Pathologic classification and clinical behavior of the spectrum of goblet cell carcinoid tumors of the appendix

Appendiceal tumors exhibiting both neuroendocrine and glandular differentiation are uncommon and have caused difficulty in pathologic classification, prediction of prognosis, and clinical management. Previously, such lesions have been variously designated as adenocarcinoid, goblet cell carcinoid (GCC), and mixed adenocarcinoma carcinoid. In this study, we undertook a retrospective investigation of 63 such cases and classified them as typical GCC (group A) and adenocarcinoma ex GCC on the basis of the histologic features of the tumor at the primary site. The adenocarcinoma ex GCC group was further divided into signet ring cell type (group B) and poorly differentiated adenocarcinoma type (group C). The clinical characteristics and prognosis were compared within these groups and with conventional de novo appendiceal adenocarcinomas. Both groups A and B tumors shared a similar immunoprofile, which included generally focal immunoreactivity for neuroendocrine markers, and a normal intestinal type mucin glycoprotein profile (negative MUC1 expression and preserved MUC2 immunoreactivity). The proliferative index was relatively low in these tumors and slightly increased from groups A to B tumors (11% to 16%). Both beta-catenin and E-cadherin exhibited a normal membranous staining pattern in groups A and B tumors. The poorly differentiated adenocarcinomas ex GCC (group C) demonstrated abnormal p53 and beta-catenin immunoreactivity. The mean follow-up time was 49+/-5 (SE) months. The overall disease-specific survival for all subtypes was 77%, with 46% of patients without evidence of disease and 31% alive with disease. The mean survival was 43+/-7 months. All the patients with clinical stage of I or IIA disease had a favorable outcome after appropriate surgery with or without chemotherapy. Although most patients (63%) with GCC presented at an advanced clinical stage, their clinical outcome could be differentiated by subclassification of tumors. The stage IV-matched 5-year survival was 100%, 38%, and 0% for groups A, B, and C, respectively. In conclusion, GCC is a distinctive appendiceal neoplasm that exhibits unique pathologic features and clinical behavior. They display a spectrum of histologic features and possess the potential to transform to an adenocarcinoma phenotype of either signet ring cell or poorly differentiated adenocarcinoma types. Careful evaluation of the morphologic features of GCCs and appropriate pathologic classification are crucial for clinical management and prediction of outcome. Surgical management with right hemicolectomy is recommended after appendectomy for most cases, particularly those with an adenocarcinoma component (groups B and C).     

Multimodality Treatment of Thymoma: A Prospective Study

Background. Thymomas are a heterogeneous group of tumors. Treatment of invasive lesions is not well standardized. The aim of this study is to propose a clinicopathologically based protocol for multimodality therapy.

Methods. Between 1965 and 1988, we operated on 83 patients with thymoma who did not receive standardized adjuvant therapy. In 1989, on the basis of the retrospective analysis of the data, we started a multimodality therapy protocol and used it for 65 patients. Twelve patients had medullary thymoma (11 stage I and 1 stage II), 13 had mixed type (6 stage I and 7 stage II), and 40 had cortical thymoma (4 stage I, 11 stage II, 12 stage III, and 13 stage IV). We considered three groups. Group I (n = 18 patients), benign thymoma, included stage I and II medullary and stage I mixed thymomas; radical resection with no adjuvant therapy was performed. Group II (n = 22), invasive thymoma, included stage I and II cortical and stage II mixed thymomas; postoperative chemotherapy plus radiotherapy was always administered. Group III (n = 25), malignant thymoma, comprised stage III and IV cortical thymomas and stage III mixed thymomas; resectable stage III lesions were removed, and highly invasive stage III and stage IV lesions underwent biopsy, neoadjuvant chemotherapy, and surgical resection; postoperative chemotherapy and radiotherapy was administered to all patients.

Results. The 8-year survival rate for patients in stages I, II, III, and IV was 95%, 100%, 92%, and 68%, respectively. Patients with medullary thymoma had a 92% 8-year survival rate; those with mixed type, 100%; and those with cortical thymoma, 85%. Group I had an 8-year survival rate of 94%; group II, 100%; and group III, 76%. Survival was compared with that of patients operated on before 1989: differences were not significant for group I; survival improved in group II (100% versus 81%; p = not significant); and group III showed significant improvement (76% versus 43%; p < 0.049).

