Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases

Introduction

The use of self-expandable stents to treat postoperative leaks and fistula in the upper gastrointestinal (GI) tract is an established treatment for leaks of the upper GI tract. However, lumen-to-stent size discrepancies (i.e., after sleeve gastrectomy or esophageal resection) may lead to insufficient sealing of the leaks requiring further surgical intervention. This is mainly due to the relatively small diameter (≤30 mm) of commonly used commercial stents. To overcome this problem, we developed a novel partially covered stent with a shaft diameter of 36 mm and a flare diameter of 40 mm.

Methods

From September 2008 to September 2010, 11 consecutive patients with postoperative leaks were treated with the novel large diameter stent (gastrectomy, n = 5; sleeve gastrectomy, n = 2; fundoplication after esophageal perforation, n = 2; Roux-en-Y gastric bypass, n = 1; esophageal resection, n = 1). Treatment with commercially available stents (shaft/flare: 23/28 mm and 24/30 mm) had been unsuccessful in three patients before treatment with the large diameter stent. Due to dislocation, the large diameter stent was anchored in four patients (2× intraoperatively with transmural sutures, 2× endoscopically with transnasally externalized threads).

Results

Treatment was successful in 11 of 11 patients. Stent placement and removal was easy and safe. The median residence time of the stent was 24 (range, 18–41) days. Stent dislocation occurred in four cases (36 %). It was treated by anchoring the stent. Mean follow-up was 25 (range, 14–40) months. No severe complication occurred during or after intervention and no patient was dysphagic.

Conclusions

Using the novel large diameter, partially covered stent to seal leaks in the upper GI tract is safe and effective. The large diameter of the stent does not seem to injure the wall of the upper GI tract. However, stent dislocation sometimes requires anchoring of the stent with sutures or transnasally externalized threads.     

Locoregional Lymphadenectomy in the Surgical Management of Anorectal Melanoma

Background

The effect of lymph node metastasis on local tumor control and distant failure in patients with anorectal melanoma has not been fully studied. Understanding the significance of lymphatic dissemination might assist in stratifying patients for either organ preservation or radical surgery.

Methods

A retrospective review of all patients with anorectal melanoma who underwent surgery at our institution between 1985 and 2010. Abdominoperineal resection (APR) was performed in 25 patients (39 %), and wide local excision (WLE) in 40 (61%). Extent of primary surgery and locoregional lymphadenectomy (mesorectal vs. inguinal vs. none) and pattern of treatment failure were analyzed. Recurrence-free survival (RFS) and disease-specific survival (DSS) were calculated.

Results

In patients undergoing APR, DSS was not associated with presence (29 %) or absence (71 %) of metastatic melanoma in mesorectal lymph nodes. There was a trend toward improved DSS in patients with clinically negative inguinal lymph nodes (n = 17) compared with patients with proven inguinal metastasis (n = 6; P = 0.12). Type of surgery (WLE vs. APR) was not associated with subsequent development of distant disease. Twelve patients (18 %) had synchronous local and distant recurrence. Synchronous recurrence was not associated with surgical strategy used to treat primary tumor (P = 0.28). Perineural invasion (PNI) was significantly correlated with RFS (P = 0.002).

Conclusions

Outcome following resection of anorectal melanoma is independent of locoregional lymph node metastasis; lymphadenectomy should be reserved for gross symptomatic disease. PNI is a powerful prognostic marker warranting further exploration in clinical trials.     

Correlation Between gp96 Expression and the Surgical Outcome in Patients With Esophageal Squamous Cell Carcinoma

Background

Heat-shock protein gp96 plays an important role in antitumor immunoreactions. Gp96 has a close relationship with antitumor immunity. This study evaluated the correlation between gp96 expression and the prognosis in esophageal squamous cell carcinoma.

Methods

Seventy-eight patients with primarily resected esophageal squamous cell carcinoma were enrolled onto this study, and gp96 expression was evaluated by immunohistochemical staining. The association of clinicopathological factors and patients’ survival was calculated by univariate (log rank test) and multivariate (Cox proportional hazard regression method) analyses.

