Carcinoma in a fibroadenoma

A carcinoma arising within a fibroadenoma is an unusual occurrence, with only a little over 100 reported cases. The purpose of this report is to increase the awareness of this entity and to discourage the practice of rendering a diagnosis on gross examination of the tumor. We are reporting a case with two distinct primary tumors within the same breast, one of which was arising within the fibroadenoma. Only two such cases have been previously reported.     

Informed Decision-Making for Bariatric Surgery: Benefits,Risks, Uncertainties and Choices

Decision-making is a critical aspect of good surgical care, and this principle is particularly important in bariatric surgery. Adequate communication of information to patients is essential in order to facilitate optimal uptake of bariatric surgery and choice of the most suitable procedure. This article reviews the most relevant advances in understanding of long-term efficacy associated with gastric banding, gastric bypass and sleeve gastrectomy.     

Non-operative management of the primary tumour in patients with incurable stage IV colorectal cancer

BACKGROUND: Excision of primary colorectal cancer associated with irresectable synchronous metastases confers high morbidity and mortality with uncertain benefit. METHODS: For patients with incurable stage IV colorectal cancer, minimally symptomatic primary tumours were left in situ and 5-fluorouracil-based chemotherapy was administered systemically. Primary tumour-specific complications and survival were monitored. RESULTS: There were 13 men and 11 women with primary tumours in the right colon (eight), transverse colon (one), sigmoid colon (eight) or rectum (seven). Eleven patients had metastases limited to the liver (liver replacement less than 25 per cent in one, 25-50 per cent in four and more than 50 per cent in six) and 13 patients had extrahepatic disease (lung or peritoneum). Four patients with sigmoid colon tumours developed bowel obstruction, which required an uncomplicated operation in two and deployment of colonic stents in two patients, at 1, 3, 12 and 20 months from diagnosis. Three further patients underwent right hemicolectomy for abdominal pain of uncertain aetiology, with poor symptomatic relief, and another had a potentially curative operation following disease downstaging. The overall median survival was 10.3 months with a 1-year actuarial survival rate of 44 per cent. CONCLUSION: A policy to defer resection of minimally symptomatic primary colorectal cancer is associated with a low risk of complications before death from progressive systemic disease.     

Diagnostic variation and outcome for high-grade gastric epithelial dysplasia

HYPOTHESIS: High-grade dysplasia (HGD) of the gastric epithelium is associated with high prevalence of invasive carcinoma, and distinction by endoscopic biopsy is difficult. DESIGN: Cohort study, 1996 to 2003. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 22 patients with initial diagnosis of gastric HGD by endoscopic biopsy. Biopsy specimens were separately reviewed by 3 experienced pathologists. Clinical management was individually decided. MAIN OUTCOME MEASURES: Strength of interpathologist agreement (kappa) and final pathological diagnosis. RESULTS: The diagnosis was revised to intramucosal carcinoma in 14% to 32% of patients or suspicious for invasive carcinoma in 23% to 41%. The strength of agreement between any 2 pathologists for distinguishing between dysplasia and invasive carcinoma was fair (kappa = 0.35-0.36). A diagnosis of intramucosal carcinoma or suspicious for invasive carcinoma by 2 pathologists correlated strongly with subsequent detection of invasive carcinoma. Three patients underwent gastrectomy for HGD, and invasive carcinoma was detected in all (2 patients, T1 N0; 1 patient, T2 N0). Six patients had invasive carcinoma on endoscopic surveillance at a median of 15 months (range, 3-34 months) after diagnosis of HGD and underwent endoscopic mucosal resection (2 patients, T1 NX), gastrectomy (2 patients, T1 N0), or no resection (2 patients). Another patient had metastatic gastric adenocarcinoma despite having a diagnosis of only HGD by endoscopy. Seven patients (32%) died of unrelated causes, without invasive carcinoma, at a median of 19 months (range, 1-38 months). Three patients were alive with persistent HGD at 26 to 61 months. Two patients had no dysplasia on follow-up. CONCLUSIONS: Experienced pathologists often disagreed in distinguishing invasive carcinoma from HGD in gastric biopsy specimens. One third of patients with gastric HGD died of causes unrelated to cancer. Invasive carcinoma was detected in 67% of the remainder.     