Conclusions. Multimodality treatment with neoadjuvant chemotherapy and adjuvant chemotherapy plus radiotherapy may improve the results of radical resection and the survival of patients with invasive and malignant thymoma.     

Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma

OBJECTIVE: To determine the survival curves for laparoscopic resection (LR) of colorectal cancer. SUMMARY BACKGROUND DATA: Laparoscopic resection for cure of colorectal cancer is controversial, and survival curves have not been determined. METHODS: A prospective database of 177 consecutive LRs of colorectal cancers performed between November 1991 and 1997 was reviewed. The TNM classification (stage 0, I, II, III, and IV) for colorectal cancers and the Kaplan-Meier method were used to determine survival curves. RESULTS: Of the 177 patients, 5 were excluded for not having adenocarcinomas. Twenty-five patients (14.5%) had conversion to open surgery; most of these patients had rectal cancer or tumor invasion to adjacent organs. Twelve patients were lost to follow-up. All 135 remaining patients had follow-up. Overall, 28 deaths occurred during the follow-up period, 15 of which were cancer-related. The median follow-up was 24 months for patients with stage I, II, and III disease and 9 months for patients with stage IV disease. Observed 2-year survival rates were 100% stage I, 88.7% stage II, 80.6% stage III, and 28.6% stage IV. Survival rates at 4 years were 100% stage I, 79.5% stage II, 53.7% stage III, and 0% stage IV. No trocar site recurrence was observed. CONCLUSIONS: Early survival curves for patients with colorectal cancer who underwent LR do not differ negatively from historical controls for conventional surgery. Further validation is needed.     

Are transverse colon cancers suitable for laparoscopic resection?

Background The large randomized trials reporting on laparoscopic versus open colon surgery for cancer have all excluded patients with transverse colon cancer lesions. This study was undertaken to review our experience with surgery for curable transverse colon cancer. Methods A database of 938 laparoscopic colon resections performed between April 1991 and September 2004 was reviewed. Of 514 procedures for cancer, stage IV disease, mid to low rectal cancers, and total colectomies were excluded. On an intent-to-treat basis, outcomes of surgery for transverse colon lesions (TC) were compared with outcomes of segmental colon resections for other lesions (OC). Results A total of 22 TC were resected compared with 285 OC. Patients with TC were similar to patients with OC in age, gender, weight, and body mass index (BMI). Cancer stage was equivalent between patients with TC (9 Stage I, 7 Stage II, 6 Stage III) and OC (66 Stage I, 126 Stage II, 93 Stage III, p = 0.170) as was tumor size. Patients with TC underwent 9 transverse colectomies, 12 extended right hemicolectomies, and 1 extended left hemicolectomy. Patients with OC underwent 126 right hemicolectomies, 24 left hemicolectomies, and 135 sigmoid colectomies or anterior resections. There were no differences in conversion rate (18.2% vs. 13.3%, p = 0.752) or in intraoperative (9% vs. 8%, p = 0.814) or postoperative (41% vs. 30%, p = 0.418) complications. Operating time was longer with TC (209 ± 63 min vs. 176 ± 60 min, p = 0.042) and lymph node harvest was higher (15.3 ± 11.6 vs. 10.8 ± 7.6, p = 0.011). At a median followup of 17.2 months and 17.1 months, respectively, there were two (9%) recurrences after resection of TC and 17 (6%) recurrences after resection of OC. Conclusions Laparoscopic resection of transverse colon cancers is technically feasible and not associated with a significantly higher rate of complications or conversions or with impaired oncologic outcomes compared with patients having segmental laparoscopic resections for other colon cancers. Operating time is longer. Presented at the 13th International Congress of the European Association for Endoscopic Surgery, Venice, Italy, June 2–4, 2005     

Female and Male Differences in the Survival of Patients Undergoing Resection for Lung Cancer

Objective: In recent years much attention has been focused on the rapidly increasing incidence of primary lung cancer in women. The aim of this study was to determine gender differences in patients treated surgically for lung cancer.

Methods: We performed a retrospective review of patients who had lung resection for primary lung cancer from January 1994 to December 1998.