Results

Fifty-seven (73%) of 78 cases were gp96 positive, and 21 were negative (27%). The survival of patients with gp96-negative disease was significantly shorter (5-year survival, 22.9 months) than with gp96-positive disease (45.8 months; P = 0.049), and the multivariate analysis showed that gp96 negativity is an independent risk factor for poor survival (hazard ratio, 2.577; P = 0.040). Gp96-negative cases had more metastatic lymph nodes than did negative cases, especially in T1 cases (4.8 in gp96-negative cases vs. 0.84 in gp96-positive cases; P = 0.064)

Conclusions

The downregulation of gp96 expression is closely correlated with poor survival in esophageal squamous cell carcinoma.     

Melanoma Patients with an Unknown Primary Tumor Site Have a Better Outcome than Those with a Known Primary Following Therapeutic Lymph Node Dissection for Macroscopic (Clinically Palpable) Nodal Disease

Background

Several reports in the literature suggest a difference in outcome between melanoma patients with macroscopic (clinically palpable) nodal disease from an unknown primary (MUP) and a known primary (MKP). The purpose of this study was to compare the outcomes for MUP and MKP patients after therapeutic lymph node dissection (TLND) for macroscopic nodal disease.

Methods

From a large, prospective, single-institution database, the details of melanoma patients who first presented with macroscopic nodal disease and underwent TLND between 1971 and 2010 were extracted and analyzed.

Results

There were 287 MUP patients and 264 MKP patients who fulfilled the study selection criteria. MUP patients had better disease-free, distant metastasis-free, and melanoma-specific survival after their TLND than MKP patients (all p < 0.001). Extranodal melanoma extension, >3 positive lymph nodes, and administration of adjuvant radiotherapy were all independent predictors of reduced disease-free and melanoma-specific survival (all p < 0.05). MUP patients also had a better prognosis than MKP patients whose primary melanoma had regression (p = 0.001).

Conclusions

The occurrence and improved outcome of MUP patients may be due to immune-induced total regression of the primary tumor and better immunologic prevention or control of distant metastatic disease. Alternatively, in some MUP patients, melanoma may not be metastatic but may originate de novo from nevus cells in lymph nodes, with the more favorable prognosis attributable to their primary nodal origin and complete surgical resection.     

A Collision of Diseases: Chronic Lymphocytic Leukemia Discovered During Lymph Node Biopsy for Melanoma

Background

In the United States in 2012, there were 16,060 new cases of chronic lymphocytic leukemia (CLL). Often CLL is clinically occult and first detected during pathologic evaluation of the sentinel lymph node biopsy (SLNB). We reviewed our experience of patients with the coexisting diagnosis of melanoma and CLL.

Methods

An institutional review board-approved review was performed on patients with CLL and melanoma treated from 1995 to 2009 at Moffitt Cancer Center and compared with the incidence of melanoma and CLL in our tumor registry patients with breast, prostate, lung, and colon cancer.

Results

Fifty-two patients (44 males; median age, 71 years [range, 46–88]) were identified with concurrent diagnoses of melanoma and CLL. Twenty-two patients (42 %) had CLL on SLNB for their melanoma. Thirty-two patients (62 %) were diagnosed with melanoma before CLL. Concomitant or prior cancer diagnoses included nonmelanoma skin cancers (N = 29), prostate (N = 6), colorectal (N = 2), and Merkel cell carcinoma (N = 2). Five of 20 patients (25 %) had metastatic melanoma found at the time of SLNB. Patients with melanoma had a tenfold increase of CLL diagnosis compared with colorectal cancer patients, an eightfold increase compared to prostate cancer patients, and a fourfold increase compared with breast cancer patients.

Conclusions

We have confirmed an increased association of CLL and melanoma. This may be related to an underlying immunologic defect; however, there has been scant investigation into this phenomenon. Surgeons and pathologists should understand this occurrence and recognize that not all grossly enlarged or abnormal sentinel lymph nodes in melanoma patients represent melanoma.     

Mesenteric Lymph Node Involvement in Advanced Ovarian Cancer Patients Undergoing Rectosigmoid Resection: Prognostic Role and Clinical Considerations

Background

The aim of this retrospective study was to investigate the incidence of mesenteric lymph node (MLN) involvement, and its prognostic role in advanced ovarian cancer (OC).

Methods

OC patients undergoing rectosigmoid resection during primary debulking surgery or interval debulking surgery were recorded. Progression-free survival (PFS) and overall survival were calculated from the date of diagnosis to the date of relapse/progression, death of disease, or the date of last follow-up.

