Morbidity and mortality of aggressive resection in patients with advanced neuroendocrine tumors

BACKGROUND: There is considerable controversy about the treatment of patients with malignant advanced neuroendocrine tumors of the pancreas and duodenum. Aggressive surgery remains a potentially efficacious antitumor therapy but is rarely performed because of its possible morbidity and mortality. HYPOTHESIS: Aggressive resection of advanced neuroendocrine tumors can be performed with acceptable morbidity and mortality rates and may lead to extended survival. DESIGN: The medical records of patients with advanced neuroendocrine tumors who underwent surgery between 1997 and 2002 by a single surgeon at the University of California, San Francisco, were reviewed in an institutional review board-approved protocol. MAIN OUTCOME MEASURES: Surgical procedure, pathologic characteristics, complications, mortality rates, and disease-free and overall survival rates were recorded. Disease-free survival was defined as no tumor identified on radiological imaging studies and no detectable abnormal hormone levels. Proportions were compared statistically using the Fisher exact test. Kaplan-Meier curves were used to estimate survival rates. RESULTS: Twenty patients were identified (11 men and 9 women). Of these, 10 (50%) had gastrinoma, 1 had insulinoma, and the remainder had nonfunctional tumors; 2 had multiple endocrine neoplasia type 1, and 1 had von Hippel-Lindau disease. The mean age was 55 years (range, 34-72 years). In 10 patients (50%), tumors were thought to be unresectable according to radiological imaging studies because of multiple bilobar liver metastases (n = 6), superior mesenteric vein invasion (n = 3), and extensive nodal metastases (n = 1). Tumors were completely removed in 15 patients (75%). Surgical procedures included 8 proximal pancreatectomies (pancreatoduodenectomy or whipple procedure), 3 total pancreatectomies, 9 distal pancreatectomies, and 3 tumor enucleations from the pancreatic head. Superior mesenteric vein reconstruction was done in 3 patients. Liver resections were done in 6 patients, and an extended periaortic node dissection was performed in 1. The spleen was removed in 11 patients, and the left kidney was removed as a result of tumor metastases in 2. Eighteen patients had primary pancreatic tumors, and 2 had duodenal tumors; 2 patients with multiple endocrine neoplasia type 1 had both pancreatic and duodenal tumors. The mean tumor size was 8 cm (range, 0.5-23 cm). Of the patients, 14 (70%) had lymph node metastases and 8 (40%) had liver metastases. The mean postoperative hospital stay was 11.5 days (range, 6-26 days). Six patients (30%) had postoperative complications. There was a significantly greater incidence of pancreatic fistulas with enucleations compared with resections (P =.04). There were no operative deaths. The mean follow-up period was 19 months (range, 1-96 months); 18 patients (90%) are alive, 2 died of progressive tumor, and 12 (60%) are disease-free. The actuarial overall survival rate is 80% at 5 years, and disease-free survival rates indicate that all tumors will recur by the 7-year follow-up visit. CONCLUSIONS: Aggressive surgery including pancreatectomy, splenectomy, superior mesenteric vein reconstruction, and liver resection can be done with acceptable morbidity and low mortality rates for patients with advanced neuroendocrine tumors. Although survival rates following surgery are excellent, most patients will develop a recurrent tumor. These findings suggest that conventional contraindications to surgical resection, such as superior mesenteric vein invasion and nodal or distant metastases, should be reconsidered in patients with advanced neuroendocrine tumors.     

Estimation of the Architectural Properties of Cortical Bone Using Peripheral Quantitative Computed Tomography

