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Devaud NA, Butte JM, De la Maza JC, von Mühlenbrock Hugo S, Cardona K. Complex Vascular Resections for Retroperitoneal Soft Tissue Sarcoma. Curr Oncol 2023; 30:3500-3515. [PMID: 36975479 PMCID: PMC10047166 DOI: 10.3390/curroncol30030266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Retroperitoneal sarcomas (RPSs) are locally aggressive tumors that can compromise major vessels of the retroperitoneum including the inferior vena cava, aorta, or main tributary vessels. Vascular involvement can be secondary to the tumor's infiltrating growth pattern or primary vascular origin. Surgery is still the mainstay for curing this disease, and resection of RPSs may include major vascular resections to secure adequate oncologic results. Our improved knowledge in the tumor biology of RPSs, in conjunction with the growing surgical expertise in both sarcoma and vascular surgical techniques, has allowed for major vascular reconstructions within multi-visceral resections for RPSs with good perioperative results. This complex surgical approach may include the combined work of various surgical subspecialties.
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Affiliation(s)
- Nicolas A Devaud
- Sarcoma Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | - Jean M Butte
- Sarcoma Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | - Juan C De la Maza
- Vascular Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | | | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30307, USA
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2
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Gajardo JA, Matute J, Charles R, Devaud N, Hoefler S, Schmied S, Rigo-Righi D, Butte JM. Starting a peritoneal carcinomatosis treatment program in a developing country: A prospective analysis. J Surg Oncol 2021; 124:1154-1160. [PMID: 34324203 DOI: 10.1002/jso.26626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/31/2021] [Accepted: 07/18/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) has become a valuable treatment strategy for selected patients with peritoneal carcinomatosis (PC). In Chile, it is an emerging technique. The aim of this study is to describe our protocol and report our perioperative results. METHODS A prospectively maintained database for patients undergoing exploratory surgery for PC was reviewed. Eligible patients were selected using the peritoneal cancer index in correlation with the primary tumor. Patients underwent HIPEC using mitomycin C. Clinical data and postoperative results were analyzed. RESULTS Seventy-six patients underwent exploratory surgery. Most patients were female (55%) with a median age of 62 years (range, 25-83). Complete CRS and HIPEC were achieved in 53 patients. The most frequent primary tumor site was colon-rectum (49%). The median number of resected organs was 4 (range, 1-13). Overall 90-day incidence of major complications was 26%. After a median follow-up of 26 months, 44 patients (83%) in the resected group were alive with no evidence of disease. CONCLUSIONS The PC treatment program at our institution has been established in a safe manner, with acceptable morbidity comparable to high-volume centers. A comprehensive preoperative evaluation, careful patient selection, and a cohesive team are necessary for successful results.
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Affiliation(s)
- Jorge A Gajardo
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Jorge Matute
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Roberto Charles
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Nicolás Devaud
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Sebastian Hoefler
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Silvia Schmied
- Anesthesia Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Daniella Rigo-Righi
- Anesthesia Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | - Jean M Butte
- Gastrointestinal Surgical Oncology Service, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
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3
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Villanueva L, Anabalon J, Butte JM, Salman P, Panay S, Milla E, Gallardo C, Hoefler S, Charles R, Reyes F, Barajas O, Matamala L, Molina A, Portiño S, Berrios M, Caglevic C, Mahave M. Total neoadjuvant chemotherapy with FLOT scheme in resectable adenocarcinoma of the gastro-oesophageal junction or gastric adenocarcinoma: impact on pathological complete response and safety. Ecancermedicalscience 2021; 15:1168. [PMID: 33680082 PMCID: PMC7929772 DOI: 10.3332/ecancer.2021.1168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Indexed: 11/06/2022] Open
Abstract
Background Gastric cancer is the fifth cause of cancer incidence worldwide. Multidisciplinary approaches that improve the survival are needed. Perioperative chemotherapies show improvement in pathological complete remission (pCR) and overall survival (OS), but less than 50% of the patients completed the chemotherapeutic regimen. The recent 5-fluorouracil, leucovorin, oxaliplatin, docetaxel-4 (FLOT4) study shows OS 50 months and pCR 16.6%, but only 46% of the patients completed pre- and postoperative treatment. This case series report evaluated pCR and safety in patients that received complete preoperative chemotherapeutic with FLOT. Methods Patients received eight cycles FLOT regimen before surgery. Each cycle comprised 50 mg/m2 docetaxel intravenous (iv) on day 1, 85 mg/m2 oxaliplatin iv on day 1, 200 mg/m2 leucovorin iv on day 1 and 2,600 mg/m2 5-fluorouracil iv in a 24-hour infusion on day 1, every 2 weeks. Results Fifty-nine patients were evaluated, 58 patients received preoperative cycles. Thirty-one patients received all eight cycles of preoperative therapy. 65.5% patients presented any major adverse event. Thirty-nine patients underwent surgery. Thirty-three biopsy reports were obtained. Six patients (18.2%) presented pCR, 13 patients (39.4%) had no lymph node involvement. OS was 21.32 months. Patients with histology of signet ring carcinoma cells had a shorter survival than other histologies. Conclusion Total neoadjuvant with FLOT chemotherapy presents an adequate safety profile, a similar pathologic regression rate, and a slightly higher rate of completing treatment to report in perioperative FLOT regimen studies. A prospective clinical study with suitable diagnostic, staging tools and an adequate follow-up may prove total neoadjuvant chemotherapy’s efficacy.