Results

MLNs were detected in 102/148 cases (68.9 %); the rate of MLN involvement was 47.0 %. The percentage of metastatic MLNs was higher in cases with >5 MLNs removed compared with cases with ≤5 MLNs removed (62.7 % vs. 31.3 %; p = 0.0027). A progressive increase in the rate of metastatic MLNs was documented in association with depth of bowel infiltration (p = 0.026). Cases with metastatic MLNs experienced isolated celiac trunk or aortic lymph node recurrences more frequently than patients without MLN involvement (44.8 % vs. 10.7 %; p = 0.0008). PFS did not differ between cases with positive versus negative MLN involvement (2-year PFS = 31 % vs. 43 %; p = 0.58).

Conclusion

OC patients undergoing rectosigmoid resection showed metastatic MLN involvement in 47.0 % of cases. Metastatic MLN status is associated with a high rate of isolated aortic and celiac trunk lymph node recurrences.     

Sentinel Node Dissection Delays Recurrence and Prolongs Melanoma-Related Survival: An Analysis of 673 Patients from a Single Center with Long-Term Follow-Up

Background

The status of the sentinel lymph node is an important predictor for survival in melanoma patients, but it is still unclear if early removal of micrometastases by sentinel lymph node dissection (SLND) alters survival. A large series of melanoma patients from a single center with long-term follow-up was analyzed with regard to a possible effect of SLND on the prognosis.

Materials and Methods

A total of 673 consecutive melanoma patients were assessed treated in our center either without SLND (377 patients, pre-SLN group, between January 1995 and March 2000) or with SLND (296 patients, SLN group, between April 2000 and March 2003). The median follow-up was 64.0 months in the pre-SLN and 72.5 months in the SLN group.

Results

The pre-SLN group and SLN group did not differ significantly with regard to characteristics of the primary melanoma thickness and ulceration, sex, and age. Kaplan–Meier analyses showed a significantly better recurrence-free survival (P < .001), distant metastases free survival (P = .006), and overall survival (P = .049) for patients of the SLN group; the 5-year melanoma-specific survival rates were 80.3% in pre-SLN patients and 84.8% in SLN patients. Initial metastases in the in-transit region and distant locations were of similar frequency in the pre-SLN and SLN groups (P = .191 and P = .959, respectively), but initial regional lymph node metastases were significantly more frequent in the pre-SLN group (P < .001).

Conclusions

Our data point toward a subgroup of melanoma patients who might have a prognostic benefit from SLN.     

Patterns of Recurrence and Survival After Lymphadenectomy in Melanoma Patients: Clarifying the Effects of Timing of Surgery and Lymph Node Tumor Burden

Background

Melanoma patients with lymph node (LN) metastases have variable survival after lymphadenectomy. This study investigates whether lymphadenectomy at different times in the course of disease progression influences disease-free survival (DFS; time from primary diagnosis to first recurrence after lymphadenectomy), post recurrence survival (PRS; time from first recurrence after lymphadenectomy to death), and overall survival (OS; time from diagnosis to death).

Methods

Between 1992 and 2010, a total of 1,704 patients underwent lymphadenectomy; 502 underwent immediate completion lymphadenectomy (ICL) after positive sentinel node biopsy (SNB), 214 had delayed completion lymphadenectomy (DCL) for regional recurrence after positive SNB with no ICL or after an earlier false-negative SNB, 709 had no SNB and later required delayed therapeutic lymphadenectomy (DTL) for clinically evident metastasis, and 279 had immediate therapeutic lymphadenectomy (ITL) for clinically positive LNs at primary melanoma diagnosis.

Results

Median DFS for ICL, DCL, DTL, and ITL was 68, 48, 82, and 16 months, respectively (p < 0.001). Median PRS for ICL, DCL, DTL, and ITL was 14, 8, 9, and 9 months, respectively (p < 0.001). Median OS for ICL was not reached whilst for DCL, DTL, and ITL it was 71, 101, and 29 months, respectively (p < 0.001). Extranodal spread and tumor, node, metastasis classification system N stage were the only significant prognostic factors for OS within each group. ICL patients had significantly improved DFS (p = 0.005) and OS (p = 0.012) beyond 5 years compared to DTL patients.

Conclusions

Variable outcomes after lymphadenectomy were observed with different timing of surgery and LN tumor burden. ICL patients had the best outcome.     

Predictors of septic shock in obstructive acute pyelonephritis

Purpose

Acute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi.

