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PubMed2003

The rational principles of neo-adjuvant therapy for rectal cancer.

BACKGROUND: Aim of the study is to analyze rational principles which at present govern the neoadjuvant therapy for rectal cancer and justify his application. First step is definition of targets: cellular replication block, volumetric reduction of rectal cancer, mesorectum and lateral nodes (Down staging), reduction of side-effects on close organs, radiation on more limited tissue volumes, major series of sphincter saving procedures, minor risk of microscopic tumour deposits. Second step regards standards which Protocols strive in order to: patients selection, therapeutic index, restaging before surgery, total mesorectal excision (TME). Further step accounts for evidence of drawbacks, related to Neoadjuvant approach, both Radiotherapy alone (RT) or Radiochemotherapy (CH-RT). METHODS: Indications for neoadjuvant therapy, basing a difference between the absolute and relative one, are explained. Given that granting role to such therapy still now remain partially unclear, we have outlined the following topics: A) survey of main protocols is managed, taking care on dose/response ratio, focusing on enhanced supply for fixed tumours, checking on a list of several drugs (oxaliplatinum, capecitabin, raltitrexed, CPT-11, eniluracil), which are medicated with RT and furthermore on a list of substitute RT methods (HART, IORT, Endocavitary). B) following whole treatments, according such a different approaches, analysis of obtained outcomes in the literature are carried out. C) Personal experience, basing on a previous series where Down-staging has been sought, comparing indicatively clinical and diagnostic data before neoadjuvant therapy and before surgery. D) List of open issues, not solved at present, is shown CONCLUSIONS: Neoadjuvant therapy may be considered a rational approach for treatment of curative rectal cancer; indeed, preliminary results seem to introduce a real advantage compared to adjuvant therapy, even if is mandatory to associate proper surgical procedure, as TME, to warrant low local recurrences. Targets, related to such therapy, may be noticed ideal even though outcomes don't come up always to statements. So, continuous efforts to ameliorate rates of free-disease series, as well mortality rates and toxical effects are advised.

Chemotherapy, Adjuvant↗
PubMed1986

Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence.

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.

Clinical Trials as Topic↗
PubMedDate not supplied

Treatment of lymphoma in the elderly: an update.

Recent studies specifically directed toward assessing the outcome of older patients with non-Hodgkin's lymphoma (NHL) indicate that age per se is an important and independent prognostic factor for response and survival. Prospective studies have addressed therapeutic approaches in these patients. Direct comparison of trial results is difficult since different age limits were set for the inclusion of patients in study. These studies suggest that older patients with aggressive NHL should be treated with curative intent. We report on selected prospective clinical trials of the literature and the Aviano Group experience in the treatment of NHL in the elderly. In particular we refer our data of a randomized study (CHOP vs VMP), conducted within the EORTC Lymphoma Group, and the results obtained with chemotherapy and granulocyte colony-stimulating factor.

Age Factors↗
PubMed2002

Bicalutamide as immediate therapy either alone or as adjuvant to standard care of patients with localized or locally advanced prostate cancer: first analysis of the early prostate cancer program.

PURPOSE: We determine the efficacy and tolerability of bicalutamide as immediate therapy, either alone or as adjuvant to treatment of curative intent, in patients with clinically localized or locally advanced prostate cancer. MATERIALS AND METHODS: This international program consists of 3 ongoing, randomized, double-blind, placebo controlled clinical trials (trials 23, 24, and 25). Men with localized or locally advanced (T1-T4, Nx/N0, M0) prostate cancer were randomized to receive 150 mg. bicalutamide daily or placebo, in addition to standard care with radical prostatectomy, radiotherapy or watchful waiting. Primary end points are time to objective progression and overall survival. In this first analysis data from the trials were combined in a single overview analysis according to protocol. RESULTS: Data are available for 8,113 patients (4,052 randomized to bicalutamide, 4,061 to standard care alone) at a median followup of 3.0 years. Treatment with bicalutamide provided a highly significant reduction of 42% in the risk of objective progression compared with standard care alone (9.0% versus 13.8%, hazards ratio 0.58; 95% confidence interval 0.51, 0.66; p <<0.0001). The overall result was reflected in 2 of the 3 trials (trials 24 and 25) with trial 3 (trial 23) showing a nonsignificant difference at this time. Reductions in the risk of disease progression were seen across the entire patient population, irrespective of primary treatment or disease stage. Overall survival data are currently immature and longer followup will determine if there is also a survival benefit with bicalutamide. The most frequently reported side effects of bicalutamide were gynecomastia and breast pain. CONCLUSIONS: Immediate treatment with 150 mg. bicalutamide daily, either alone or as adjuvant to treatment of curative intent, significantly reduces the risk of disease progression in patients with localized or locally advanced prostate cancer. This benefit must be balanced with the morbidity associated with long-term hormonal therapy. Followup is ongoing to determine potential survival benefits of this treatment approach.