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Affiliation(s)
- Luis Villanueva
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile.,Department of Oncology, Hospital Clinico Universidad de Chile, Santiago, 8380456, Chile
| | - Jaime Anabalon
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Jean M Butte
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Pamela Salman
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Sergio Panay
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Elizabeth Milla
- Department of Oncology, Hospital Clinico San Borja Arriaran, Santiago, 8360160, Chile
| | - Carlos Gallardo
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Sebastian Hoefler
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Roberto Charles
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Felipe Reyes
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile.,Department of Oncology, Instituto Nacional del Cancer, Santiago, 8380455, Chile
| | - Olga Barajas
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile.,Department of Oncology, Hospital Clinico Universidad de Chile, Santiago, 8380456, Chile
| | - Luis Matamala
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile.,Department of Oncology, Instituto Nacional del Cancer, Santiago, 8380455, Chile
| | - Angelica Molina
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Sergio Portiño
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Marcela Berrios
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile.,Department of Oncology, Instituto Nacional del Cancer, Santiago, 8380455, Chile
| | - Christian Caglevic
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
| | - Mauricio Mahave
- Department of Oncology, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, 7500921, Chile
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4
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Narayan RR, Creasy JM, Goldman DA, Gönen M, Kandoth C, Kundra R, Solit DB, Askan G, Klimstra DS, Basturk O, Allen PJ, Balachandran VP, D'Angelica MI, DeMatteo RP, Drebin JA, Kingham TP, Simpson AL, Abou-Alfa GK, Harding JJ, O'Reilly EM, Butte JM, Matsuyama R, Endo I, Jarnagin WR. Regional differences in gallbladder cancer pathogenesis: Insights from a multi-institutional comparison of tumor mutations. Cancer 2018; 125:575-585. [PMID: 30427539 DOI: 10.1002/cncr.31850] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although rare in the United States, gallbladder cancer (GBCA) is a common cause of cancer death in some parts of the world. To investigate regional differences in pathogenesis and outcomes for GBCA, tumor mutations were analyzed from a sampling of specimens. METHODS Primary tumors from patients with GBCA who were treated in Chile, Japan, and the United States between 1999 and 2016 underwent targeted sequencing of known cancer-associated genes. Fisher exact and Kruskal-Wallis tests assessed differences in clinicopathologic and genetic factors. Kaplan-Meier methods evaluated differences in overall survival from the time of surgery between mutations. RESULTS A total of 81 patients were included. Japanese patients (11 patients) were older (median age, 72 years [range, 54-81 years]) compared with patients from Chile (21 patients; median age, 59 years [range, 32-73 years]) and the United States (49 patients; median age, 66 years [range, 46-87 years]) (P = .002) and had more well-differentiated tumors (46% vs 0% for Chile/United States; P < .001) and fewer gallstone-associated cancers (36% vs 67% for Chile and 69% for the United States; P = .13). Japanese patients had a median mutation burden of 6 (range, 1-23) compared with Chile (median mutation burden, 7 [range, 3-20]) and the United States (median mutation burden, 4 [range, 0-27]) (P = .006). Tumors from Japanese patients lacked AT-rich interaction domain 1A (ARID1A) and phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutations, whereas Chilean tumors lacked Erb-B2 receptor tyrosine kinase 3 (ERBB3) and AT-rich interaction domain 2 (ARID2) mutations. SMAD family member 4 (SMAD4) was found to be mutated similarly across centers (38% in Chile, 36% in Japan, and 27% in the United States; P = .68) and was univariately associated with worse overall survival (median, 10 months vs 25 months; P = .039). At least one potentially actionable gene was found to be altered in 80% of tumors. CONCLUSIONS Differences in clinicopathologic variables suggest the possibility of distinct GBCA pathogenesis in Japanese patients, which may be supported by differences in mutation pattern. Among all centers, SMAD4 mutations were detected in approximately one-third of patients and may represent a converging factor associated with worse survival. The majority of patients carried mutations in actionable gene targets, which may inform the design of future trials.