Methods

We retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was performed for empirical treatment in cases of failure of initial treatment and for severe cases. We assessed the risk factors for septic shock by multivariate logistic regression analysis.

Results

Overall, 45 patients (65.2 %) underwent emergency drainage and 23 (33.3 %) patients showed septic shock. Poor performance status and the presence of diabetes mellitus (DM) in the septic shock group were more common than in the non-septic shock group (p = 0.012 and p = 0.011, respectively). The platelet count and serum albumin level in the septic shock group were significantly lower than in the non-septic shock group (p = 0.002 and p = 0.003, respectively). Positive rates of midstream urine culture and blood culture in the septic shock group were significantly higher than in the non-septic shock group (p = 0.022 and p = 0.001, respectively). Multivariate analysis showed that decreases in the platelet count (OR 5.43, p = 0.014) and serum albumin level (OR 5.88, p = 0.023) were independent risk factors for septic shock.

Conclusion

Patients with obstructive APN associated with upper urinary tract calculi who have decreases in platelet count and serum albumin level should be treated with caution against the development of septic shock.     

Diagnosis, Management, and Outcome of Patients with Dedifferentiated Liposarcoma Systemic Metastasis

Background

Dedifferentiated liposarcomas (DDLPSs) result in worse patient outcomes than well-differentiated tumors despite shared molecular derangements. Prevalence and pattern of DDLPS systemic metastases have not been extensively reported; information regarding diagnosis, treatment, and outcomes of metastatic DDLPS patients is limited. Our study seeks to address this knowledge gap.

Methods

Metastatic patients were identified from a clinical database consisting of 277 DDLPS patients treated at the University of Texas M D Anderson Cancer Center (UTMDACC) (1993–2010). Only patients with radiologically demonstrable distant metastases were included. Patient, tumor, treatment, and outcome variables were recorded. Available imaging studies and tumor FFPE blocks were assessed.

Results

A total of 40 patients were identified, translating into a DDLPS metastatic rate of 14% (17% for de novo DDLPS and 9% for secondary dedifferentiation). The average patient age was 61 years with a male predilection. The retroperitoneum and lungs were the most common primary and metastatic tumor sites. Any of the 4 described DDLPS morphological subtypes harbored metastatic potential; MFH/UPS-like morphology was the most common. The median time from primary diagnosis to metastasis was 25 months; more than 50% of metastases developed without local failure. The median survival of metastatic patients was 11.5 months; the 5-year DSS was 5.2%. Patients amenable to complete surgical extirpation (n = 14) faired significantly better (P = .001; log rank).

Conclusions

Metastatic spread is an ominous consequence of DDLPS, especially regarding de novo tumors. Occurring relatively early in the course of disease and exhibiting a pulmonary predilection, these lesions are highly aggressive and commonly fatal. Further studies to identify metastatic biomarkers are needed.     

Postchemoradiation Resected Locally Advanced Esophageal and Gastroesophageal Junction Carcinoma: Long-Term Outcome With or Without Intraoperative Radiotherapy

Background

To report feasibility, tolerance, anatomical topography of locoregional recurrence (LRR), and long-term outcome for esophageal and esophagogastric (EG) cancer patients treated with preoperative chemoradiation (CRT) and surgery with or without a radiation boost of intraoperative electron beam radiotherapy (IOERT).

Methods

From January 1995 to December 2010, 53 patients with primary esophageal (n = 26; 44 %) or EG carcinoma (n = 30; 56 %), and disease confined to locoregional area [clinical stage: IIb (n = 30; 57 %), IIIa (n = 14; 26 %), IIIb (n = 6; 11 %), IIIc (n = 3; 6 %)], were treated with preoperative CRT, curative (R0) resection with an extended (two-field) lymph node dissection in all cases. Thirty-seven patients also received a preanastomotic reconstruction IOERT boost (applicator diameter size 6–9 cm, dose 10–15 Gy, beam energy 6–15 MeV) over the tumor bed in the mediastinum and upper abdominal lymph node area.

Results

With a median follow-up time of 27.9 months (range, 0.2–148), LRR rate was 15 % (n = 8). Five-year overall survival (OS) and disease-free survival was 48 and 36 %, respectively. Univariate log-rank analyses showed that receiving IOERT was associated with lower risk of LRR (p = 0.004). On multivariate analysis, only the IOERT group retained significance in relation to LRR (odds ratio, 0.08; 95 % confidence interval, 0.01–0.48; p = 0.01). Postoperative mortality and perioperative complications were 11 % (n = 6) and 30 % (n = 16).