Results: There were 530 men and 42 women. Women were younger than men (55.6 ± 10 versus 57 ± 9.9). The difference was not statistically significant (p = 0.9). The mean cigarette consumption was greater in men than in women (p < 0.001). We observed a higher operative morbidity and mortality rate in men compared to women (p < 0.05). Men had more squamous cell carcinoma (61.7%). In female patients, squamous cell cancer and adenocarcinoma were found with almost the same incidence (35.7% versus 33.3%). There was a significant difference in the distribution of cell types (p < 0.001). Pathologic stages for women were; I = 38.2%, II = 21.4%, IIIa = 21.4%, IIIb = 9.5%, IV = 9.5% and for men; I = 40.4%, II = 26.6%, IIIa = 24%, IIIb = 6%, IV = 3%. There was no significant difference in the stage distribution between genders (p = 0.2). Median survival for female and male patients were 38 ± 9.2 and 35 ± 3.2 months. Female patients’ survival was longer than male patients but the difference was not statistically significant (p > 0.05). Conclusions: This study emphasizes sex differences in cigarette consumption, operative mortality and the distribution of cell types of patients with primary lung cancer. These initial results should strongly encourage additional studies in different countries on the interaction between sex and lung cancer characteristics to improve clarity.     

腹腔镜右半结肠切除术35例临床分析

目的:探讨腹腔镜右半结肠切除术治疗结肠癌的安全性与有效性。方法:回顾分析2002年2月至2004年12月行腹腔镜辅助右半结肠切除术35例患者的临床资料和随访情况,以研究其手术的安全性,术后康复情况及肿瘤的根治性效果。结果:术中未发生严重并发症和死亡病例,2例(5.7%)中转开腹,手术时间(155.14±35.79)min,术中出血(111.43±87.62)ml,辅助切口长(5.69±1.00)cm,患者排气时间(2.54±1.12)d,总住院时间(14.54±6.45)d。清扫淋巴结总数14(0~50)枚,其中结肠上、旁淋巴结4(0~21)枚,系膜间淋巴结5(0~18)枚,血管根部淋巴结3(0~35)枚,手术切除标本长度(20.73±7.14)cm,肺部感染、术后腹水、腹腔局部积液、乳糜漏各1例,余者未见术后并发症,患者均获随访,平均41个月(8~68个月),2例局部复发,3例术后发生肝转移,累计生存率为76.8%。结论:腹腔镜右半结肠切除术治疗右半结肠癌安全有效,符合肿瘤根治原则。     

Clinicopathological features and the outcome of surgical management for adenocarcinoma of the appendix

AIM:To present a comprehensive analysis of incidence,clinicopathological features,appropriateness of surgical procedures,and survival for adenocarcinoma of the appendix.METHODS:A retrospective case analysis was conducted for the 10-year period 1998-2008.All patients diagnosed with adenocarcinoma of the appendix were analyzed for their demographics details,clinical features,tumor incidence and characteristics,tumor stage,surgical procedures performed,and their survival.RESULTS:Nine thousand three hundred and twentythree patients underwent appendectomies during the study period,and of these,10 (0.1%:8 men and 2 women with a mean age of 53.1 years,age range 21-83 years) were found to have primary adenocarcinoma of the appendix.Appendicular neoplasia was not suspected pre-operatively in any of the patients.Six (60%) patients underwent secondary right hemicolectomy.Four (40%) cases had appendectomy alone,and two of them died,whereas all those who underwent right hemicolectomy are alive and disease free.Five (50%) were reported to have grade 1 disease,three (30%) grade 2,and two (20%) grade 3 with mean survival of 34,48,and 22 mo,respectively.Six (60%) patients presented with advanced disease (Duke’s C and D).At the end of follow up (mean period:37.9 mo),eight patients are alive and disease free at the end of follow up.Overall mean survival was 36.3 mo (conf idence interval;16%-56%) with 41.3 and 16 mo for men and women,respectively.Mean survival for those with and without lymph node involvement was 33.6 and 40.2 mo,respectively.Right hemicolectomy gave better results than appendectomy alone,although the difference was not statistically signif icant due to the small number of cases.CONCLUSION:Adenocarcinoma of the appendix is extremely rare neoplasm with varied presentations,and is usually advanced when diagnosed.Right hemicolectomy is the treatment of choice for such tumors.     

COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer

BACKGROUND: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. METHODS: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial that began in 1997. In 27 hospitals in Sweden, The Netherlands, Germany, France, Italy, Spain, and the United Kingdom, 1200 patients will be included. The primary endpoint of the study is cancer-free survival after 3 years. RESULTS: In <3.5 YEARS, >850 patients have been randomized for right hemicolectomy (47%), left hemicolectomy (11%), and sigmoidectomy (42%). Fifty seven patients were excluded after randomization. Forty six months after the start of the trial, the overall recurrence rate is 6.8%. The distribution of stage of disease is as follows: stage I, 25%; stage II, 41%; stage III, 32%; stage IV, 2%. CONCLUSION: Although laparoscopic surgery appears to be of value in the treatment of colorectal cancer, the final, results of randomized trials need to be considered to determine its definitive role. Given the current accrual rate, the COLOR study will be completed in 2002.     