Adult↗
PubMed2000

Curative resection of microgastrinomas based on the intraoperative secretin test.

The intravenous secretin injection test (secretin test) has been used for the differential diagnosis of gastrinoma. In this study we report that the intraoperative secretin test (IOS test) is also useful for determining the extent of curability in patients with Zollinger-Ellison syndrome (ZES). Twelve patients with ZES underwent surgical exploration and the IOS test. The results of the IOS test were obtained by rapid radioimmunoassay of the serum gastrin level (IRG) within 60 minutes. The test was diagnosed as negative when the maximum increase of serum IRG was less than 80 pg/ml and also less than 20% of the basal serum IRG level. Three of the twelve patients underwent pancreatoduodenectomy (PD), and two patients underwent distal pancreatectomy. Extirpation of duodenal tumors with dissection of regional lymph nodes was performed in seven patients. In two of the seven patients the IOS test remained positive after extirpation of the duodenal tumors and the dissection of regional lymph nodes. In one patient PD was performed on the basis of the positive results, and the IOS test became negative after PD. In the other patient, two tiny metastatic liver tumors were identified and were resected, but the IOS test did not become negative. We closed the abdomen in 11 patients when we obtained negative results from the IOS test. The results of the IOS test were almost identical to the data obtained by the standard assay postoperatively. The serum IRG levels of all but one patient fell to the normal level, and the secretin test became negative postoperatively. The IOS test is thus useful and indispensable for curative resection of microgastrinomas in patients with ZES.

Adult↗
PubMed2003

Extended lymphadenectomy and vein resection for pancreatic head cancer: outcomes and implications for therapy.

HYPOTHESIS: An aggressive strategy that includes extended lymphadenectomy and vein resection may improve the results of surgical treatment of pancreatic head cancer. DESIGN: Nonrandomized control trial. SETTING: Tertiary care referral center. PATIENTS: The study included 149 consecutive patients undergoing macroscopically curative resection for periampullary adenocarcinoma from January 1, 1988, to December 31, 1998. INTERVENTIONS: A standard resection was performed in 122 cases; an extended lymphadenectomy in 37. Twenty-four patients underwent venous resection. MAIN OUTCOME MEASURES: Data on surgical mortality, morbidity, and postoperative outcome, pathological findings, and long-term survival were analyzed. RESULTS: In-hospital and 60-day operative mortality was 5.4%. Morbidity was 37.5%. Mortality, morbidity, and postoperative stay were nonsignificantly modified by extended lymphadenectomy or venous resection. Extended resection permitted the identification of a significantly higher percentage of nodal metastases beyond the peripancreatic node groups. In patients undergoing vein resection, a significantly higher rate of positive retroperitoneal margin was found. In the 100 patients with ductal adenocarcinoma, the median overall survival and the 5-year actuarial survival rate were 15 months and 8.4%, respectively. A trend toward a better survival was observed in the first 2 years after operation in the extended resection group compared with the standard resection group. Nodal status was the most powerful predictor of overall survival by multivariate analysis. CONCLUSIONS: Extended lymphadenectomy and vein resection did not adversely affect postoperative mortality and morbidity. Patients who required a vein resection were less likely to receive a microscopically curative pancreatectomy. Extended resection permitted better pathological staging and was associated with an early advantage in survival, but long-term survival was possible only in patients with favorable prognostic factors.

Adenocarcinoma↗
PubMed1993

Biologic distinctions between cure and time to death in 2892 patients with intraocular melanoma.

BACKGROUND: For certain types of cancer, resection alone rarely achieves a cure, but patients nevertheless tend to have a prolonged survival before they die of the tumor. For other types of cancer, the opposite scenario prevails, suggesting that those biologic mechanisms that allow a curative resection are not identical to those that determine survival time among uncured patients. METHODS: The multivariate log-normal model can be used to detect the association of cured fraction and median survival time of patients with specific prognostic covariates. This model was applied to survival data from 2892 patients with intraocular melanoma who were treated by enucleation. RESULTS: This analysis showed that large tumor size and pleomorphic nucleoli within the tumor were associated independently with a low probability of cure and short median survival time. Advanced patient age and mixed cell type, however, were highly associated with only a short median survival time. CONCLUSIONS: For patients with intraocular melanoma treated only by enucleation, the median survival time is not modulated by the same biologic factors that determine the likelihood of a curative resection.