We assessed the volumetric bone mineral density (vBMD) and cross-sectional architecture of cortical bone at the distal radius by peripheral quantitative computed tomography (pQCT). The volumetric bone mineral density [integral bone mineral density (BMDi), trabecular bone mineral density (BMDt) and cortical with subcortical bone mineral density (BMDsc)] and the architectural parameters [cortical bone area (CBA), cortical thickness (C-th), moment of inertia (Im) and polar moment of inertia (Ip)] were measured in 115 healthy premenopausal women, 48 osteoporotic postmenopausal women and 78 age-matched healthy postmenopausal women. Age-matched healthy women had higher values of vBMD and architectural parameters at the distal radius than osteoporotic women. Premenopausal women had higher values of vBMD and architectural parameters at the distal radius than postmenopausal women. The differences in the architectural parameters between age-matched healthy women and osteoporotic women were more pronounced when only the high density area (threshold 0.70 cm^–1) was included. However, the differences in architectural parameters between premenopausal women and postmenopausal women were significant using even the lowest threshold value of 0.50 cm^–1 in the calculation. Receiver operating characteristic (ROC) curves were constructed and the areas under the curves calculated to evaluate the discriminating power of vBMD and architectural parameters. Comparison of the different ROC curves showed no statistical significance. In conclusion, our results suggest that both the density and mass distribution of the radius were clearly different between the healthy women and osteoporotic women. The differences in architectural parameters were more useful for studying the pathopysiology of osteoporosis than for contributing to the diagnosis. Determination of the cross-sectional mass distribution of bone combined with BMD should offer more information than BMD alone in the study of the pathophysiology of osteoporosis. Received: 22 December 1998 / Accepted: 2 June 1999     

Radical operations for carcinoma of the gallbladder: Present status in Germany

Despite the overall poor prognosis of gallbladder carcinoma, it appears that, in resectable lesions, an aggressive surgical approach promises improvement in survival rates. Radical treatment of gallbladder carcinoma is based on a detailed knowledge of the lymphatic, venous, direct, and intraductal modes of spread of gallbladder carcinoma. Customized therapy of gallbladder carcinoma takes staging into consideration: if one is dealing with gallbladder carcinoma with macroscopic liver infiltration (T3 or T4), or with a pre- or intraoperatively diagnosed gallbladder carcinoma with an unknown depth of infiltration, an en bloc resection of the gallbladder with adjacent liver segments IVb and V, perhaps including VI, as well as a dissection of the hepatoduodenal ligament should be performed. If the carcinoma is missed intraoperatively at the time of cholecystectomy for other indications, in the presence of a T2 gallbladder carcinoma in proximity to the liver bed, reoperation with dissection of the hepatoduodenal ligament and resection of liver segments IVb and V should be performed. In the presence of T1 gallbladder carcinoma, simple cholecystectomy is adequate.This concept is based on our experience with 113 patients with gallbladder carcinoma who underwent treatment in our department from January, 1970 to June, 1989. Sixty-seven percent of the gallbladder carcinomas were resected, 30% for cure and 37% palliatively. In 33%, the operation was limited to an exploratory laparotomy or a palliative operation, or no operation was performed. Of the curatively resected carcinomas (n=34), 7 were Stage I, 7 Stage II, 9 Stage III, and 11 Stage IV.The average follow-up or survival time following curative resection at first operation (n=21) was 48.1 months; survival in patients who underwent curative resection at reoperation, in the presence of distant metastases, if there was tumor spillage, and in the presence of synchronous tumor was 14.0 months; survival following palliative resection was 5.8 months, and after exploratory laparotomy, palliative operation, or no operation was 3.6 months.Compared to palliative resection, customized therapy of gallbladder carcinoma for cure at the time of initial operation leads to a significant improvement in prognosis.

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Resumen A pesar del pobre pronóstico general del carcinoma de la vesícula biliar, es aparente que en las lesiones resecables un aproche quirúrgico radical promete mejores tasas de sobrevida. El tratamiento radical del carcinoma de la vesícula biliar se fundamenta en un conocimiento detallado de las modalidades de extensión linfática, venosa, directa, e intraductal del carcinoma de la vesícula biliar. La terapia es individualizada de acuerdo al estadio: si se trata de un carcinoma con infiltración macroscópica del hígado (T3 o T4), o de un carcinoma diagnosticado pre- o intraoperatoriamente con grado de infiltración no determinado, se debe proceder con una resección en bloque de la vesícula biliar y los segmentos hepáticos adyacentes IVb, y V, tal vez incluyendo VI, junto con disección del ligamento hepatoduodenal. Si el carcinoma no es detectado intraoperatoriamente en el momento de una colecistectomía realizada por otra indicación, en presencia de un carcinoma T2 en proximidad al lecho hepático, se debe emprender la reoperación con disección del ligamento hepatoduodenal y resección de los segmentos hepáticos IVb y V. En presencia de un carcinoma T1, la simple colecistectomía constituye tratamiento adecuado.Este concepto se fundamenta en nuestra experiencia con 113 pacientes con carcinoma de la vesícula biliar que fueron sometidos a tratamiento en nuestro departamento entre enero de 1970 y junio de 1989. Sesenta y siete por ciento de los carcinomas fueron resecados, 30% en forma curativa y en 37% en forma paliativa. En 33% la operación estuvo limitada a una laparotomía exploratoria o una intervención paliativa, o no se realizó operación. De los carcinomas resecados en forma curativa (n= 34), 7 fueron Estado I, 7 Estado II, 9 Estado III, y 11 Estado IV.El seguimiento promedio o tiempo de sobrevida después de una resección curativa en la primera intervención (n=21) fue 48.1 meses; después de una resección curativa en reoperación, en presencia de metástasis distantes, o si hubo desgarre del tumor o en presencia de tumor sincrónico, fue 14.0 meses; después de resección paliativa 5.8 meses y después de laparotomía exploratoria, operación paliativa o no operación, 3.6 meses.En comparación con la resección paliativa, la terapia indiviudalizada del carcinoma de la vesícula biliar con intención de curación realizada, en el momento de la primera operación, da lugar a una mejoría significativa del prónostico.