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Affiliation(s)
- Raja R Narayan
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - John M Creasy
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cyriac Kandoth
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ritika Kundra
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Solit
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gokce Askan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David S Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter J Allen
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vinod P Balachandran
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ronald P DeMatteo
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amber L Simpson
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ghassan K Abou-Alfa
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James J Harding
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eileen M O'Reilly
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jean M Butte
- Department of Gastrointestinal Surgery, Arturo Lopez Perez Foundation Cancer Institute, Santiago, Chile
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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5
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Villanueva L, Anabalon J, Barajas O, Gallardo C, Leal JL, Mahave M, Matamala L, Molina A, Reyes F, Salman P, Butte JM, Charles R, Devaud N, Hoefler S, Panay SE, Milla E, Muñoz MA, Caglevic C. Complete preoperative chemotherapy regimen FLOT: Evaluating the safety and histopathologic results in gastric cancer (GC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e16016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Luis Villanueva
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Jaime Anabalon
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Olga Barajas
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Carlos Gallardo
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Jose Luis Leal
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Mauricio Mahave
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Luis Matamala
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Angelica Molina
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Felipe Reyes
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Pamela Salman
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Jean M Butte
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Roberto Charles
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Nicolas Devaud
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | | | | | - Elizabeth Milla
- Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
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6
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Are C, Ahmad H, Ravipati A, Croo D, Clarey D, Smith L, Price RR, Butte JM, Gupta S, Chaturvedi A, Chowdhury S. Global epidemiological trends and variations in the burden of gallbladder cancer. J Surg Oncol 2017; 115:580-590. [DOI: 10.1002/jso.24546] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 12/17/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Chandrakanth Are
- Division of Surgical Oncology; Department of Surgery; University of Nebraska Medical Center; Omaha Nebraska
| | - Humera Ahmad
- Department of Surgery; Gundersen Medical Foundation; La Crosse Wisconsin
| | | | - Darren Croo
- Division of Surgical Oncology; Department of Surgery; University of Nebraska Medical Center; Omaha Nebraska
| | - Dillon Clarey
- Division of Surgical Oncology; Department of Surgery; University of Nebraska Medical Center; Omaha Nebraska
| | - Lynette Smith
- College of Public Health; University of Nebraska Medical Center; Omaha Nebraska
| | - Ray R. Price
- University of Utah Health Care; Salt Lake City; Utah
| | - Jean M. Butte
- Department of Surgery; Instituto Oncológico Fundación Arturo López Pérez; Rancagua 878 Santiago Chile
| | - Sameer Gupta
- Department of Surgical Oncology; King George's Medical University; Lucknow India
| | - Arun Chaturvedi
- Department of Surgical Oncology; King George's Medical University; Lucknow India
| | - Sanjib Chowdhury
- Section of Gastroenterology; Department of Medicine; Boston University Medical Center; Boston Massachusetts
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7
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Caglevic C, Gallardo J, de la Torre M, Mahave M, Müller B, Solé S, Moscoso Y, De La Fuente H, Roa JC, Hoefler S, Butte JM, González M P, O'Connor JM, Torres J, Pérez Encalada V, Alarcón Cano D, Ubillos L, Rolfo C, Lingua A, Díaz Romero C, Padilla Rosciano A, Cuartero V, Calderillo Ruiz G, Schwartsmann G, Kon Jara X, Andrade G A, Mas López L, Barajas O, Carballido M, Lembach H, Morillas G L, Roca E, Lobatón J, Montenegro B P, Yepes A, Marsiglia H. [Recommendations for the management of pancreatic cancer type adenocarcinoma: A consensus statement reached during the 2015 Latin American Symposium on Gastroenterological Oncology]. Rev Med Chil 2017; 144:1305-1318. [PMID: 28074986 DOI: 10.4067/s0034-98872016001000010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreatic cancer is a malignancy of great impact in developed countries and is having an increasing impact in Latin America. Incidence and mortality rates are similar for this cancer. This is an important reason to offer to the patients the best treatments available. During the Latin American Symposium of Gastroenterology Oncology (SLAGO) held in Viña del Mar, Chile, in April 2015, a multidisciplinary group of specialists in the field met to discuss about this disease. The main conclusions of this meeting, where practitioners from most of Latin American countries participated, are listed in this consensus that seek to serve as a guide for better decision making for patients with pancreatic cancer in Latin America.