Conclusions

Local control is high in the radiation-boosted area, but OS remains modest, given the high risk of distant metastases. Intensified locoregional treatment needs to be tested in the context of more efficient concurrent, neo-, and adjuvant systemic therapy.     

Surgical Endoscopic Vacuum Therapy for Defects of the Upper Gastrointestinal Tract

Introduction

Intraluminal therapy used in the gastrointestinal (GI) tract was first shown for anastomotic leaks after rectal resection. Since a few years vacuum sponge therapy is increasingly being recognized as a new promising method for repairing upper GI defects of different etiology. The principles of vacuum-assisted closure (VAC) therapy remain the same no matter of localization: Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema. At the same time, perfusion and granulation is promoted. However, data for endoscopic vacuum therapy (EVT) of the upper intestinal tract are still scarce and consist of only a few case reports and small series with low number of patients.

Objectives

Here, we present a single center experience of EVT for substantial wall defects in the upper GI tract.

Methods

Retrospective single-center analysis of EVT for various defects of the upper GI tract over a time period of 4 years (2011–2015) with a mean follow-up of 17 (2–45) months was used. If necessary, initial endoscopic sponge placement was performed in combination with open surgical revision.

Results

In total, 126 polyurethane sponges were placed in upper gastrointestinal defects of 21 patients with a median age of 72 years (range, 49–80). Most frequent indication for EVT was anastomotic leakage after esophageal or gastric resection (n?=?11) and iatrogenic esophageal perforation (n?=?8). The median number of sponge insertions was five (range, 1–14) with a mean changing interval of 3 days (range, 2–4). Median time of therapy was 15 days (range, 3–46). EVT in combination with surgery took place in nine of 21 patients (43 %). A successful vacuum therapy for upper intestinal defects with local control of the septic focus was achieved in 19 of 21 patients (90.5 %).

Conclusion

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. In this series, EVT was combined with operative revision in a relevant proportion of patients.

     

Outcome of Negative-Pressure Wound Therapy for Open Abdomen Treatment After Nontraumatic Lower Gastrointestinal Surgery: Analysis of Factors Affecting Delayed Fascial Closure in 101 Patients

Background

Few studies have focused on the risk factors for failure to achieve fascial closure after use of negative-pressure wound therapy (NPWT) in an open abdomen (OA). We aimed at analyzing possible risk factors for failure of fascial closure and the risk of fistulas after nontrauma lower gastrointestinal (GI) tract surgery treated with OA.

Methods

This retrospective study included 101 nontrauma patients treated with OA from 2007 to 2011. Multivariate analyses of risk factors were performed.

Results

Indications for OA were diffuse peritonitis (n = 47), need for second look (n = 26), failure to achieve fascial closure (e.g., bowel edema) at primary laparotomy (n = 24), and fascial necrosis (n = 4). Of the 101 patients, 61 (60 %) were alive at discharge, with one death possibly related to OA (fistula from an iatrogenic perforation). Delayed fascial closure was obtained in 40 (66 %) of the surviving patients, with 80 % when the indications for OA was need for second look and 72 % in cases of diffuse peritonitis. Compared with need for second look [hazard ratio (HR = 1), 95 % CI], proportional HR for failure of delayed fascial closure were peritonitis 1.96 (1.10–3.49) and failure to achieve fascial closure at primary laparotomy 4.70 (2.17–10.2). In the presence of a stoma the HR was 2.02 (1.13–3.63).

Conclusions

OA using NPWT seems to be a safe procedure, with few procedure-related complications. Failure of fascial closure is related to the indication of OA and the presence of a stoma. Prospective multicenter studies are needed to establish which patients with lower GI surgery benefit from OA.     

The use of a ureteral access sheath does not improve stone-free rate after ureteroscopy for upper urinary tract stones

Purpose

To evaluate the impact of a ureteral access sheath (UAS) on stone-free (SF) rate after flexible ureteroscopy for upper urinary tract stones.

Materials and methods

We retrospectively reviewed 280 patients who underwent flexible ureteroscopy (URS) for upper urinary tract stone between 2009 and 2012. Patients were divided into two groups based on whether a UAS was used (n = 157) or not (n = 123). SF rate was evaluated at one and three months after surgery by abdominal imaging. Quantitative and qualitative variables were compared with Student’s t test and χ2 test, respectively. A logistic regression model was used to determine the predictive factors of SF status.