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Résumé Bien que le pronostic de cancer de la vésicule biliaire soit généralement mauvais, il semble que pour les lésions qu'on peut réséquer, l'approche chirurgicale agressive permette d'améliorer les taux de survie. Le traitement radical de la vésicule biliaire repose sur la connaissance parfaite de la dissémination à distance à partir de la vésicule dans les voies lymphatiques, veineuses, directes et biliaires. Le traitement courant du cancer de la vésicule biliaire tient compte du stade; si on traite un cancer de la vésicule biliaire avec une infiltration macroscopique du foie (T3 ou T4), ou un cancer de la vésicule biliaire diagnostiqué avant ou pendant l'intervention et dont on ne connaît pas l'étendue de l'envahissement, on doit faire une résection en bloc de la vésicule biliaire et des segments adjacents du foie IVb et V, peut-être même VI, ainsi que du ligament hépatoduodénal (petit épiploon). Si le cancer est passé inaperçu lors d'une cholécystectomie pratiquée pour d'autres diagnostics, devant un cancer T2 de la vésicule biliaire près du lit du foie, on doit faire une nouvelle intervention avec lymphadénectomie du ligament hépatoduodénal et une résection des segments IVb et V du foie. Pour un cancer T1 de la vésicule biliaire, la simple cholécystectomie suffit.Cette théorie se fonde sur notre expérience de 113 patients ayant un cancer de la vésicule biliaire et ayant eu un traitement dans notre service de janvier 1970 à juin 1989. Dans 67% des cas de cancers de la vésicule biliaire, on a fait une résection, à visée curative chez 30% des patients et à visée palliative chez 37%, Chez 33% des patients, l'intervention a été limitée à la laparotomie exploratrice ou à une intervention palliative, ou bien aucune intervention n'a été pratiquée. Pour les résections à visée curative (n=34), 7 cancers étaient de Stade I, 7 de Stade II, 9 de Stade III, et 11 de Stade IV.Le temps moyen de survie après résection à visée curative en première intervention (n=21) était de 48.1 mois; après résection à visée curative en seconde intention, avec métastases à distance, s'il y a eu effraction de la capsule tumorale et avec tumeur synchrone, 14.0 mois; après résection à visée palliative, 5.8 months et après laparotomie exploratrice, intervention à visée palliative ou pas d'opération, 3.6 mois.Comparé à la résection à visée palliative, le traitement courant du cancer de la vésicule biliaire au moment de la première intervention améliore le pronostic de façon significative.

     

Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection

PURPOSE: We describe a modular stent graft for use in endovascular repair of aneurysms of the aortic arch. METHOD: Carotid-carotid and left carotid-subclavian bypass grafts are created surgically. Two large, fully stented grafts are inserted endoluminally. The proximal component is bifurcated, with a wide proximal trunk and two distal limbs, one long and narrow, the other short and wide. This component is inserted through the carotid artery and deployed with the trunk and short wide limb in the ascending thoracic aorta; the long narrow limb opens into the innominate artery. After delivery system removal and carotid artery repair, a distal component is inserted through a femoral approach to bridge the gap between the short, wide distal limb of the proximal component and the nondilated descending thoracic aorta. The result is a branched stent graft, implanted proximally into the ascending aorta and distally into the innominate artery and descending thoracic aorta. CONCLUSION: The system has been used successfully to treat a large wide-necked pseudoaneurysm of the aortic arch.     