Severity of illness scores and the outcome of acute tubular necrosis

The outcome of patients with acute renal failure (ARF)due to acute tubular necrosis (ATN) was evaluated inthis study. Two hundred and twenty-two patients witha mean age of 55.l ± 17.7 years (range 19–97years; male 153, female 69) who developed ATN in theperiod from July 1991 through January 1997 werestudied. Patients were divided into four groupsaccording to their APACHE II scores at the time of thediagnosis of ATN. Group I included patients with anAPACHE II score of 14 or less (n = 70), Group II with ascore of 15–18 (n = 52), Group III with a score of 19–23(n = 58), and group IV with a score of 24 or above(n = 42). The mean APACHE II score for each of the fourstudy groups was 11 ± 0.4, 16 ± 0.2, 20 ±0.2, and 29 ± 0.7, respectively. Patient survivalwas evaluated by the Kaplan-Meier analysis withcensorship at 12 months. Survival rates at 180 dayswere 67%, 47%, 39%, and zero%, for group I through IV respectively, χ² = 27.99, p < 0.0001,with a median survival of >365, 120, 31, and 11days, for groups I through IV, respectively. For patients with oliguria (n = 88) survival at 180days was 23% vs. 58% for patients without oliguria(n = 134), p < 0.0001, median survival 13 vs. 364 d.Six months survival of those who required dialysis(n = 79) was 25% vs. 58% for those whom dialysis wasnot needed (n = 143), p = 0.001, median survival 15 vs.364 d, respectively. In patients with sepsis (n = 58),6 months survival was 35% vs. 50% for those withoutsepsis (n = 164), p = 0.013, median survival 14 vs. 169 d. In patients who required mechanical ventilation(n = 72), 6 months survival was 17% vs. 62% for those whodid not need respiratory support (n = 150), p = 0.0001,median survival 13 vs. > 365 d, respectively. Finally, 6 months survival in patients with one(kidney only), two, three, and four organ failure was76, 30, 11, and zero percent, respectively, p = 0.0001,median survival > 365, 16, 11, and 12 days,respectively. We conclude that the use of the APACHE II score forthe stratification of the severity of illness could beof clinical utility in predicting mortality inpatients with ATN. Other predictors of poor prognosisinclude the need for dialysis, the presence ofoliguria, the need for mechanical ventilation, thepresence of sepsis, and the number of failed organs. This revised version was published online in August 2006 with corrections to the Cover Date.     

Prospective randomized trial of early postoperative intraperitoneal chemotherapy as an adjuvant to resectable gastric cancer.

OBJECTIVE: Surgeons have postulated on numerous occasions that cancer resection may participate in the dissemination of a malignancy. This randomized trial sought to determine whether a large volume of chemotherapy solution used perioperatively to flood the peritoneal cavity could eliminate microscopic residual disease and thereby improve survival of patients with gastric cancer. SUMMARY BACKGROUND DATA: Surgical treatment failures in patients with gastric cancer are confined to the abdomen in most patients. Resection site and peritoneal surface spread, along with liver metastases, are the most common areas of recurrence. Survival and quality of life of patients with gastric cancer would be improved if disease progression at these anatomic sites was reduced. METHODS: In a prospective randomized trial of 248 patients, intraperitoneal mitomycin C on day 1 and intraperitoneal 5-fluorouracil on days 2 through 5 were administered after gastric cancer resection. Patients who were thought to have stage II or stage III disease were randomized after resection to surgery alone versus surgery plus early postoperative intraperitoneal chemotherapy. After final pathologic examinations, there were 39 patients with stage I, 50 with stage II 95 with stage III, and 64 with resected stage IV cancer. RESULTS: The 5-year survival of the surgery-only group was 29.3%, and the surgery-plus-intraperitoneal chemotherapy group was 38.7% (p = 0.219). In a subset analysis, the patients with stage I, stage II, and stage IV disease showed no statistically significant difference in survival. The 5-year survival rate of patients with stage III disease who underwent surgery only was 18.4% versus a survival rate of 49.1% for patients who underwent surgery plus intraperitoneal chemotherapy (p = 0.011). CONCLUSIONS: In a subset analysis, patients with stage III gastric cancer have shown a statistically significant improvement in survival when treated with perioperative intraperitoneal chemotherapy. Further studies in patients with gastric cancer with surgically directed chemotherapy are suggested.     