Hepatic and mesenteric nitric oxide synthase expression in a rat model of CCl(4)-induced cirrhosis

BACKGROUND: Cirrhosis and portal hypertension are frequently linked with changes in expression of nitric oxide synthase (NOS) and/or endotoxaemia. AIMS: This study tested the following hypothesis: that inducible (i)NOS activity is increased within the visceral circulation concurrently with decreased constitutive (c)NOS activity in the hepatic sinusoids and that the concentration of NO metabolites in portal blood is consequent on endotoxin concentration. MATERIALS AND METHODS: Plasma concentrations of (nitrite + nitrate) and endotoxin, together with hepatic and mesenteric NOS activity (arginine/citrulline method) and protein expression (histochemistry) plus portal and arterial blood pressure, were determined in rats made severely cirrhotic by intragastric CCl(4) over 14 weeks (n = 6) compared with age-matched controls (n = 5). The concentrations of [nitrite + nitrate] and endotoxin in portal plasma were also directly compared in rats made cirrhotic for a period of 8-14 weeks (n = 10). RESULTS: In rats with advanced cirrhosis, arterial [nitrite + nitrate] was 93.1 (22.4) micromol/L (mean, SEM) compared with 29.1 (6.1) micromol/L in controls (P < 0.05); portal plasma [NO(2)(-) + NO3(-)] was 127.1 (27.2) compared with 24.7 (4.7) micromol/L in controls (P < 0.05). Cirrhotic rats had higher endotoxin concentration in plasma compared with controls (systemic: 85.0 (24.5) versus 1.7 (0.2) EU/ml, P < 0.05; portal: 180.3 (47.9) versus 1.7 (0.2) EU/ml, P < 0.05). The same severely cirrhotic rats possessed decreased cNOS activity in liver (2.95 [0.40] versus 5.29 [0.85] pmol/min/g; P < 0.05) and increased iNOS activity in mesentery (4.83 [1.23] versus 1.47 [0.15] pmol/min/g; P < 0.05) compared with controls. Histochemical observations confirmed these findings. Rats given CCl(4) for a period of 8-14 weeks possessed high endotoxin concentration in portal plasma, with correspondingly high [nitrite + nitrate] (r(2) = 0.954; P < 0.001). CONCLUSIONS: An endotoxin-induced increase in mesenteric iNOS activity and a decrease in hepatic cNOS activity may account for, respectively, the hyperdynamic visceral circulation and the increased intrahepatic resistance of cirrhosis.     

Neoadjuvant Chemotherapy and Surgery for Esophageal Adenocarcinoma: Prognostic Value of Circumferential Resection Margin and Stratification of N1 Category

Background  In the UK, it is standard practice to treat esophageal adenocarcinoma with neoadjuvant chemotherapy (no radiation) and surgery. We examined the prognostic value of the status of the circumferential resection margin (CRM) and stratification of the N1 category into 1–4 nodes or ≥5 nodes. Methods  Between 2000 and 2006, 105 patients with radiologically staged T3, T4 or N1 esophageal adenocarcinoma had preoperative chemotherapy. One hundred and one patients had an Ivor Lewis operation with two-field lymphadenectomy, three had a transhiatal operation and one had a three-incision operation. CRM was assessed by painting the specimen with India ink and transverse sections at 5–10 mm intervals. The CRM was considered positive (CRM+) if malignant cells were within 1 mm of the inked margin. Results  There were 87 men. The median age was 61 years (range 37–81 years). Median lymph node yield was 28 (4–77); 86 patients (83%) had ≥18 nodes. Seventy-four patients (70%) had N1 disease, with 1–4 involved nodes in 41 patients (39%) and ≥5 nodes in 33 patients (31%). The CRM was positive in 38 patients (36%). On multivariate analysis, nodal metastasis [N0 versus N1; hazard ratio (HR) 3.3, 3-year survival 80% versus 40%; P = 0.004], CRM status (CRM– versus CRM+: HR 2.6, 3-year survival 64% versus 26%; P = 0.002) and vascular invasion (V0 versus V1: HR 2.2, 3-year survival 67% versus 39%; P = 0.014) retained independently significant prognostic value. N1 patients with 1–4 nodes had longer survival than those with ≥5 nodes (56% versus 21%; P < 0.001). Conclusions  CRM involvement and stratification of the N1 category are independent prognostic factors after multimodal therapy for esophageal adenocarcinoma.     

Gastric adenocarcinoma with distant metastasis: is gastrectomy necessary?