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Affiliation(s)
| | | | - Marcela de la Torre
- Centro Especializado en Terapia Radiante, Hospital Clínicas San José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Mauricio Mahave
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile,
| | | | | | - Yuri Moscoso
- Unidad de Cuidados Paliativos, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | | | | | | | - Jean M Butte
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
| | | | - Juan Manuel O'Connor
- Sección de Tumores Gastrointestinales, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Javiera Torres
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Luis Ubillos
- Servicio de Oncología Clínica, Hospital de Clínicas, Montevideo, Uruguay
| | - Christian Rolfo
- Unidad de Desarrollo Temprano de Drogas-Estudios Fase I, Hospital Universitario de Antwerp, Amberes, Bélgica
| | - Alejo Lingua
- Área Oncología Digestiva, Clínica Privada Universitaria Reina Fabiola, Córdoba, Argentina
| | - Consuelo Díaz Romero
- Unidad Funcional de Tumores Digestivos, Instituto Nacional de Cancerología, México, México
| | | | | | | | | | | | | | - Luis Mas López
- Instituto Nacional de Enfermedades Neoplásicas,Lima,Perú
| | - Olga Barajas
- Instituto Oncológico Fundación Arturo López Pérez,Santiago,Chile
| | - Marcela Carballido
- Hospital de Gastroenterologia Dr. Carlos Bonorino Udaondo,Buenos Aires,Argentina
| | | | - Lena Morillas G
- Centro de Enfermedades Neoplásicas ONCOVIDA, La Paz, Bolivia
| | - Enrique Roca
- Hospital de Gastroenterologia Dr. Carlos Bonorino Udaondo,Buenos Aires,Argentina
| | | | | | - Andrés Yepes
- Fundación Colombiana de Cancerología, Medellín,Colombia
| | - Hugo Marsiglia
- nstituto Oncológico Fundación Arturo López Pérez,Santiago,Chile
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8
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Edwards JP, Bressan A, Dharampal N, Grondin SC, Datta I, Dixon E, Cleary SP, Barkun JS, Butte JM, Ball CG. Hepato-pancreato-biliary surgery workforce in Canada. Can J Surg 2015; 58:212-5. [PMID: 26011855 DOI: 10.1503/cjs.011414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This article characterizes the Canadian hepato-pancreato-biliary (HPB) surgery workforce (demographics, practice patterns, career satisfaction, education and recruitment plans). This information will serve as a baseline for future national comparisons, allow informed workforce planning and facilitate mathematical modelling of the HPB workforce in Canada.
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Affiliation(s)
- Janet P Edwards
- The Division of Thoracic Surgery, University of Calgary, Calgary, Alta
| | | | - Navjit Dharampal
- The Division of General Surgery, University of Calgary, Calgary, Alta
| | - Sean C Grondin
- The Division of Thoracic Surgery, University of Calgary, Calgary, Alta
| | - Indraneel Datta
- The Division of General Surgery, University of Calgary, Calgary, Alta
| | - Elijah Dixon
- The Division of General Surgery, University of Calgary, Calgary, Alta
| | - Sean P Cleary
- The Division of General Surgery, University of Toronto, Toronto, Ont
| | - Jeffrey S Barkun
- The Division of General Surgery, McGill University, Montréal, Que
| | - Jean M Butte
- The Division of General Surgery, University of Calgary, Calgary, Alta
| | - Chad G Ball
- The Division of General Surgery, University of Calgary, Calgary, Alta
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9
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Butte JM, Hameed M, Ball CG. Hepato-pancreato-biliary emergencies for the acute care surgeon: etiology, diagnosis and treatment. World J Emerg Surg 2015; 10:13. [PMID: 25767562 PMCID: PMC4357088 DOI: 10.1186/s13017-015-0004-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/02/2015] [Indexed: 12/19/2022] Open
Abstract
Hepatopancreatobiliary (HPB) emergencies include an ample range of conditions with overlapping clinical presentations and diverse therapeutic options. The most common etiologies are related to cholelithiasis (acute cholecystitis, pancreatitis, and cholangitis) and non-traumatic injuries (common bile duct or duodenal). Although the true incidence of HPB emergencies is difficult to determine due to selection and reporting biases, a population-based report showed a decline in the global incidence of all severe complications of cholelithiasis, primarily based on a reduction in acute cholecystitis. Even though patients may present with overlapping symptoms, treatment options can be varied. The treatment of these conditions continues to evolve and patients may require endoscopic, surgical, and/or percutaneous techniques. Thus, it is essential that a multidisciplinary team of HPB surgeons, interventional gastroenterologists and radiologists are available on an as needed basis to the Acute Care Surgeon. This focused manuscript is a contemporary review of the literature surrounding HPB emergencies in the context of the acute care surgeon. The main aim of this review is to offer an update of the diagnosis and management of HPB issues in the acute care setting to improve the care of patients with potential HPB emergencies.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, AB Canada
