How I Do It: Surgical Management of Gastrointestinal Stromal Tumors

The surgical management of gastrointestinal stromal tumors (GISTs) has been impacted by the development of tyrosine kinase inhibitors (TKIs), advances in surgical technique, and a better understanding of the natural history of this unique disease. In this article, we review the technical aspects of the operations, the expanding role of laparoscopy, and the indications for neoadjuvant and neoadjuvant TKI therapy in primary GIST. Furthermore, we explore the rationale for and incorporation of surgery in the multidisciplinary management of advanced GIST.     

Natural history and selective management of in transit melanoma

Ninety five patients who developed in transit melanoma either as their initial site of recurrent melanoma or following regional node metastases were retrospectively reviewed. In transit melanoma occurred most frequently on the lower extremity and appeared to be associated with deeply invasive primary tumors. The median time to development of in transit melanoma was 16 months. Eighty-two (86%) of these patients have progressed to systemic disease from 2 to 244 months (median 16 months) following the development of in transit melanoma, and 72 (79%) died (median survival 19 months). Survival appears to correlate with the extent of in transit melanoma and with the disease-free interval. These findings suggest that in transit melanoma represents an early manifestation of systemic disease, warranting careful clinical follow-up and perhaps systemic treatment, when effective therapy becomes available. However, some patients will respond to local immunotherapy, surgical excision, and isolated limb perfusion and will enjoy significant length and quality of life. This sequential approach remains the treatment of choice for this manifestation of metastatic melanoma.     

脊柱转移瘤的MRI诊断

目的：探讨脊柱转移瘤的MRI表现及诊断价值。材料与方法：回顾性分析52例经临床和病理证实的脊柱转移瘤的MRI表现。结果：（1）52例共累及209节椎体,167节附件,“跳跃征”发生率占71．7％。（2）病灶T1WI均表现为低信号,T2WI因其类型不同而分为高（24．4％）,低（30．1％）和混杂（45．5％）信号,“晕征”出现率占26．9％。（3）椎旁肿块、椎管受累和椎间隙狭窄发生率分别为57．1％、60．7％和64．3％。结论：MRI对脊柱转移瘤的诊断有重要的价值。     

Improved imaging of hepatic metastases with delayed pulse inversion harmonic imaging using a contrast agent SH U 508A: preliminary study

To investigate the feasibility of delayed pulse-inversion harmonic imaging (PIHI) with the SH U 508A to improve imaging of hepatic metastases, we evaluated 20 patients with known hepatic metastases. Conventional ultrasound (US) was performed before administration, and PIHI was performed 5 min after a bolus injection of 4 G of microbubble contrast agent (300 mg/mL of SH U 508A). Intense, homogeneous enhancement in the liver parenchyma was seen in all patients on delayed PIHI. In 10 patients (50%), 1 or more focal liver lesions that were not seen on unenhanced imaging were detected on delayed PIHI. When comparing 55 lesions that were seen on both techniques, delayed PIHI was superior to unenhanced imaging in terms of lesion conspicuity and lesion-to-liver contrast (p < 0.001, respectively). Delayed PIHI with SH U 508A can improve conspicuity of hepatic metastases and reveal focal liver lesions that are not detected on unenhanced imaging.     

Palliative chemotherapy in elderly patients with common metastatic malignancies: A Hellenic Cooperative Oncology Group registry analysis of management, outcome and clinical benefit predictors

INTRODUCTION: Cancer in the elderly is a common health issue in developed societies. We sought to present epidemiology, management and outcome data on fit elderly patients with common metastatic cancers and to identify predictors of clinical benefit from palliative chemotherapy. METHODS: All patients aged >65 years who were diagnosed with metastatic breast, colorectal or non-small cell lung carcinomas and managed with palliative chemotherapy in the context of Hellenic Cooperative Oncology Group (HeCOG) clinical trials or protocols were eligible for electronic data retrieval and analysis. Common eligibility criteria included adequate performance status (ECOG 0-3), organ function and absence of severe co-morbidity forbidding cytotoxic chemotherapy. RESULTS: One thousand three hundred and seventy-two fit patients (PS 0-1 in 73%) with a median age of 70 years diagnosed with metastatic breast (n=250), colorectal (n=621) or lung cancer (n=501) received chemotherapy from 1991 until 2006. Most patients received modern full-dose chemotherapy regimens including platinum, taxanes, anthracyclines, fluoropyrimidines, oxaliplatin or irinotecan. Mild to moderate co-morbidity was present in 35%. At a median follow-up of 3 years, objective responses were seen in 41% of patients with breast cancer, 25% with colorectal cancer and 31% with lung cancer, while median survival was 21, 16 and 9.4 months, respectively. Grade 3 or 4 toxicity was seen in a quarter of patients, the most common being neutropenia (14%), diarrhoea (6%), neurotoxicity (4%), fatigue, nausea and febrile neutropenia (each 2%). In multivariate analysis, diagnosis of colorectal or lung cancer, metastases in multiple organ sites, presence of liver/brain/peritoneal deposits, impaired PS and low baseline serum albumin levels were prognostic factors for adverse outcome. The same factors excluding metastatic sites and with the addition of anemia predicted for resistance to chemotherapy. Toxicity was more likely in females with low serum albumin and renal dysfunction. A six-variable geriatric assessment for palliation (GAP) score that included tumour type, sites of metastatic dissemination, impaired PS, low serum albumin and anemia classified elderly patients to groups with low, intermediate and high risk for disease progression and death (relative risks of 1.59 and 2.50 for resistance to therapy and 1.87 and 3.12 for death in the intermediate and high-risk groups). CONCLUSIONS: Our data indicate that relatively fit elderly patients with advanced cancer safely tolerate modern chemotherapy and enjoy disease control in a manner comparable to younger patients. Our GAP score, if further validated, offers promise for geriatric application in combination to comprehensive geriatric assessment tools for the optimisation of palliative therapy on an individualised basis.     

