What is the role of the (1→3)‐β‐d‐glucan assay in the screening of patients undergoing autologous haematopoietic stem‐cell transplantation?

The aim of this study is to determine the clinical contribution of (1→3)‐β‐d ‐glucan (BDG) screening in the case of patients undergoing autologous haematopoietic stem‐cell transplantation (HSCT). The records at our stem‐cell transplantation centre were reviewed to identify the patients who underwent autologous HSCT between April 2009 and December 2010. Patients were classified as having proven invasive aspergillosis (IA), probable IA, or possible IA on the basis of the criteria established by the European Organization for Research and Treatment of Cancer and Mycoses Study Group (independent of the BDG results). During the study period, the patients were screened for BDG twice a week from transplant (day 0) until engraftment. Three patients were diagnosed with probable IA and five were diagnosed with possible IA. A total of 354 serum samples from79 patients who met the study inclusion criteria were used for statistical analysis. At the cut‐off value of 80 pg ml^?1, the sensitivity was 27.2% [95% confidence interval (CI); 7.3–60.6]; specificity, 94.4% (95% CI; 91.3–96.5); positive predictive value, 6.2%; and negative predictive, 93.7%. The clinical contribution of the BDG assay as a screening test was relatively limited in this cohort of patients undergoing autologous HSCT.     

Should the splenic hilar lymph node be dissected for the management of adenocarcinoma of the esophagogastric junction?

BackgroundSplenic hilar lymphadenectomy is not recommended for advanced proximal gastric cancer that does not invade the greater curvature according to the results of the previous studies. The efficacy of splenic hilar lymphadenectomy for type II and type III adenocarcinomas of the esophagogastric junction and easy spread to the greater curvature of the stomach remains unclear. This study aimed to investigate the efficacy of splenic hilar lymphadenectomy and identify the risk factors for metastasis to splenic hilar nodes.MethodsWe examined patients who underwent R0/1 gastrectomy for Siewert types II and III at a single high–volume center in Japan. We analyzed the metastatic incidence, therapeutic value index, and risk factors for splenic hilar lymph node metastasis.ResultsWe examined 126 patients (74, type II; 52, type III). Splenectomy was performed in 76 patients. Metastatic incidence and the therapeutic value index of splenic hilar lymph nodes in patients with type II and type III tumors were 4.5% and 0, and 21.9% and 9.4, respectively. In the patients who underwent splenectomy, we identified Siewert type III tumors (odds ratio: 6.93, 95% confidence interval: 1.24–38.8, p = 0.027) and tumor location other than the lesser curvature (odds ratio: 7.36, 95% confidence interval: 1.32–41.1, p = 0.023) to be independent risk factors. The metastatic incidence (46.2%) and therapeutic value index (15.4) were high in patients with both risk factors.ConclusionsSplenic hilar lymphadenectomy may contribute to the survival of patients with Siewert type III tumors, especially when the predominant location is not the lesser curvature.     

‘I know they are distressed. What do I do now?’

Significant advances have been made in our understanding of psychological adjustment to cancer over the last 40 years. Most clinicians now recognise the importance of psychosocial factors and the need for skills in emotional support. In the first phase of psycho‐oncology, pioneering work in the 1970s and 1980s mapped the extent of psychological morbidity in cancer. This has been followed by a second phase where clinical trials have demonstrated that psychological treatments are effective. But although clinicians may feel more confident in identifying distress and listening to the patient, they rarely feel confident that they possess the skills to help. This paper will review the progress through the first two phases and argue that we are now in the third phase where we can begin to examine methods for delivering cost‐effective psychological care. One of these methods is to equip staff with basic skills to understand and manage psychological distress. This paper will also describe a programme over the last 10 years to evaluate the effectiveness and clinical impact of such training for palliative care professionals. Copyright © 2013 John Wiley & Sons, Ltd.     

Evaluation of Siewert classification in gastro‐esophageal junction adenocarcinoma: What is the role of endoscopic ultrasonography?

BACKGROUND: Preoperative assessment of gastro-esophageal junction (GEJ) adenocarcinoma stage and its location according to Siewert are essential for planning the therapeutic approach. The present study was aimed at analyzing the utility of endoscopic ultrasonography (EUS) in evaluating GEJ adenocarcinoma stage and whether this modality added to EGD improves assessment of Siewert type. METHODS: The results of 51 patients studied by EGD plus EUS (EGD/EUS group) were compared with the results of 54 patients studied by EGD only (EGD group). RESULTS: A differentiation of pT1 tumors was attempted by measurement of the tumor length using 4 cm as a criterion. This goal was not achieved because of a high rate of advanced tumors less than 4 cm (sensitivity and specificity were 81.3% and 34.2%, respectively). Conversely EUS ability in pT1 assessment was very reliable (92%). The accuracy in defining the Siewert type was 72.5% and 64.8% for EGD/EUS and EGD groups, respectively (P = 0.394). Some difficulties in distinguishing between type II and III tumors were observed in both groups with an extremely low specificity (44%) in classifying type II tumors by EGD group. CONCLUSIONS: EUS seems to be essential in differentiating pT1 from advanced tumors. It shows an accuracy in defining the Siewert type of 72.5%, with some difficulties in distinguishing from type II and III tumors.     