| | - Morad Hameed
- University of British Columbia, Vancouver, BC Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, AB Canada
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10
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Butte JM, Gönen M, Allen PJ, Peter Kingham T, Sofocleous CT, DeMatteo RP, Fong Y, Kemeny NE, Jarnagin WR, D'Angelica MI. Recurrence After Partial Hepatectomy for Metastatic Colorectal Cancer: Potentially Curative Role of Salvage Repeat Resection. Ann Surg Oncol 2015; 22:2761-71. [PMID: 25572686 DOI: 10.1245/s10434-015-4370-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with recurrence after complete resection of colorectal liver metastases (CLM) are considered for repeat resection as a potential salvage therapy (PST). However, outcomes for this approach are not well defined. We sought to analyze the natural history of recurrence and PST in a large cohort of patients with long-term follow-up. METHODS Recurrence patterns, treatments, and outcomes in consecutive patients undergoing resection for colorectal liver metastases were analyzed retrospectively. PST was defined as repeat resection of all recurrent disease and effective salvage therapy (EST) as free of disease for 36 months after last PST. Factors associated with PST, EST, and outcomes were analyzed. RESULTS Of 952 patients who underwent resection, 594 (62 %) experienced recurrence (median interval = 13 months). Initial recurrences involved liver (n = 157,26 %), lung (n = 167,28 %), multiple sites (n = 171,29 %), and other single sites (n = 99,17 %). PST was performed in 160 (27 %) of 594, most commonly with a single site of recurrence (n = 149). Young age (p = 0.01), negative initial resection margin (p = 0.003), initial tumor size <5 cm (p = 0.006), and recurrence pattern (p < 0.001) were independently associated with PST. Thirty-six patients experienced EST (25 % of PSTs). Overall median survival was 61 and 43 months in those with recurrence. Median survival of patients undergoing PST was 87 months compared to 34 months for those who did not. CONCLUSIONS Recurrence is common after CLM resection, but 27 % of patients were able to undergo PST. Approximately one-quarter of these experienced EST and may be cured. PST is associated with long-term survival and possible cure, and therefore active surveillance after CLM resection is justified.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Butte JM, Grendar J, Bathe O, Sutherland F, Grondin S, Ball CG, Dixon E. The role of peri-hepatic drain placement in liver surgery: a prospective analysis. HPB (Oxford) 2014; 16:936-42. [PMID: 25041265 PMCID: PMC4238861 DOI: 10.1111/hpb.12310] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/02/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The standard use of an intra-operative perihepatic drain (IPD) in liver surgery is controversial and mainly supported by retrospective data. The aim of this study was to evaluate the role of IPD in liver surgery. METHODS All patients included in a previous, randomized trial were analysed to determine the association between IPD placement, post-operative complications (PC) and treatment. A multivariate analysis identified predictive factors of PC. RESULTS One hundred and ninety-nine patients were included in the final analysis of which 114 (57%) had colorectal liver metastases. IPD (n = 87, 44%) was associated with pre-operative biliary instrumentation (P = 0.023), intra-operative bleeding (P < 0.011), Pringle's manoeuver(P < 0.001) and extent of resection (P = 0.001). Seventy-seven (39%) patients had a PC, which was associated with pre-operative biliary instrumentation (P = 0.048), extent of resection (P = 0.002) and a blood transfusion (P = 0.001). Patients with IPD had a higher rate of high-grade PC (25% versus 12%, P = 0.008). Nineteen patients (9.5%) developed a post-operative collection [IPD (n = 10, 11.5%) vs. no drains (n = 9, 8%), P = 0.470]. Seven (8%) patients treated with and 9(8%) without a IPD needed a second drain after surgery, P = 1. Resection of ≥3 segments was the only independent factor associated with PC [odds ratio (OR) = 2, P = 0.025, 95% confidence interval (CI) 1.1-3.7]. DISCUSSION In spite of preferential IPD use in patients with more complex tumours/resections, IPD did not decrease the rate of PC, collections and the need for a percutaneous post-operative drain. IPD should be reserved for exceptional circumstances in liver surgery.