Age Factors↗
PubMed1998

Esophagectomy for carcinoma of the esophagus in the elderly: results of current surgical management.

OBJECTIVE: This study aims to evaluate the risk of esophagectomy in the elderly compared with younger patients and to determine whether results of esophagectomy in the elderly have improved in recent years. SUMMARY BACKGROUND DATA: An increased life expectancy has led to more elderly patients presenting with carcinoma of the esophagus in recent years. Esophagectomy for carcinoma of the esophagus is associated with significant morbidity and mortality, and advanced age is often considered a relative contraindication to esophagectomy despite advances in modern surgical practice. METHODS: The perioperative outcome and long-term survival of 167 elderly patients (70 years or more) with esophagectomy for carcinoma of the esophagus were compared with findings in 570 younger patients with esophagectomy in the period 1982 to 1996. Changes in perioperative outcome and survival between 1982 to 1989 and 1990 to 1996 were separately analyzed. RESULTS: The resection rate in the elderly was 48% (167/345), lower than the 65% (570/874) resection rate in younger patients (p < 0.001). There were significantly more preoperative risk factors and postoperative medical complications in the elderly, but no significant differences were observed in surgical complications. The 30-day mortality rate was higher in the elderly (7.2%) than in younger patients (3.0%) (p = 0.02), but the hospital mortality rate was not significantly different in the elderly (18.0%) and younger age groups (14.4%) (p = 0.27). The long-term survival after curative resection in elderly patients was worse than younger patients (p = 0.01). However, when deaths from unrelated medical conditions were excluded from analysis, survival was similar between the two age groups (p = 0.23). A comparison of data for the periods 1982 to 1989 and 1990 to 1996 revealed that the resection rate had increased from 44% to 54% in the elderly, with significantly fewer postoperative complications and lower 30-day and hospital mortality rates. Long-term survival has also improved, although this has not reached a statistically significant level. CONCLUSIONS: With current surgical management, esophagectomy for carcinoma of the esophagus can be carried out with acceptable risk in the elderly, but intensive perioperative support is required. The improved results of esophagectomy in the elderly in recent years are attributed to increased experience and better perioperative management. Long-term survival was similar to that of younger patients, excluding deaths caused by unrelated medical conditions.

Age Factors↗
PubMed1976

Should curative surgery be attempted in patients with cancer of the main stem bronchus?

Among tumors of the lung, main stem bronchial cancer offers a particularly unfavorable prognosis, probably because of its rapid extension to the segmental bronchi, trachea, and extrapulmonary structures. However, analysis of data gathered by the End Results Group indicates that survival among those patients with main stem bronchial cancer whose tumor was resected was virtually the same as that of patients with resectable lung cancer of other sites. From these data it is impossible to assess what role, if any, the resection itself played, and a randomized trial would be necessary to determine whether resection improves the probability of patient survival. On the other hand, it is not now advisable to deny resection to patients with operable main stem bronchial tumors (except oat cell tumors) on the basis of the available nonexperimental evidence alone.

Adenocarcinoma↗
PubMed2000

K-ras point mutation in the nerve plexuses around the superior mesenteric artery in resectable adenocarcinoma of the pancreatic head: distribution pattern and related factors.