Results

Stone size was similar in both groups (15.1 vs. 13.7 mm, p = 0.21). SF rates at one and 3 months were comparable in UAS and non-UAS groups (76 vs. 78 % and 86 vs. 87 %, p = 0.88 and 0.89, respectively). Complication rates were similar in both groups (12.7 vs. 12.1 %, p = 0.78). In multivariable analysis, stone size was the only predictive factor of SF rate (p = 0.016).

Conclusion

The routine use of a UAS did not improve SF rate in patients undergoing flexible URS for upper urinary tract calculi.     

Reproducibility of AJCC Staging Parameters in Primary Cutaneous Melanoma: An Analysis of 4,924 Cases

Background

Pathology reports are of critical importance for conveying information to clinicians who must make important management decisions for their patients. This study sought to assess and compare the precision, reproducibility, and completeness of external pathology reports and pathology reports generated by central review of each case in a large cohort of primary cutaneous melanoma patients.

Methods

Details of matched external pathology reports and corresponding review reports for 4,924 primary cutaneous invasive melanomas diagnosed and treated at Melanoma Institute Australia (MIA) between 2001 and 2011 were analyzed.

Results

Interobserver agreement was excellent for American Joint Committee on Cancer (AJCC) T staging parameters: Breslow thickness (intraclass correlation coefficient [ICC] 0.984), mitotic rate (ICC 0.833), and ulceration (kappa statistic [κ] 0.823). All three of these important pathologic variables were included in 92.4 and 66.9 % of review (MIA) and external (non-MIA) pathology reports, respectively. Completeness of MIA and non-MIA pathology reports for the three essential T-staging criteria increased significantly from 87.9 to 94.6 % (χ ² = 9.1, df = 1, P = 0.003) and from 53.2 to 74.3 % (χ ² = 35.0, df = 1, P < 0.001) over the 10-year study period. The AJCC N staging parameter of microsatellites was recorded in only 43 % of non-MIA reports and demonstrated moderate concordance (κ = 0.560).

Conclusions

Reproducibility and completeness of pathology reports for many important histopathologic features have improved in recent years. Nevertheless, the documentation of microsatellites remained poor in external pathology reports. To enhance the usefulness of the pathology report for the provision of optimal melanoma patient care, continued efforts to encourage pathologists to document its key features appear warranted.     

S-100B: A Stronger Prognostic Biomarker than LDH in Stage IIIB–C Melanoma

Background

In melanoma patients with nodal macrometastases, the distinction between good and poor prognosis is based on the presence of primary melanoma ulceration or metastatic involvement of 4 or more lymph nodes in the 7th edition of the American Joint Committee on Cancer (AJCC) classification. We hypothesized that biomarkers would increase the accurateness of staging in these patients. The aim was to assess and compare the prognostic impact of biomarkers S-100B and LDH and to determine the best timing of their measurement in stage IIIB–C melanoma.

Methods

A total of 119 patients underwent therapeutic lymph node dissection (TLND) for nodal macrometastases with serum S-100B and LDH level measurements preoperatively. In 75 of them, S-100B and LDH were also measured on postoperative days 1 and 2. S-100B and LDH levels on days 0, 1, and 2 were compared for their association with disease-free survival (DFS) and disease-specific survival (DSS).

Results

At a median follow-up of 17 (range 1–89) months, S-100B levels at all time points were associated with DFS. In multivariable analysis, preoperative S-100B and S-100B measured on day 2 showed the strongest association with DFS (hazard ratio [HR] 2.55, P = 0.007 and HR 3.80, P = 0.01). For DSS, the preoperative S-100B level was the strongest independent predictor (HR 2.81, P = 0.01). LDH measurements showed a significant association with DSS in univariate analysis only when measured preoperatively (HR 2.46, P = 0.01). In multivariable analysis, LDH measurement was not associated with melanoma prognosis.

Conclusions

The S-100B level measured preoperatively is, in contrast to LDH, one of the most important independent predictors of melanoma prognosis in patients undergoing TLND for nodal macrometastases.     