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Affiliation(s)
| | | | | | | | | | | | - Elijah Dixon
- Correspondence: Elijah Dixon, Division of General Surgery, Faculty of Medicine, University of Calgary, EG – 26, Foothills Medical Centre, 1403-29 Street NW, Calgary, AB, Canada T2N 2T9. Tel: +1 403 944 3045. Fax: +1 403 944 1277. E-mail:
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Butte JM, Kingham TP, Gönen M, D'Angelica MI, Allen PJ, Fong Y, DeMatteo RP, Jarnagin WR. Residual disease predicts outcomes after definitive resection for incidental gallbladder cancer. J Am Coll Surg 2014; 219:416-29. [PMID: 25087941 DOI: 10.1016/j.jamcollsurg.2014.01.069] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 12/24/2013] [Accepted: 01/13/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Residual disease (RD) at definitive resection of incidental gallbladder cancer (IGBCA) influences outcome, but its clinical relevance with respect to anatomic site is incompletely characterized. STUDY DESIGN Consecutive patients with IGBCA undergoing re-exploration from 1998 to 2009 were identified; those submitted to a complete resection were analyzed. Demographics and tumor- and treatment-related variables were correlated with RD and survival. Cancer-specific survival was stratified by site of RD (local [gallbladder bed]; regional [bile duct, lymph nodes]; distant [discontiguous liver, port site, peritoneal]). RESULTS Of the 135 patients submitted to re-exploration, RD was found in 82 (61%) overall and in 63 (54%) of 116 patients submitted to resection; the most common site was regional (n = 27, 43%). The T stage of the gallbladder specimen was the only independent predictor of RD (T1b = 35.7%, T2 = 48.3%, T3 = 70%, p = 0.015). The presence of RD at any site dramatically reduced median disease-free survival (DFS) (11.2 vs 93.4 months, p < 0.0001) and disease-specific survival (DSS) (25.2 months vs not reached, p < 0.0001) compared with no RD, respectively. Disease-specific survival did not differ according to RD location, with all anatomic sites being equally poor (p = 0.87). Residual disease at any site predicted DFS (hazard ratio [HR] 3.3, 95% CI 1.9 to 5.7, p = 0.0003) and DSS (HR 2.4, 95% CI 1.2 to 4.6, p = 0.01), independent of all other tumor-related variables. CONCLUSIONS Survival in patients with RD at local or regional sites was not significantly different than that seen in stage IV disease, with neither subgroup clearly benefiting from reoperation. Outcomes were poor in all patients with RD, regardless of location.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
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Butte JM, Ball CG, Dixon E. Treatment of Unresectable Liver-Only Disease: Systemic Therapy versus Locoregional Therapy. Curr Surg Rep 2014. [DOI: 10.1007/s40137-014-0050-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tan MCB, Butte JM, Gonen M, Kemeny N, Fong Y, Allen PJ, Kingham TP, DeMatteo RP, Jarnagin WR, D'Angelica MI. Prognostic significance of early recurrence: a conditional survival analysis in patients with resected colorectal liver metastasis. HPB (Oxford) 2013; 15:803-13. [PMID: 23782400 PMCID: PMC3791120 DOI: 10.1111/hpb.12136] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/29/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND For patients undergoing liver resection for colorectal metastases, specific clinico-pathological variables have been shown to be prognostic at baseline. This study analyses how the prognostic capability of these variables changes in a conditional survival model. METHODS Retrospective review of a prospectively maintained database of patients who underwent an R0 resection of colorectal liver metastases from 1994 to 2004 at a single institution. RESULTS In total, 807 patients were identified, with an 87-month median follow-up for survivors. Five- and 10-year disease-specific survivals (DSS) were 68% and 55%, respectively. The probability of further survival increased as the survival time increased. For 3-year survivors (n = 504), DSS were no longer significantly different between patients with a low (0-2) or high (3-5) clinical risk score (CRS, P = 0.19). On multivariate analysis, independent predictors of DSS for 3-year survivors were recurrence within the first 3 years after a liver resection, a pre-operative carcinoembryonic antigen (CEA) >200 ng/ml and disease-free interval <12 months prior to the diagnosis of liver metastasis. However, for those patients who were recurrence free at 1 year, no clinico-pathological variables retained prognostic significance. DISCUSSION After 3 years of DSS and 1 year of recurrence-free survival, baseline clinico-pathological variables have a limited ability to predict future survival. Early post-operative recurrence appears to be the most useful single clinical feature in estimating conditional DSS.