BACKGROUND: Adenocarcinoma of the pancreas is likely to spread into the nerve plexuses around the superior mesenteric artery (SMA) at a microscopic level. Since there has been no detailed report on how minute cancer invasion is distributed among the peri-SMA plexuses or which cases are more vulnerable to such an event, it has long been controversial how to treat this area when resecting the pancreatic head cancer. HYPOTHESIS: The K-ras mutation assay is more sensitive than the conventional histologic diagnosis in detecting minute cancer invasion around the SMA. DESIGN: Prospective consecutive series. SETTING: Cancer center hospital. PATIENTS AND METHODS: The entire circle of the peri-SMA tissues was obtained from 24 patients who had received an extended pancreatectomy for adenocarcinoma of the pancreatic head. They were divided into right and left hemicircular samples (48 samples), and each sample was used for both histologic and genetic diagnoses. Since all patients' primary tumors were positive for point mutation at codon 12 of the K-ras gene, the presence or absence of the mutation was determined for the peri-SMA plexuses using the mutant allele specific amplification method. RESULTS: Compared with results of the histologic examination, the K-ras mutation assay was more sensitive in detecting positive findings in the peri-SMA plexuses (12 samples from 9 patients). According to the distribution of the K-ras mutation into the right- and left-half samples, 24 patients were classified into the following 4 patterns (right/left): negative/negative in 15 patients; positive/negative in 6 patients; positive/positive in 3 patients; and negative/positive in 0 patients. In 3 patients who showed a positive/positive pattern in the genetic diagnosis, their right-half samples included more cancer cells that were detectable by routine microscopy. There was no relation between K-ras mutation and lymphatic invasion, while K-ras mutation was particularly related with the invasion of portal vein (P =.04) and posterior peripancreatic tissues (P =.002). All 3 patients with K-ras mutation in bilateral plexuses were classified by the TNM staging system as T4 using Union Internationale Contre le Cancer classification. CONCLUSIONS: The K-ras mutation (at codon 12) assay indicated a simple and regular pattern of cancer extension into the nerve plexuses around the SMA from adenocarcinoma of the pancreatic head: (1) The left half of the plexus was unlikely to be involved by cancer in cases in which the right half was intact. (2) Cancer extension into the peri-SMA plexuses occurred after the posterior confine of the pancreas had been involved by direct invasion from the primary pancreatic tumor. (3) The left half was not involved in cancerous tumors classified as T1 to T3 but was occasionally involved in those classified as T4 tumors. These data seem to provide a useful indicator of some additional treatments (resection, irradiation, etc) for the peri-SMA region when a locally advanced pancreatic head cancer is treated with a curative intent.

Adenocarcinoma↗
PubMed2004

Does serum CA19-9 play a practical role in the management of patients with colorectal cancer?

PURPOSE: CA19-9 is often used in combination with carcinoembryonic antigen to manage patients with colorectal cancer, even though there is insufficient evidence to support this use of CA19-9. Carcinoembryonic antigen, by contrast, has been regarded as a better indicator of poor prognosis and recurrence. The purpose of this study is to clarify whether CA19-9 is, in fact, a useful marker in the management of colorectal cancer patients by comparing it with carcinoembryonic antigen. METHODS: A retrospective investigation was done for a consecutive series of 155 patients with colorectal adenocarcinoma who underwent potentially curative surgery between 1995 and 1999. Excluded were patients with postoperative assays performed less than three times for either carcinoembryonic antigen or CA19-9 and those who had developed secondary cancers. Data from 118 patients were analyzed in terms of prediction of prognosis and detection of recurrences. RESULTS: The sensitivities of preoperative CA19-9 and carcinoembryonic antigen were 29.8 percent and 45.3 percent, respectively. In the univariate analysis of preoperative carcinoembryonic antigen and CA19-9 assays in 114 patients, high carcinoembryonic antigen level was significantly associated with poor prognosis (P = 0.0090) by log-rank test). We could not find a significant association between preoperative CA19-9 abnormality and survival (P = 0.12). Multivariate analysis of preoperative factors indicated significance in TNM stage (P = 0.0094) and tumor location (P = 0.036) but in neither carcinoembryonic antigen (P = 0.061) nor CA19-9 (P = 0.22). Among 40 patients with recurrences, postoperative elevations of tumor markers were seen in 19 cases for CA19-9 and in 37 for carcinoembryonic antigen throughout the follow-up periods. Sensitivity, specificity, positive predictive value, and negative predictive value were 0.48, 0.88, 0.68, and 0.77, respectively, for CA19-9, and 0.93, 0.88, 0.80, and 0.96, respectively, for carcinoembryonic antigen. In patients with recurrences, the initial postoperative elevation of tumor markers was seen earlier than the detection of recurrence in 68.4 percent of those with CA19-9 elevation and in 67.6 percent of those with carcinoembryonic antigen elevation. There was only one patient with recurrence who had CA19-9 elevation without carcinoembryonic antigen elevation, while 19 recurrent patients had carcinoembryonic antigen elevation without CA19-9 elevation. Multivariate analysis showed a significant risk of carcinoembryonic antigen elevation against recurrence with an odds ratio of 32.0 (P < 0.0001), in contrast to an insignificant association of CA19-9 elevation (P = 0.23). CONCLUSION: We could not find clinical significance to support the use of CA19-9 to predict the prognosis and detect recurrence of colorectal cancer. Because of this, we do not recommend routine use of CA19-9 in staging and surveillance of colorectal cancer patients.