Surgical Resection of Hypopharynx and Cervical Esophageal Cancer with a History of Esophagectomy for Thoracic Esophageal Cancer

Background

Cancer of the hypopharynx and cervical esophagus (PhCe cancer) frequently develops synchronously or metachronously with esophageal cancer. The surgical approach is usually difficult, especially in metachronous PhCe cancer after esophagectomy. The purpose of this study was to clarify the treatment outcomes of patients with metachronous PhCe cancer with a history of esophagectomy.

Methods

The subjects evaluated in this study were 14 patients with metachronous PhCe cancer who underwent pharyngo-laryngo-esophagectomy after subtotal esophagectomy and gastric tube pull-up for primary esophageal cancer.

Results

Definitive chemoradiotherapy (CRT; radiation dose >50 Gy) was performed for primary laryngeal (n = 1), pharyngeal (n = 2), esophageal (n = 1), and recurrent esophageal cancer (n = 2). For seven patients with metachronous PhCe cancer, induction CRT (radiation dose <40 Gy) was performed. In all 14 patients, pharyngo-laryngo-esophagectomy was followed by free jejunal graft interposition with reconstruction of the jejunal vessels. Although postoperative complications developed in four patients, no perioperative death or necrosis of the reconstructed free jejunum occurred. The 2- and 5-year overall survival rates were 84 and 50 %, respectively.

Conclusions

Pharyngo-laryngo-esophagectomy with free jejunal transfer is considered to be safe for metachronous PhCe cancer, even in patients with a history of CRT and esophagectomy.     

Metastatic Behavior of Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: Association with Primary Tumor Location

Purpose

To investigate the site-specific pattern of disease recurrence and/or metastasis and the associated patient outcomes after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC).

Methods

A total of 733 patients with UTUC from a retrospective multi-institutional cohort were included, with a median follow-up of 34 months. Associated patient outcomes were analyzed by multivariate analysis. To evaluate the influence of primary tumor location, we divided it into four areas: renal pelvis, and upper, middle, and lower ureter.

Results

A total of 218 patients experienced disease recurrence, with the majority of relapses occurring within the first 3 years. Cumulative incidence rates of first disease recurrence at 1 and 3 years were 18.9 and 29.8 %, respectively. Of these patients, 38.5 % developed distant recurrence; 17.4 % experienced both local and distant recurrences; and 44.0 % developed isolated local recurrence. The predominant sites of distant metastasis were lung, liver, and bone. Multivariate analysis revealed that the prevalence of local recurrence and lung metastasis was significantly associated, with primary tumor location being independent of other clinicopathological variables. Lower/middle ureter tumors had a higher rate of local recurrence in the pelvic cavity, and renal pelvic tumors had a higher prevalence of distant relapse in the lungs. Similar results were obtained when rerunning the data set by excluding patients who received adjuvant chemotherapy (n = 131).

Conclusions

This multi-institutional study provided a detailed picture of metastatic behavior after RNU, and primary tumor locations were associated with unique patterns of metastatic spread in UTUC patients.     

Prognostic Factors and Causes of Death in Patients Cured of Esophageal Cancer

Background

The number of patients cured of esophageal cancer after esophagectomy is gradually increasing owing to advances in surgical techniques, perioperative management, and adjuvant therapies. This study assessed the clinical course and sought to identify the prognostic factors of these patients.

Methods

A series of 220 consecutive patients who underwent esophagectomy and survived for more than 5 years with no relapse were enrolled. Survival analysis was performed using 25 variables including patient characteristics and operative and perioperative factors. Potential prognostic factors were identified by univariate and multivariate analyses, and the development of other primary cancers and the causes of death were retrospectively reviewed.

Results

The overall 10-, 15-, and 20-year survival rates were 71.6, 50.1, and 32.2 %, respectively, with a median survival time of 180 months (range, 61–315 months). The negative independent prognostic factors identified were age at surgery [hazard ratio (HR), 1.05; P < .01], being male (HR, 2.62; P = .02), pulmonary comorbidities (HR, 2.03; P = .02), synchronous presence of other cancers (HR, 2.35; P < .01), colonic/jejunal interposition (HR, 1.76; P = .03), perioperative blood transfusion (HR, 1.92; P = .02), development of pulmonary complications (HR, 1.71; P = .02), and adjuvant radiotherapy (HR, 2.13; P = .01). Pulmonary diseases and other primary cancers were found to be the most common causes of death.

Conclusions

Careful follow-up including the surveillance of other primary cancers is required for long-term survivors of esophageal cancer after esophagectomy.