[Show abstract][Hide abstract] ABSTRACT: Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC.
Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO.
Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was >97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO.
Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.
Journal of palliative medicine 07/2011; 14(7):822-8. · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Gallbladder cancer has historically been considered an incurable malignancy; although, extended resection has been associated with cure in selected patients. However, the optimal extent of resection is unknown. The objective of this study was to analyze the impact of the extent of resection for gallbladder adenocarcinoma on disease-specific survival (DSS) and perioperative morbidity. Analysis of a prospective hepatobiliary surgery database identified patients undergoing surgical resection for gallbladder adenocarcinoma from 1990 to 2002. Clinicopathologic factors including extent of resection were analyzed for their association with DSS and perioperative morbidity. Long-term outcome was evaluable in 104 patients. With median follow-up of 58 months for survivors, the actuarial 5-year DSS was 42%. Thirty-six patients (35%) underwent major hepatectomy, but in 15 this was not mandatory to clear all disease. Sixty-eight patients (65%) underwent common bile duct (CBD) excision, but 32 were performed empirically. Twenty-one patients (20%) underwent en bloc resection of adjacent organs other than the liver. The performance of a major hepatectomy or a CBD excision was not associated with other clinicopathologic variables or long-term survival. Resection of adjacent organs were associated with advanced T stage but not with survival. T stage, N stage, histologic differentiation, and CBD involvement were independently associated with survival. Major hepatectomy and CBD excision were significantly associated with perioperative morbidity. We conclude that tumor biology and stage, rather than extent of resection, predict outcome after resection for gallbladder cancer. Major hepatic resections, including major hepatectomy and CBD excision, are appropriate when necessary to clear disease but are not mandatory in all cases.
Annals of Surgical Oncology 12/2008; 16(4):806-16. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Despite data suggesting a rising worldwide incidence, intrahepatic cholangiocarcinoma (IHC) remains an uncommon disease. This study analyzes changes in IHC frequency, demographics, and treatment outcome in a consecutive and single institutional cohort.
Consecutive patients with confirmed IHC seen and treated over a 16-year period were included. The trend in IHC frequency over the study period was compared with that of hilar cholangiocarcinoma patients (HCCA) seen during the same time. Demographics and patient disposition, histopathologic, treatment, recurrence, and survival data were analyzed; changes in these variables over time were assessed.
From December 1990 through July 2006, 594 patients were evaluated (IHC = 270, HCCA = 324). Over the study period, the average annual increase in new IHC patients was 14.2% (P < 0.001). Relative to HCCA, the proportional increase in IHC was nearly 3-fold, and new IHC patients have outnumbered those with HCCA by 2:1 over the last 3 years. Conditions associated with IHC were rarely seen, with only 7 patients having a history of sclerosing cholangitis and/or inflammatory bowel disease and none with hepatolithiasis or biliary parasitic disease; however, heavy tobacco use (27%) and diabetes mellitus (16.4%) were particularly prevalent. The majority of patients were not candidates for resection, most commonly because of advanced hepatic disease. After resection (n = 82), median disease-specific survival was 36 months; recurrence was observed in 62.2% of patients at a median follow-up of 26 months, with the liver remnant involved most frequently (62.7%). Multiple hepatic tumors (P < 0.001), regional nodal involvement (P = 0.012), and large tumor size (P = 0.016) independently predicted poor recurrence-free survival. Most patients (n = 115, 73.7%) with unresectable disease were treated with chemotherapy, either systemic alone (n = 75) or combined with regional hepatic arterial floxuridine (FUDR) (n = 28). Compared with the first 10 years of the study (1990-2000), the last 6 years saw an overall improvement in disease-specific survival for all patients (22 vs. 12 months, P = 0.002), which was particularly notable for patients with unresectable disease (15 vs. 6 months, P = 0.003).
At Memorial Sloan-Kettering Cancer Center, IHC incidence has increased dramatically in the last 16 years. Resection offers the best opportunity for long-term survival but is possible in the minority, and patients with large, node-positive or multifocal IHC seem to derive little benefit. Establishing and maintaining control of the intrahepatic disease remains the biggest problem for all IHC patients. The recent increase in survival seems largely because of improved nonoperative therapy for unresectable disease.
Annals of surgery 07/2008; 248(1):84-96. · 7.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: An understanding of the methods of detection of recurrent melanoma after sentinel lymph node biopsy (SLNB) is essential for the coordination of a rational plan of follow-up.
Clinical stage I/II melanoma patients who underwent SLNB from 1991 to 2004 were identified from a prospectively maintained single-institution database. Detection of recurrence by self (awareness of symptoms or abnormal physical findings) or physician (discovered on routine physical or scheduled test) and timing of clinic visit were recorded. Postoperative follow-up included physical exam every 3-4 months for the first year, every 3-6 months for the second year, and every 6-12 months thereafter. Serum lactate dehydrogenase (LDH) and chest X-ray (CXR) were obtained annually. Computed tomography (CT) and positron emission tomography (PET) were performed selectively.