Adenocarcinoma↗
PubMed1992

A study of quality of life in cancer patients receiving palliative chemotherapy.

Although primary treatment for cancer has been associated with psychosocial distress, less research has focused on patients with advanced disease. Traditionally, the outcomes of treatment have been assessed using biomedical criteria, including tumour regression, progression and survival. It is argued that these data are inadequate to understand the impact of cancer upon the patient. Instead, quality of life considerations are crucial when treatments are aversive, especially when the aims are palliative rather than curative. Fifty-three patients with advanced breast cancer or ovarian cancer were studied prospectively for 6 months to assess whether the site and method of chemotherapy administration influenced their quality of life. Patients received palliative chemotherapy either at home or in hospital. Quality of life was operationalized as measurement of anxiety, depression, self-esteem, health locus of control, physical performance and symptoms. In addition, semi-structured interviews explored social roles, relationships, and perceptions of treatment. Hospital administered chemotherapy was perceived to be most distressing. Regression analysis indicated that anxiety and depression accounted for most of the variance in quality of life. Patients who died during the study 13 (24%) experienced considerable psychological and physical morbidity. Women over 60 years, experienced less psychological and physical distress. Quality of life broadens the criteria by which cancer treatments are evaluated, to include the experience of the patient.

Adult↗
PubMed2006

Treatment of oligometastases after successful immunotherapy.

Local destruction of individual metastases by any of a number of effective modalities fails as a treatment for most patients with disseminated cancer because of the presence of either undetected micrometastases or simply too many lesions. The availability of a systemic therapy that could reduce the number of metastases to a manageable few would dramatically increase the utility of surgical metastasectomy or other locally ablative measures. Interleukin-2-based immunotherapy can serve exactly this function in some patients with renal cancer or melanoma. We review the effectiveness of surgery in treating limited relapses or residual disease in patients who have responded to systemic immunotherapy. These data indicate that a surprising percentage of such patients can enjoy durable disease-free survival after surgical removal of their oligometastases, and, for a significant minority, it appears to be curative.

Antineoplastic Agents↗
PubMed1998

Long-term results after repeated surgical removal of pulmonary metastases.

BACKGROUND: Although surgical resection is accepted widely as first-line therapy for pulmonary metastases, few data exist on the surgical treatment of recurrent pulmonary metastatic disease. In a retrospective study, we analyzed patients who were operated on repeatedly for recurrent metastatic disease of the lung with curative intent over a 20-year period. METHODS: From 1973 to 1993, 396 metastasectomies were performed in 330 patients. The study population included patients with any histologic tumor type who had undergone at least two (range, 2 to 4) complete surgical procedures because of recurrent metastatic disease. Surgical and functional resectability of the recurrent lung metastases and control of the primary lesion served as objective criteria for reoperation. A subgroup of 35 patients that included patients with histologic findings such as epithelial cancer and osteosarcoma then was analyzed retrospectively to calculate prognosis and define selection criteria for repeated pulmonary metastasectomy. RESULTS: The 5- and 10-year survival rates after the first metastasectomy were 48% and 28%, respectively. The overall median survival was 60 months. A mean disease-free interval (calculated for all intervals, with a minimum of two) of greater than 1 year was significantly associated with a survival advantage beyond the last operation. Univariate analysis failed to show size, number, increase or decrease in number or size, or distribution of metastases as factors related significantly to survival. CONCLUSIONS: Although patients with different histologic tumor types were included, the study population appeared to be homogeneous in terms of survival benefit and prognostic factors, and it probably represented the selection of biologically favorable tumors in which histology, size, number, and laterality are of minor importance. We conclude that patients who are persistently free of disease at the primary location but who have recurrent, resectable metastatic disease of the lung are likely to benefit from operation a second, third, or even fourth time.

Adolescent↗
PubMed2000

Radiation therapy of the older patient.

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

Age Factors↗
PubMed2003

Barrett's esophagus: endoscopic resection.

