or T4 invasive lobular primary tumor. Of 24 patients with T1 or T2 primary tumors and IHC-detected metastases who underwent CALND, none had additional metastases detected. Median follow-up was 14.5 months. All patients with IHC-detected SLN metastases were treated with adjuvant systemic therapy. None of the five patients with IHC-detected metastases not undergoing CALND has subsequently manifested clinical axillary disease.Conclusions: CALND could have been or was safely omitted in 29 of 29 patients with T1 or T2 primary tumors and metastases detected by IHC. Such patients should be counseled about this low risk before CALND is recommended.