Goblet cell carcinoids of the appendix: Tumor biology,mutations and management strategies

Malignant neoplasms of the appendix are rare and represent less than 1% of gastrointestinal cancers. Goblet cell carcinoids (GCC) tumors are a distinctive group of heterogeneous appendiceal neoplasm that exhibit unique clinical and pathologic features. This review focuses on the current diagnostic procedures, pathogenesis, possible signaling mechanisms and treatment options for GCC. Perspectives for future research are discussed. The tumor likely arises from pluripotent intestinal epithelial crypt base stem cells. Previous findings of Notch signaling as a tumor suppressor in Neuroendocrine tumors may have a similar role in this tumor too. Loss of Notch signaling may be the driver mutation with other successive downstream mutations likely favors them into progressing and behavior similar to poorly differentiated adenocarcinoma with minimal neuroendocrine differentiation. A multidisciplinary approach is suggested for optimal outcomes. Surgery remains the main treatment modality. Simple appendectomy may be sufficient in early stages while right hemicolectomy is recommended for advanced tumors. Cytoreductive surgery with heated intraperitoneal chemotherapy may improve survival in a select few with metastatic peritoneal disease. These tumors have an unpredictable behavior even in early stages and local recurrence and delayed metastases may be seen. Lifelong surveillance is warranted.     

Can perforated appendicitis be diagnosed preoperatively based on admission factors?

The optimal initial treatment for selected patients with perforated appendicitis may be nonoperative. For this reason it is important to be able to diagnose perforated appendicitis preoperatively. The purpose of this study was to determine the accuracy of diagnosing perforated appendicitis using only admission factors. The study population was comprised of 366 adult patients who underwent appendectomy for presumed appendicitis during 1997. Admission factors associated with perforated appendicitis were determined using univariate and multivariate analyses. These variables were then used to formulate a rule for the diagnosis of perforated appendicitis. Sensitivity and specificity were calculated for this rule. The admission factors analyzed were sex, race, age, days of pain, temperature, heart rate, symptoms, physical examination findings, and laboratory findings. Multivariate regression analysis revealed days of pain, temperature, and localized tenderness outside the right lower quadrant to be significant (P <0.05). Using two or more days of pain, a temperature of >101° F (38.3° C), or localized tenderness outside the right lower quadrant as criteria to indicate perforation, we achieved a sensitivity of 86% and a specificity of 58% for distinguishing perforated from nonperforated appendicitis. We concluded that (1) perforated appendicitis cannot reliably be distinguished from nonperforated appendicitis based on admission factors, and (2) two or more days of pain, localized tenderness outside the right lower quadrant, and a temperature of ±101° F (38.3° C) define a group of patients with appendicitis who have a high incidence of perforation.     

Unsuspected residual disease at the resection margin after surgery for lung cancer: fate of patients after long-term follow-up.

OBJECTIVE: This retrospective study evaluates the survival impact of the residual margin disease after bronchial resection for cancer and suggests tactics in cases of microresidual disease. METHODS: Between March 1988 and 1998, 4530 consecutive patients underwent surgery for non-small cell lung cancer at our institution. Only incomplete resections after microscopic evaluation (R1) were included in the study. Residual tumour cells were found on the bronchial resection margins of 39 lobectomies, 12 pneumonectomies, 4 segmental resections and one bilobectomy. Histological findings were: squamous cell carcinoma in 38 cases, adenocarcinoma in 15 and large cell carcinoma in three. In all 56 cases, invasive mucosal carcinoma was found exclusively on the bronchial resection margin. Nineteen tumours were stage I; 12, stage II; 17, stage IIIa; 5, stage IIIb; and three, stage IV. Nineteen patients (59.3%) with early stage tumours (I and II) received adjuvant radiation therapy and only three chemotherapy. RESULTS: The prognosis in these cases was disease-stage related (21 and 38.4% of deaths due to the disease). Forty-one percent of the stage IIIa patients received radiation therapy and 17.6% chemotherapy: 70.6% died of tumour relapse. Forty percent of the stage IIIb patients received radiation therapy and 20% chemotherapy: 60% died of disease progression. All of the stage IV patients died within 3 months from surgical resection. At the end of the study, 21 patients were alive after an interval of 22-142 months (18 in stage I or II). The 10-year actuarial survival rate was 44%. The percentage survival for stage IIIa was 16.8, after 10 years, and fell to 45 months for stage IIIb. CONCLUSIONS: The prognosis of our stage I or II patients with microresidual tumour on the bronchial resection margin (R1) was similar to that of the patients in the same disease stage, whose resection was microscopically radical (R0) and the same was true of the patients in stage III. In patients with residual tumour cells on the bronchial stump we did not observe worsened long-term survivals.     