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Affiliation(s)
- Marcus CB Tan
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Nancy Kemeny
- Department of Medicine, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
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Smith JD, Butte JM, Weiser MR, D'Angelica MI, Paty PB, Temple LK, Guillem JG, Jarnagin WR, Nash GM. Anastomotic leak following low anterior resection in stage IV rectal cancer is associated with poor survival. Ann Surg Oncol 2013; 20:2641-6. [PMID: 23385965 DOI: 10.1245/s10434-012-2854-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Indexed: 01/15/2023]
Abstract
BACKGROUND Anastomotic leak is a serious complication of low anterior resection (LAR). The risk of leak in stage IV rectal cancer patients treated with synchronous or staged resection of the primary tumour and metastatic sites has not been reported. We measured the incidence of anastomotic leak and its association with clinical outcome. METHODS With institutional review board approval, patients undergoing LAR and resection of metastatic disease were analyzed from a prospectively collected colorectal database between 1992 and 2010. Data for use of ileostomy, clinical anastomotic leak, and clinical risk score (for liver metastases, n = 86) were collected. Categorical variables were compared with the χ(2) test. Estimated overall survival was compared using log-rank method and Cox regression analysis. RESULTS A total of 184 patients with LAR and stage IV disease were identified. Of those, 123 had curative resection for disease at distant sites. 72 % underwent simultaneous resection, 28 % staged resection. Median follow-up was 2.9 years for survivors. Anastomotic leak occurred in 6.5 %. There was one perioperative death (not attributable to leak). Overall 3-year survival following a leak was significantly worse compared with patients without a leak (35 vs. 73 %, P = 0.01). Clinical leak was associated with worse survival when controlled for use of diverting stoma, operative year, clinical risk score, and timing of resection of metastatic disease. CONCLUSIONS In this series of patients with stage IV rectal cancer, anastomotic leak was uncommon. However, patients who developed a clinical leak following surgery had worse survival. This finding was independent of use of diverting stoma or staged resection.
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Affiliation(s)
- James D Smith
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Butte JM, Torres J, Veras EF, Matsuo K, Gönen M, D'Angelica MI, Waugh E, Meneses M, Inayama Y, Fong Y, Dematteo RP, De La Fuente H, Endo I, Klimstra DS, Jarnagin WR. Regional differences in gallbladder cancer pathogenesis: insights from a comparison of cell cycle-regulatory, PI3K, and pro-angiogenic protein expression. Ann Surg Oncol 2012; 20:1470-81. [PMID: 23212762 DOI: 10.1245/s10434-012-2761-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The variable incidence of gallbladder cancer (GBCA) suggests regional pathogenetic differences. This study compares cell cycle-regulatory, angiogenesis-related, and PI3K pathway protein expression in GBCAs from three continents. METHODS Immunohistochemical expression of several proteins was assessed, correlated with clinicopathologic variables, and compared among centers from Chile (Fundación Arturo López Pérez [FALP]), Japan (Yokohama City University [YCU]), and the United States (Memorial Sloan-Kettering Cancer Center [MSKCC]). Hierarchical clustering was used to partition the data based on protein-expression and treatment center. RESULTS Tissue from 117 patients (MSKCC = 76; FALP = 22; YCU = 19) was analyzed. Mdm2 overexpression was seen only at MSKCC (p < 0.0001). Absence of p21 (p = 0.03) and VEGFR2 (p = 0.018) were more common and p27 expression was less frequent (p = 0.047) in tumors from YCU. Ki-67 labeling index in YCU tumors (median = 10) was two-thirds lower than at other centers. On hierarchical clustering analysis, all YCU patients (p = 0.017) and those with early tumors (p = 0.017) clustered separately from MSKCC. Median disease-specific survival after curative intent (R0) resection was 27 months and was similar among centers (p = 0.9). Median disease-specific survival of patients with early tumors was 28.4 months and was higher at YCU (not reached, p = 0.06). CONCLUSIONS Cell cycle-regulatory protein expression patterns of YCU tumors differed from those treated at FALP and MSKCC. The differential clustering of protein expression and survival in patients with early tumors suggest regional differences in pathogenesis and disease biology.