Of 1062 patients who underwent SLNB, 203 (19%) experienced 230 initial sites of recurrence; 198 patients were evaluable for follow-up. Median follow-up after first recurrence was 17 months. Symptoms and self-detected physical findings were present in 109 patients (55%); 85 patients (78%) were seen earlier than their scheduled visit. Self-detected physical findings identified in-transit (n = 26; 24%) and nodal (n = 25; 23%) disease. Physician detection occurred in 89 patients (45%), nearly half by a scheduled radiographic test (CXR, 16%; CT, 29%; PET, 1%). The method of detection significantly predicted post-recurrence survival (p < 0.05).
More than half of melanoma recurrences are self-detected; these patients have the most favorable post-recurrence survival rates because of the type of recurrence detected. The mode of detection is a significant predictor of post-recurrence survival. This supports an aggressive program of patient education in self-examination after SLNB for melanoma.
Annals of Surgical Oncology 06/2008; 15(8):2206-14. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lipomatous tumors range from benign lipomas to high-grade liposarcomas. Liposarcomas are classified into five histologic subtypes: well-differentiated, dedifferentiated, myxoid, round cell, and pleomorphic, which differ in outcomes and patterns of recurrence. Surgical resection is the mainstay of curative treatment; however, large, high grade liposarcomas may benefit from multimodality treatment with chemotherapy and radiation. A histologic-subtype specific nomogram provides accurate survival predictions. Prospective randomized clinical trials will continue to improve our care of patients with liposarcoma.
Journal of Surgical Oncology 04/2008; 97(4):298-313. · 2.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. Epstein-Barr virus (EBV)-related smooth muscle neoplasms (SMNs) have been associated with immune dysregulation, most notably in patients who have undergone solid organ transplantation or in patients with HIV/AIDS. Objective. to report our experience with EBV-related neoplasms as well as describing the first EBV-related SMN in the setting of administration of glucocorticoids and the tumor necrosis factor inhibitor etanercept. Design. We have case reports, of minimum 3-year follow-up, 2002-2005. Setting. It was held in an academic and tertiary referral cancer center. Patients. Patients are with dysregulated immunity after solid organ transplantation, HIV/AIDS, or with psoriasis after treatment with etanercept. Interventions. There were discontinuation of etanercept, right hepatic trisegmentectomy, and chemotherapy. Measurements. We use survival as a measurement here. Results. Patients who were able to withstand reduction in immunosuppression survived. Surgical resection or chemotherapy was successful in delaying progression of disease. Limitations. There was a relatively short follow-up for these slow-growing neoplasms. Conclusion. EBV-related SMNs have variable aggressiveness. While chemotherapy may slow disease progression, resection and improving the host immune status provide the best opportunity for primary tumor control.
[Show abstract][Hide abstract] ABSTRACT: Gastric cancer patients with positive (+) peritoneal cytology have a prognosis similar to stage IV patients. We studied the ability of quantitative reverse transcriptase polymerase chain reaction (RT-PCR) to detect peritoneal micrometastases in patients undergoing staging laparoscopy.
Peritoneal washings were obtained prospectively from 34 patients with gastric adenocarcinoma undergoing staging laparoscopy and 6 patients undergoing laparoscopy for benign disease. Each sample underwent cytologic and RT-PCR analysis for tumor markers: carcinoembryonic antigen (CEA), cytokeratin 20 (CK20), survivin, and MUC2. Markers were evaluated on the basis of their deviance from the ideal marker.
Pathologic stages for the gastric cancer patients were: stage I, 9 (27%); stage II, 7 (21%); stage III, 15 (44%); and stage IV, 3 (9%). The four cytology (+) patients were: stage II, 1; stage III, 1; and stage IV, 2. Fifteen patients were RT-PCR (+), including all cytology (+) patients. The optimal threshold for cycle amplification was 35, based on a receiver operating characteristic curve. CEA had the smallest deviance.
RT-PCR using a panel of tumor markers, including CEA, detects (+) cytology. The clinical significance of "false-positive" overexpression of CEA, survivin, or CK20 but cytology (-) remains to be defined. RT-PCR could represent a more sensitive method than cytology for detection of subclinical peritoneal tumor dissemination; this may be useful in improving patient selection for operative management and clinical trials.
Gastric Cancer 02/2008; 11(4):206-13. · 4.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pancreatic cancer patients with positive (+) peritoneal cytology have a prognosis similar to stage IV patients. We studied the ability of quantitative real time-polymerase chain reaction (RT-PCR) to detect micrometastases in patients undergoing staging laparoscopy.
Peritoneal washes were obtained prospectively from 35 consecutive patients with pancreatic adenocarcinoma undergoing staging laparoscopy and 16 patients undergoing laparoscopy for benign disease. Each sample was assessed by cytologic examination and RT-PCR analysis for tumor markers: CEA, CK7, Kras2, and MUC1. Markers and their combinations were evaluated on the basis of their deviance from the ideal marker.