Is laparoscopic resection of colorectal polyps beneficial?

Background: We set out to compare the results of laparoscopic and open resections of colorectal polyps. Methods: Forty-five consecutive patients who underwent operation by a single surgeon for endoscopically irretrievable colonic polyps between April 1992 and March 1996 were classified into the following two groups: group I, laparoscopic procedures for colonic polyps (n= 23); and group II, open procedures for colonic polyps (n= 22). Results: No significant differences were seen between the groups relative to age [71.7 ± 10.7 versus 70.6 ± 13.7 years], gender [male:female = 10:13 versus 13:9], history of previous abdominal operation (eight of 23 [34.8%] versus 10 of 22 [45.5%]), type of pathology (villous: seven of 23 [30.4%] versus four of 22 [18.1%], tubulovillous: nine of 23 [39.1%] versus six of 22 [27.2%], tubular: three of 23 [13.0%] versus seven of 22 [31.8%]), size of polyps (2.6 ± 1.7 cm versus 2.7 ± 1.5 cm), or type of procedures (right hemicolectomy: 15 of 23 [65.2%] versus 11 of 22 [50%], sigmoid colectomy: five of 23 [21.7%] versus six of 22 [27.3%], left hemicolectomy: two of 23 [8.7%] versus two of 22 [9.1%]). There was no mortality and no difference in the incidence of postoperative complications (four of 23 [17.4%] versus seven of 22 [31.8%]), blood loss (167 cc versus 243 cc), number of retrieved lymph nodes (7.1 ± 5 versus 6.6 ± 4), incidence of carcinoma in polyps (two of 23 [13.0%] versus four of 22 [18.2%]), or medical cost ($22,840 versus $18,420), respectively, between the two groups. There were statistically significant differences in length of ileus (3.5 ± 1.0 days versus 5.5 ± 1.8 days), postoperative pain (2.3 ± 1.4 versus 3.7 ± 1.9 on postoperative day 1 [patient pain rating scale 1–10]), length of hospital stay (6.5 ± 2.0 days versus 9.4 ± 2.7 days), and return to normal activity (5.2 ± 4.2 weeks versus 9.3 ± 12.1 weeks) in group I compared to group II, respectively. However, patients in group II had a longer mean specimen length (18.5 ± 6.4 cm versus 29.1 ± 22.7 cm) and a shorter mean operative time (177.6 ± 52.7 min versus 143 ± 51.4 min) than patients in group I. Conclusions: Laparoscopic colectomy for colonic polyps has definite advantages over traditional open surgery, including less postoperative pain, earlier return of bowel function, and earlier return to normal activity. Conversely, its disadvantages include longer operative time and a shorter specimen. Received: 27 January 1997/Accepted: 2 February 1998     

Adenocarcinoma of the appendix. A multicenter study from AURC

Thirty-two patients with primary adenocarcinoma of the appendix were studied in this collective review. Diagnosis was never suspected preoperatively. Immediate operation was performed in 21 patients with a diagnosis of acute appendicitis. At operation, tumor of the appendix was only identified in 50 percent of the 32 patients. One patient with an obstructing tumor and peritoneal involvement died postoperatively. Estimated survival rate was 46% at five years. Probability of survival was unrelated to the histologic tumor type but significantly correlated with the extent of tumor spread. Right hemicolectomy led to a significant increase in survival compared with appendectomy alone and to a significant decrease in risk of recurrence. In Dukes' B2 and C patients, differences in the survival curves were in favor of right hemicolectomy. In patients with pseudomyxoma peritonei, long-term survival was obtained by repeated laparotomy with resection of mucinous material. Our results indicate that, in good risk patients, right hemicolectomy performed as first or second operation, provides better results than appendectomy alone.     