Aggressive surgical management after transarterial chemoembolization （TACE） for liver metastases from ocular melanoma

Metastatic melanoma is also a challenge for surgeons. Recently, it has been reported that aggressive surgery combined with supportive therapy may be potential benefit for the condition. Therefore, we report a case of ocular melanoma metastatic to multiple visceral sites treated by cytoreductive surgery after initial intra-,arterial hepatic chemoembolization     

Metastatic Merkel Cell Carcinoma in the Rectum: Report of a Case

Merkel cell carcinoma is a rare, aggressive skin malignancy of neuroendocrine origin with predominant occurrence in the elderly males. Approximately 50 percent of patients with Merkel cell carcinoma develop distant metastasis at some point during the disease course; hence, Merkel cell carcinoma always has a poor prognosis. Distant metastasis has never been disclosed in the rectum to the best of our knowledge. We present a 76-year-old male with clinical manifestation of massive hematochezia and final diagnosis of metastatic Merkel cell carcinoma in the rectum. We conclude that radical resection of rectal metastatic Merkel cell carcinoma is important in the management strategy of a patient with recurrence and lymph node metastases. Presented at the meeting of the Taiwan Surgical Association, Linkou, Taoyuan, Taiwan, March 25 and 26, 2006.     

Combined PET/CT in the follow-up of differentiated thyroid carcinoma: what is the impact of each modality?

Purpose ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a well-established method in the follow-up of patients with differentiated thyroid carcinoma (DTC), elevated thyroglobulin (Tg) and negative ¹³¹I scans. This retrospective clinical study was designed to evaluate the impact of computed tomography (CT) and that of FDG-PET in combined FDG-PET/CT examinations on the restaging of DTC patients. Methods Forty-seven FDG-PET/CT scans of 33 patients with a history of DTC, elevated Tg levels and negative ¹³¹I uptake or additionally suspected ¹³¹I-negative lesions were studied. PET and CT images were analysed independently by an experienced nuclear medicine specialist and a radiologist. Afterwards a final consensus interpretation, the gold standard in our department, was provided for the fused PET/CT images and, if available, for supplementary investigations. Results Thirty-five investigations (74%) revealed pathological FDG-PET/CT findings. In summary, 25 local recurrences, 62 lymph node metastases and 122 organ metastases (41 lung, 60 bone, 21 other organs) were diagnosed. In 36 out of 47 examinations (77%), the original PET diagnoses were modified in the final consensus interpretation owing to the CT assessments. In 8 of the 35 pathological FDG-PET/CT examinations (23%), the final consensus interpretation of the PET/CT images led to an alteration in the treatment plan. Conclusion PET/CT is a powerful fusion of two pre-existing imaging modalities, which not only improves the diagnostic value in restaging DTC patients with elevated Tg and negative ¹³¹I scan, but also provides accurate information regarding subsequent treatment options and may lead to a change in treatment management.     

脊椎转移瘤的影像学诊断与鉴别诊断

目的提高脊椎转移瘤影像诊断与鉴别诊断的准确性。方法搜集经病理确诊及临床证实的脊椎转移瘤56例,密切结合临床资料,综合性分析以CT为例的影像学表现。结果56例转移瘤均累及椎体、附件骨性结构,脊柱转移灶累及多个椎体及附件54例,单个椎体2例。溶骨性转移37例,成骨性转移16例,混合性转移3例,出现病理性骨折3例,椎旁形成软组织肿块7例。病灶位于颈段者3例,胸段15例,腰段20例,骶段3例,颈胸段4例,胸、腰段同时受累8例,腰、骶段3例。结论CT是诊断脊柱转移瘤较重要的影像学检查方法。