Pathologic stages for pancreatic cancer patients were: 1A-1 (3%), IB-1 (3%), IIA-5 (15%), IIB-13 (38%), III-5 (15%), IV-9 (26%). Eight patients were cytology (+) and stages IIA-1, IIB-2, IV-5. Twenty-five patients were RT-PCR (+). The optimal threshold for cycle amplification was 35 based on a receiver operating characteristic curve. CEA had the best profile of sensitivity, specificity, PPV, NPV, and the smallest deviance.
RT-PCR using a panel of tumor markers, including CEA, was comparable in sensitivity, specificity, PPV, and NPV to cytology. RT-PCR could represent a more sensitive method for detection of subclinical peritoneal tumor dissemination; this may be useful in patient selection for operative management and clinical trials.
Journal of Gastrointestinal Surgery 01/2008; 11(12):1598-605; discussion 1605-6. · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sentinel lymph node biopsy (SLNB) has become well accepted in management of patients with primary cutaneous melanoma. An understanding of the pattern of recurrence after SLNB is helpful in coordinating a rational plan of follow-up in these patients. We sought to determine the site and timing of initial recurrence and post-recurrence survival after SLNB.
Stage I/II melanoma patients who underwent SLNB during 1991-2004 were identified from a prospective single-institution database. Site and date of first recurrence after SLNB were recorded. Patterns of recurrence after SLNB and post-recurrence survival were analyzed.
One thousand and forty-six patients underwent SLNB. The sentinel lymph node (SLN) was positive in 164 patients (16%). Median follow-up was 36 months for survivors. Median and 3-year relapse-free survival for SLN-positive patients were 41 months and 56%, and for SLN-negative patients were not reached and 87%, respectively (P < .0001). Of the SLN-positive patients, 47% experienced recurrence, compared with 14% SLN-negative patients. The pattern of recurrence stratified by SLN status was similar between the two groups (P = NS). After recurrence, the site of recurrence was the only significant prognostic factor influencing survival (P < .0001).
Although SLN-positive patients experience recurrence far earlier and more frequently than SLN-negative patients, the pattern of recurrence is similar. After recurrence, its site is the primary determinant of survival.
Annals of Surgical Oncology 06/2007; 14(6):1934-42. · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the prognostic significance of histologic subtype in a large series of patients with primary liposarcoma (LS) and to construct a LS-specific postoperative nomogram for disease-specific survival (DSS).
Nomograms, used to define and predict outcome following operative intervention, may contain variables not conventionally used in standard staging systems. A 12-year DSS postoperative nomogram for all sarcomas has already been established.
From a single-institution prospective sarcoma database, patients with primary extremity, truncal, or retroperitoneal LS treated between 1982 and 2005 were identified. Histology was reviewed by a sarcoma pathologist and divided into 5 subtypes. A nomogram predictive of 5- and 12-year DSS was developed.
Of 801 patients with primary LS resected with curative intent, 369 (46%) presented with well-differentiated, 143 (18%) dedifferentiated, 144 (18%) myxoid, 81 (10%) round cell, and 64 (8%) pleomorphic histology. The median tumor burden was 15 cm (range, 1-139 cm). At last follow-up, 560 patients were alive with a median follow-up time of 45 months (range, 1-264 months) and 51 months for surviving patients. The 5- and 12-year DSS rates were 83% (95% confidence interval [CI], 80%-86%) and 72% (95% CI, 67%-77%), respectively. The nomogram was drawn on the basis of a Cox regression model. The independent predictors of DSS were age, presentation status, histologic variant, primary site, tumor burden, and gross margin status. The nomogram was internally validated using bootstrapping and shown to have excellent calibration. The concordance index was 0.827 compared with 0.776 for the general sarcoma postoperative nomogram for 12-year DSS.
The LS-specific nomogram based on histologic subtype provides more accurate survival predictions for patients with primary LS than the previously established generic sarcoma nomogram. DSS nomograms aid in more accurate counseling of patients, identification of patients appropriate for adjuvant therapy, and stratification of patients for clinical trials and molecular analysis.
Annals of Surgery 10/2006; 244(3):381-91. · 7.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is an increasing awareness of the association of papillary thyroid carcinoma and familial adenomatous polyposis (FAP). Although the incidence is rare, most tend to occur in women. Several authors have described a distinctive histologic variant of papillary thyroid carcinoma, the cribriform-morular variant, which is associated with FAP but also may be encountered in patients with non-FAP. This diagnosis may precede the symptoms of colorectal polyposis.
A healthy 36-year-old woman was seen with a left thyroid nodule, and a 34-year-old woman with FAP was seen with a right thyroid nodule; both masses were suspicious for papillary thyroid carcinoma. Both patients underwent total thyroidectomy.
Pathologic examination of both specimens revealed papillary thyroid carcinoma, cribriform-morular variant. The first patient subsequently underwent colonoscopy, which was negative for polyposis.
Patients diagnosed with the cribriform-morular variant of papillary thyroid cancer should be screened for the presence of FAP.
Head & Neck 06/2006; 28(5):471-6. · 3.01 Impact Factor