HYPOTHESIS: For distant metastatic (M1) gastric adenocarcinoma, a policy to maximally avoid resection of the primary tumor is safe and efficacious. DESIGN: Cohort study. SETTING: Academic tertiary care center. PATIENTS: Sixty-seven (32%) of 211 consecutive patients with adenocarcinoma of the stomach or gastroesophageal junction had synchronous M1 disease on computed tomography or laparoscopy. Sixty-three patients with M1 disease were treated nonoperatively, and complete data sets were available for 40 men and 15 women (median age, 73 years). Pretreatment functional performance status was good in 67%. The primary tumor was at the gastroesophageal junction in 20% and was poorly differentiated in 60%. The M1 disease involved the peritoneum in 80% or was exclusively nonperitoneal in 20%. Systemic chemotherapy was administered to 67%. MAIN OUTCOME MEASURES: Incidence of subsequent invasive intervention for primary tumor-related complications and survival in 55 nonoperatively managed patients with M1 disease. RESULTS: Fourteen patients (25%) had intervention a median of 5 months after diagnosis. Eight patients had more than 1 intervention. Intervention was for gastric obstruction (20%), bleeding (7%), or perforation (2%). No patient underwent gastrectomy. Laparotomy was performed in 9%; the remainder had endoscopic or radiologic procedures or radiotherapy. There was no intervention-related mortality. Median survival was 7 months (95% confidence interval, 4-10 months). In Cox regression univariate analysis, good functional performance status, exclusively nonperitoneal metastasis, nonpoor differentiation, and chemotherapy predicted significantly longer survival; chemotherapy was the only independently significant predictive factor. CONCLUSIONS: Palliative interventions were performed in 25% of patients, with no mortality. Survival characteristics were similar to those of previous series of noncurative gastrectomy for M1 disease.     

Randomized clinical trial of torsional versus linear mode ultrasonically activated devices for laparoscopic cholecystectomy

Background  Conventional ultrasonically activated devices use linear mode vibration. Torsional mode ultrasonically activated device (TM) that oscillate around an arc have been recently introduced in the hope that the design may result in faster cutting and better hemostasis. Methods  Patients undergoing elective laparoscopic cholecystectomy were randomized to TM or linear mode ultrasonically activated device (LM). Intraoperative events were recorded. Postoperatively, a sample of suction fluid was analyzed for hemoglobin concentration to calculate intraoperative blood loss. Results  Seventy-five patients were randomized to TM and 76 patients to LM. Median blood loss was 5 (interquartile range (IQR), 1–19.7) ml with TM and 10.5 (IQR, 2.3–23) ml with LM (p = 0.105). The 95% confidence interval for the difference in median operative blood loss was −1.3 to +9.5 ml. Median gallbladder dissection time was similar in both groups (17 (IQR 11–29) minutes for TM vs. 21 (IQR, 12–29) minutes for LM; p = 0.248). Other modalities of hemostasis were required in 14 patients (19%) in the TM group compared with 21 patients (28%) in the LM group. One patient in the LM group developed postoperative hemoperitoneum and required urgent laparoscopic exploration. No patient required blood transfusion or suffered any other significant complication. Conclusion  TM has similar effectiveness to LM for laparoscopic cholecystectomy. Registration number: ISRCTN87527062 (). This paper was based on a previous presentation at the International Surgical Congress of the Association of Surgeons in Great Britain and Ireland, Bournemouth, May 16, 2008.     

Entirely laparoscopic radical gastrectomy for adenocarcinoma: lymph node yield and resection margins

Background  Laparoscopic assisted distal gastrectomy for adenocarcinoma has been widely reported from Japan and Korea but there are sparse data for Western patients. This study aimed to describe and compare the perioperative outcomes and pathological staging for consecutive patients who underwent laparoscopic or open gastrectomy by a single surgeon in the UK. Methods  During the period from April 2005 to May, 2007, patients with gastric adenocarcinoma were selected for open or laparoscopic resection at the discretion of the surgeon. Gastric resections for gastrointestinal stromal tumour (GIST) or benign disease were excluded. Laparoscopic gastrectomy was performed entirely laparoscopically with intracorporeal anastomosis, followed by specimen retrieval via a suprapubic incision. Results  There were 21 men and 8 women, median age 75 years (range 45–88 years), with American Anaesthesiology Association scores of 3 or 4 in 19 patients. Gastrectomy was performed laparoscopically in 18 patients (62%; total gastrectomy, 6 patients) or open in 11 patients (total gastrectomy, 7). Five laparoscopic gastrectomies were converted to open procedures, three patients had re-laparoscopy and one patient had subsequent laparotomy. As compared with open gastrectomy, laparoscopic resection had longer operation time and similar length of hospital stay. There was one postoperative mortality in each group. There was similar lymph node retrieval for laparoscopic or open resection [23 (range 10–44) versus 26 (8–95), respectively; p = 0.40], with inadequate lymphadenectomy (<15 nodes) in two laparoscopic cases and one open case. R1 resection was limited to patients with pT3 disease (laparoscopic, 4; open, 2). Conclusions  Perioperative outcomes were similar for laparoscopic or open gastrectomy. Lymphadenectomy was adequate in 89% of laparoscopic gastrectomies. pT3 tumours were at risk of noncurative resection, as described in large Western series of open gastrectomy.