Is resection of colorectal liver metastases after a second‐line chemotherapy regimen justified?

BACKGROUND:

Patient outcomes following resection of colorectal liver metastases (CLM) after second‐line chemotherapy regimen is unknown.

METHODS:

From August 1998 to June 2009, data from 1099 patients with CLM were collected prospectively. We retrospectively analyzed outcomes of patients who underwent resection of CLM after second‐line (2 or more) chemotherapy regimens.

RESULTS:

Sixty patients underwent resection of CLM after 2 or more chemotherapy regimens. Patients had advanced CLM (mean number of CLM ± standard deviation, 4 ± 3.5; mean maximum size of CLM, 5 ± 3.2 cm) and had received 17 ± 8 cycles of preoperative chemotherapy. In 54 (90%) patients, the switch from the first regimen to another regimen was motivated by tumor progression or suboptimal radiographic response. All patients received irinotecan or oxaliplatin, and the majority (42/60 [70%]) received a monoclonal antibody (bevacizumab or cetuximab) as part of the last preoperative regimen. Postoperative morbidity and mortality rates were 33% and 3%, respectively. At a median follow‐up of 32 months, 1‐year, 3‐year, and 5‐year overall survival rates were 83%, 41%, and 22%, respectively. Median chemotherapy‐free survival after resection or completion of additional chemotherapy administered after resection was 9 months (95% confidence interval, 4‐14 months). Synchronous (vs metachronous) CLM and minor (vs major) pathologic response were independently associated with worse survival.

CONCLUSIONS:

Resection of CLM after a second‐line chemotherapy regimen was found to be safe and was associated with a modest hope for definitive cure. This approach represents a viable option in patients with advanced CLM. Cancer 2011;. © 2011 American Cancer Society.     

What to do for the incidental pancreatic cystic lesion?

BackgroundIncidental pancreatic cysts are identified in 1% of all patients undergoing CT scans of the abdomen for whatever reason. The aim of this review was to provide an overview of the current evidence relating to the investigation and management of these lesions.MethodsPubMed was searched to identify relevant studies relating to the investigation and management of incidentally discovered pancreatic cystic lesions.ResultsInitial investigation of incidentally discovered pancreatic cysts should be with either specific pancreas protocol CT or contrast enhanced MRI with MRCP. The diagnostic yield of these investigations can be increased with the addition of EUS/FNA and cyst fluid analysis in appropriately selected patients. Surgical intervention may be indicated in otherwise fit patients who are identified as having mucinous neoplasms.ConclusionApplying a systematic approach to the investigation of incidentally discovered pancreatic cysts means that in the majority of cases cyst aetiology can be accurately determined and appropriate management plans developed.     

What to do with IL-2?

It has been 15 years since the first positive clinical reports of Interleukin-2 (IL-2) appeared in the medical literature, ten years since moderate dose continuous infusion IL-2 was approved in Europe, and five years since high-dose bolus IL-2 was approved for general use in the United States. IL-2 is accepted as a standard treatment used alone, or in combination with chemotherapy or biotherapy in the management of metastatic melanoma and metastatic renal cell carcinoma. Various physicians utilize high-dose bolus IL-2, moderate-dose continuous infusion IL-2, and low-dose outpatient intravenous or subcutaneous IL-2. There is still no consensus regarding the best way to deliver IL-2 alone in terms of dose and schedule of administration from a risk-to-benefit standpoint. Despite yielding higher tumor response rates, regimens that combine IL-2 with chemotherapy and/or interferon have not produced better long-term survival.     

What is the meaning of palliative care in the Asia‐Pacific region?

This paper describes the preliminary work required to understand cultural differences in palliative care in the United Kingdom and three countries in the Asia-Pacific region, in preparation for a cross-country study. The study is intended to address cultural understandings of palliative care, the role of the family in end of life care, what constitutes good care and the ethical issues in each country. Suggestions are then made to shape the scope of the study and to be considered as outcomes to improve care of the dying in these countries. It is anticipated that the method used to achieve consensus on cross-country palliative care issues will be both qualitative and quantitative. Identifying key priorities in the delivery and quality measures of palliative care will involve participants in focus groups, a Delphi survey and in the development of clinical indicators towards creating standards of palliative care common to the Asian Pacific region.