Adenocarcinomas of the jejunum and ileum: A 25-year experience

Adenocarcinomas of the jejunum and ileum are rare gastrointestinal malignancies. Because few large published experiences exist, we reviewed patients with jejunal and ileal adenocarcinoma treated at our institution over the last 25 years. Between January 1976 and December 2001, 77 patients had an operation for a jejunal or ileal adenocarcinoma. Records were retrospectively reviewed for patient, tumor, and treatment variables. Factors affecting disease recurrence and patient survival were investigated. Fifty-two of the adenocarcinomas (67%) occurred in the jejunum and 25 occured in the ileum (33%). Mean patient age was 63 ±14 years. Segmental bowel resection was performed in 50 patients (65%) with curative intent. Palliative operative procedures including resection or bypass were performed in 27 patients (35%). One (1%) patient had stage I, 18 (23%) stage II, 19 (25%) stage III, and 39 (51%) stage IV adenocarcinoma at diagnosis. Postoperatively, 12 patients had palliative and 18 adjuvant chemotherapy (n 5 30), radiation therapy (n = 1), or combination treatment (n = 7). Median patient survival was 19 months. Sixty-six percent of patients who had a curative operation had a tumor relapse. Tumor stage had a highly significant effect (P < 0.0001) on median survival (72 months for stage I and II, 30 months for stage III, and 9 months for stage IV disease). In multivariate analysis of patients having curative treatment, tumor recurrence (P < 0.0001), stage (P < 0.0002), and weight loss (P < 0.001) were significant negative prognostic indicators. Most patients with adenocarcinoma of the jejunum or ileum present with advanced disease. Tumor stage, disease recurrence, and weight loss predicted patient outcome following a curative operation. Early recognition of these tumors requires a high index of suspicion. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisana, May 15–19, 2004 (poster presentation).     

Effects of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in the Treatment of Goblet Cell Carcinoma: A Prospective Cohort Study

Background

Goblet cell carcinoma (GCC) of the appendix is a rare disease. Treatment options vary according to disease staging. Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) may improve survival in patients with peritoneal spreading.

Objective

The aim of this study was to examine the prognosis of patients with appendiceal GCC treated per protocol, and to evaluate the results of CRS+HIPEC in cases of peritoneal spreading.

Methods

From 2009 to 2016, a total of 48 GCC patients were referred to the European Neuroendocrine Tumour Center of Excellence, Aarhus University Hospital. All patients received treatment per protocol according to disease staging. In patients with localized disease, the treatment was a right hemicolectomy. Patients with peritoneal spread who met the inclusion criteria for CRS + HIPEC, as well as patients with high-risk features of developing peritoneal spread, received CRS + HIPEC. If too-extensive disease was found, palliative chemotherapy was offered.

Results

Overall survival for patients with localized disease (n = 6) or deemed at risk of peritoneal spread (n = 8) was 100% after a median follow-up of 3.5 years. In patients with peritoneal spread and eligible for CRS+HIPEC(n = 27), the median survival was 3.2 years [95% confidence interval (CI) 2.3–4.1] and the 5-year survival rate was 57%. In contrast, the median survival for patients with too-extensive intraperitoneal disease (n = 7) was 1.3 years (95% CI 0.6–2.0), with a 3-year survival rate of 20%.

Conclusions

Long-term survival can be achieved in patients with peritoneal spread treated with CRS + HIPEC. CRS+HIPEC was associated with a favorable outcome in GCC patients at high-risk of developing peritoneal spread.

     

Laparoscopic Liver Surgery for Patients with Hepatocellular Carcinoma

Background Laparoscopic hepatectomy is feasible for hepatocellular carcinoma (HCC) today. This is a retrospective study of the patients with HCC treated by liver resection with a totally laparoscopic approach. Methods This study recruited 116 patients (92 male, 24 female) that underwent laparoscopic liver resection (LR) for HCC. Patients were divided into two groups: group I: (n = 97, 78 male,19 female) those with a volume of resection less than two segments; group II: (n = 19, 14 male, 5 female) those with a volume of resection of more than two segments. The distribution of the tumor-node–metastasis (TNM) stage of patients in the two groups was not significantly different. Results Patients resumed full diet on the second or third day after the operation, and the average length of hospital stay was 6 days. The operation time was 152.4 ± 336.3 min and 175.8 ± 57.4 min, while blood loss was 101.6 ± 324.4 mL and 329.2 ± 338.0 ml, for groups I and II, respectively. Five patients (5.2%) in group I and three patients (15.8%) in group II required blood transfusion (p = 0.122). The mortality rate was zero among our patients and complication rates were 6.2% and 5.2% for groups I and II, respectively. The 1-year, 3-year, and 5-year survival rates were 85.4%, 66.4%, and 59.4% for group I, and 94.7%, 74.2%, and 61.7% for group II, respectively, with no significant difference between two groups (p = 0.1237). Conclusion Laparoscopic liver resection is a procedure of significant risk and is more technically demanding in comparison with traditional open method. There was no significant difference in survival rates, based on the volume of resection. Laparoscopic surgery should be performed in selected patients as the postoperative quality of life of patients is better than that with open resection.     