In experienced hands, ER is a safe method of resecting dysplastic lesions and early carcinomas of the GI tract, and it has decisive advantages compared with other local endoscopic treatment procedures (such as thermal destruction and PDT). The opportunity for histological processing of the resected specimen provides information regarding the depth of invasion of the individual layers of the GI tract wall. Additionally, it has advantages regarding excision with healthy margins. This means that even when there is infiltration of the submucosa that has not been detected before treatment--in which case local endoscopic therapy is no longer appropriate--a patient with early Barrett's cancer still is able to undergo surgical resection. As was shown recently, the morbidity and mortality of ER are significantly dependent on the frequency with which esophagectomy is performed in each center. When there were more than 20 procedures of this type per year, the surgical mortality was 8%, whereas in centers conducting fewer than 10 procedures per year the rate was 21%. In view of the consequent claim that ER should only be performed at high-volume centers, curative endoscopic treatment of early esophageal carcinomas also should be performed only in centers with a similar frequency to that of the surgical high-volume centers. It is only in these conditions that the conclusion is defensible that patients with HGIN or mucosal Barrett's carcinoma should undergo ER with curative intent instead of radical ER. Randomized and controlled studies comparing radical esophagectomy with endoscopic therapy are desirable, but they are difficult to conduct, not least because valid 5-year survival data show no significant difference between patients who have undergone endoscopic treatment for early Barrett's cancers and the average German population of the same age and sex.

Adenocarcinoma↗
PubMed2005

Meta-analysis of randomised adjuvant therapy trials for pancreatic cancer.

The aim of this study was to investigate the worldwide evidence of the roles of adjuvant chemoradiation and adjuvant chemotherapy on survival in potentially curative resected pancreatic cancer. Five randomised controlled trials of adjuvant treatment in patients with histologically proven pancreatic ductal adenocarcinoma were identified, of which the four most recent trials provided individual patient data (875 patients). This meta-analysis includes previously unpublished follow-up data on 261 patients. The pooled estimate of the hazard ratio (HR) indicated a 25% significant reduction in the risk of death with chemotherapy (H = 0.75, 95% confidence interval (CI): 0.64, 0.90, P-values(stratified) (Pstrat) = 0.001) with median survival estimated at 19.0 (95% CI: 16.4, 21.1) months with chemotherapy and 13.5 (95% CI: 12.2, 15.8) without. The 2- and 5-year survival rates were estimated at 38 and 19%, respectively, with chemotherapy and 28 and 12% without. The pooled estimate of the HR indicated no significant difference in the risk of death with chemoradiation (HR = 1.09, 95% CI: 0.89, 1.32, Pstrat = 0.43) with median survivals estimated at 15.8 (95% CI: 13.9, 18.1) months with chemoradiation and 15.2 (95% CI: 13.1, 18.2) without. The 2- and 5-year survival rates were estimated at 30 and 12%, respectively, with chemoradiation and 34 and 17% without. Subgroup analyses estimated that chemoradiation was more effective and chemotherapy less effective in patients with positive resection margins. These results show that chemotherapy is effective adjuvant treatment in pancreatic cancer but not chemoradiation. Further studies with chemoradiation are warranted in patients with positive resection margins, as chemotherapy appeared relatively ineffective in this patient subgroup.

Carcinoma, Pancreatic Ductal↗
PubMed2001

Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy is now regarded as the procedure of choice for treatment of small or benign adrenal tumors, including pheochromocytoma. However, long-term outcomes have not been critically assessed. We report here 3 cases of pheochromocytomatosis recurring 3 to 4 years after laparoscopic adrenalectomy. We postulate laparoscopic-induced seeding of tumor as the mechanism of recurrence. METHODS: We retrospectively reviewed the cases of 3 patients with documented biochemical and radiolabeled metaiodobenzylguanidine evidence of recurrent pheochromocytoma after prior presumed curative laparoscopic adrenalectomy. RESULTS: Original pheochromocytomas were 5.5 to 6.5 cm in diameter. At the time of laparoscopic adrenalectomy, tumors were not believed to be malignant, based on clinical or histopathologic data. However, on 3- to 4-year follow-up, each patient developed symptoms, elevated urinary catecholamine levels, and metaiodobenzylguanidine imaging consistent with recurrence. At reoperation, multiple small tumor nodules were found in the adrenal bed near the site of the initial laparoscopic resection. The original operative notes suggested some possible method of local seeding: tumor fragmentation and spillage or excessive tumor manipulation. CONCLUSIONS: Pheochromocytoma recurrence may occur as a result of local spillage of tumor during laparoscopic adrenalectomy. The relative risk of recurrence between open and laparoscopic resection needs to be assessed. Long-term follow-up will continue to be important, regardless of operative approach.

3-Iodobenzylguanidine↗