Intraductal papillomas of the breast: diagnosis and management of 151 patients

Introduction

The assessment of papillary lesions continues to be a challenging area in breast radiology and pathology. The management of intraductal papillomas without atypia of the breast remains controversial. The purpose of the present study was to determine diagnostic accuracy of radiographical diagnosis, core biopsy, and surgical excision in papillary breast lesions.

Material and methods

By using files from 1995 to 2010, 151 cases of intraductal papilloma with or without atypia were identified. Patients were stratified as follows: core biopsy followed by surgical excision (n = 61), core biopsy alone (n = 19), and surgical excision alone (n = 71).

Results

The upstage rate of intraductal papillomas without atypia on core biopsy to atypia or malignancy on excision was 8.9%. Excision specimens revealed intraductal papillomas without atypia in 68 out of 71 cases, and atypical papillomas in 3 cases.

Conclusion

Our findings suggest that radiographic and histopathological diagnosis of intraductal papillomas show high accuracy and good concordance. In cases where the radiographic diagnosis reveals suspicious lesions core biopsy represents the first choice.     

Current TNM classification of renal cell carcinoma evaluated: revising stage T3a

PURPOSE:: Recent studies of rare cases of pT3a renal cell carcinoma extending directly into the adrenal gland showed worse survival than in other pT3a cases and recategorization as stage pT4 was suggested. We assessed the prognostic validity of a stage pT3a diagnosis based on perirenal fat infiltration. MATERIALS AND METHODS:: The records of 1,794 patients with renal cell carcinoma who underwent surgical resection between 1975 and 2000 at our institution were analyzed retrospectively. Focusing on pT3a tumors, as defined by perirenal fat infiltration, numerous clinical and histopathological parameters were investigated by univariate and multivariate statistical methods with cancer specific survival as the primary end point. RESULTS:: We identified 237 of 1,794 patients with perirenal fat infiltration, classified as having pT3a disease. In patients with pT3a tumors tumor size was a significant parameter predicting survival. The most significant cutoff value for tumor size in pT3a disease was 7 cm. Patients with distant metastasis had a worse prognosis independent of T classification. Therefore, to assess the prognostic value of the current T classification in regard to T3a tumors we excluded patients with tumor stage cM+ for further subgroup analysis. Survival comparison of pT1 pNall, cM0 (744 of 1,794 cases) and pT3a pNall, cM0 7 cm or less (100 of 237) as well as pT2 pNall, cM0 (265 of 1,794) and pT3a pNall, cM0 greater than 7 cm (93 of 237) yielded similar results. After splitting pT3a into a modified T1/T2 classification a significant difference in 5-year survival analysis for a modified T1/T2 stage was found (pT1 plus pT3a less than 7 cm 90% vs pT2 plus pT3a greater than 7 cm 73%, p <0.001). Subsequently multivariate analysis in all 1,794 patients showed that modified T stage was an independent significant predictor of cancer specific survival. CONCLUSIONS:: We suggest revising the current pT3a classification based on perirenal fat infiltration but rendering a modified pT1/pT2 classification, which resolves pT3a cases without the loss of prognostic validity. Perirenal fat infiltration should not be used to assign T category. Tumors directly infiltrating the adrenal gland should be reclassified as T4.     

Minimally invasive surgery for thoracoabdominal aortic aneurysms

Open surgical repair of thoracoabdominal aortic aneurysms (TAAA) remains a highly morbid procedure. In recent years, several minimally invasive techniques have been introduced to treat TAAA. These include hybrid procedures and purely endovascular approaches using modified aortic endografts. Although still investigational, this burgeoning technology has the potential to improve outcomes in TAAA repair, as well as to circumvent the morbidity and mortality associated with the traditional surgical approach to TAAA. While the reported experience is limited to several institutional case series, results are encouraging, and suggest that fenestrated and branched endografts are likely to figure prominently in the management of TAAA in the future. An overview of these minimally invasive techniques, as well as the role of computer-assisted imaging analysis, is provided.