Prognostic relevance of gastric cancer staging by endoscopic ultrasound

Background

Recent trials and guidelines have established the use of neoadjuvant chemotherapy for resectable UICC stage II to IV gastric cancers. In this setting, preoperative staging is pivotal for correct patient selection. This cohort study was designed to assess the accuracy of endoscopic ultrasound (EUS) and the ability to select correctly patients for neoadjuvant chemotherapy on the basis of survival outcome.

Methods

Eighty-two consecutive Caucasian patients (46 male; median age 72 years) with gastric cancer underwent EUS staging and subsequent surgery without perioperative chemotherapy or radiotherapy. Patients were followed for a median of 800 days postoperatively. Pathology and EUS UICC and T stages were compared and evaluated as predictors of survival using Kaplan–Meier and Cox regression analysis.

Results

The overall accuracy of EUS for UICC classification compared with pathology was 62 %, and the accuracy for delineation of UICC I was 89 %. For the therapeutically relevant differentiation of early gastric cancer (UICC stage I), EUS (mean survival, 2,298 days, R2 = 0.23) and pathology (2,461 days, R2 = 0.24) predicted survival equally well. Similar results were obtained for T staging by EUS (mean survival, 2,065 days for uT1/2, R2 = 0.24) or pathology (2,185 days, R2 = 0.22).

Conclusions

EUS identifies the low risk subgroup (uUICC stage I or uT1/2) with similar performance as pUICC stage I or stage pT1/2 in gastric cancer and very similar survival characteristics. EUS thus may be the noninvasive method of choice for preoperative selection of patients for immediate resection versus neoadjuvant chemotherapy.     

A comparison of the feasibility of laparoscopic resection of the primary tumor in patients with stage IV colon cancer with early and advanced disease: the short- and long-term outcomes at a single institution

Purpose

The role of resection of the primary tumor in patients with stage IV colorectal cancer (CRC) remains controversial. Laparoscopic resection has become an accepted therapeutic option for treating early stage I–III CRC; however, it has not been evaluated for use in patients with advanced stage disease.

Methods

We conducted a retrospective observational study to evaluate the feasibility of laparoscopic resection of the primary tumor exclusively in patients with stage IV colon cancer compared to open resection in patients with stage IV colon cancer and laparoscopic resection in patients with stage I–III colon cancer in terms of operative results and short- and long-term outcomes.

Results

Laparoscopic resection was performed in 35 stage IV patients and open resection was performed in 40 stage IV patients. One hundred and eighteen stage I–III patients who underwent laparoscopic resection were evaluated. In the comparison between the laparoscopic group and the open group among patients with stage IV colon cancer, postoperative recovery appeared to be better in the laparoscopic group than in the open group, as reflected by shorter times to resumption of a regular diet (p = 0.049), shorter lengths of hospitalization (p = 0.083), increased feasibility of postoperative chemotherapy (p < 0.001), shorter time intervals from surgery to chemotherapy (p = 0.031) and longer median survival (p = 0.078) at the expense of longer operative times (p = 0.025). In the comparison between the laparoscopic resection in stage IV and stage I–III disease groups, no significant differences were observed in operative results and short- and long-term outcomes, except for the rate of ostomy creation (48.5 vs. 8.5 %, p = 0.02).

Conclusion

Laparoscopic resection of the primary tumor in patients with stage IV colon cancer achieves equivalent results to that performed in patients with stage I–III disease and that performed in patients with stage IV disease using open resection. The use of a minimally invasive approach in the laparoscopic procedure is beneficial because it results in shorter times to resumption of a normal diet, shorter lengths of hospitalization, increased feasibility of postoperative chemotherapy and shorter time intervals from surgery to chemotherapy at the expense of longer operative times. We believe that patients undergoing laparoscopic resection can receive targeted chemotherapy earlier and more aggressively, which might provide a survival benefit.