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Butte JM, Gonen M, Ding P, Goodman KA, Allen PJ, Nash GM, Guillem J, Paty PB, Saltz LB, Kemeny NE, Dematteo RP, Fong Y, Jarnagin WR, Weiser MR, D'Angelica MI. Patterns of failure in patients with early onset (synchronous) resectable liver metastases from rectal cancer. Cancer 2012; 118:5414-23. [PMID: 22517058 DOI: 10.1002/cncr.27567] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 02/14/2012] [Accepted: 02/16/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal combination of available therapies for patients with resectable synchronous liver metastases from rectal cancer (SLMRC) is unknown, and the pattern of recurrence after resection has been poorly investigated. In this study, the authors examined recurrence patterns and survival after resection of SLMRC. METHODS Consecutive patients with SLMRC (disease-free interval, ≤12 months) who underwent complete resection of the rectal primary and liver metastases between 1990 and 2008 were identified from a prospective database. Demographics, tumor-related variables, and treatment-related variables were correlated with recurrence patterns. Competing risk analysis was used to determine the risk of pelvic and extrapelvic recurrence. RESULTS In total, 185 patients underwent complete resection of rectal primary and liver metastases. One hundred eighty patients (97%) received chemotherapy during their treatment course, and 91 patients (49%) received pelvic radiation therapy either before (N = 65; 71.4%), or after (N = 26; 28.6%) rectal resection. The 5-year disease-specific survival rate was 51% for the entire cohort with a median follow-up of 44 months for survivors. One hundred thirty patients (70%) developed a recurrence: Eighteen patients (10%) had recurrences in the pelvis in combination with other sites, and 7 of these (4%) had an isolated pelvic recurrence. Recurrence pattern did not correlate with survival. Competing risk analysis demonstrated that the likelihood of a pelvic recurrence was significantly lower than that of an extrapelvic recurrence (P < .001). CONCLUSIONS Of the patients with SLMRC who developed recurrent disease, systemic sites were overwhelmingly more common than pelvic recurrences. The current results indicated that the selective exclusion of radiotherapy may be considered in patients who are diagnosed with simultaneous disease.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Butte JM, Waugh E, Parada H, De La Fuente H. Combined total gastrectomy, total esophagectomy, and D2 lymph node dissection with transverse colonic interposition for adenocarcinoma of the gastroesophageal junction. Surg Today 2011; 41:1319-23. [DOI: 10.1007/s00595-010-4412-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Accepted: 06/02/2010] [Indexed: 12/17/2022]
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Butte JM, Gönen M, Allen PJ, D'Angelica MI, Kingham TP, Fong Y, DeMatteo RP, Blumgart L, Jarnagin WR. The role of laparoscopic staging in patients with incidental gallbladder cancer. HPB (Oxford) 2011; 13:463-72. [PMID: 21689230 PMCID: PMC3133713 DOI: 10.1111/j.1477-2574.2011.00325.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of staging laparoscopy (SL) in patients with incidental gallbladder cancer (IGBC) is ill defined. This study evaluates the utility of SL with the aim of identifying variables associated with disseminated disease (DD). METHODS Consecutive patients with IGBC who underwent re-exploration between 1998 and 2009 were identified from a prospective database. The yield and accuracy of SL were calculated. Demographics, tumour- and treatment-related variables were correlated with findings of DD. RESULTS Of the 136 patients submitted to re-exploration for possible definitive resection, 19 (14.0%) had DD. Staging laparoscopy was carried out in 46 (33.8%) patients, of whom 10 (21.8%) had DD (peritoneal disease [n = 6], liver metastases [n = 3], retroperitoneal disease [n = 1]). Disseminated disease was identified by SL in two patients (yield = 4.3%), whereas eight were diagnosed after conversion to laparotomy (accuracy = 20.0%). The likelihood of DD correlated closely with T-stage (T1b, n = 0; T2, n = 5 [7.0%], T3, n = 14 [26.0%]; P = 0.004). A positive margin at initial cholecystectomy (odds ratio [OR] 5.44, 95% confidence interval [CI] 1.51-24.37; P = 0.004) and tumour differentiation (OR 7.64, 95% CI 1.1-NA; P= 0.006) were independent predictors of DD on multivariate analysis. DISCUSSION Disseminated disease is relatively uncommon in patients with IGBC and SL provides a very low yield. However, patients with poorly differentiated, T3 or positive-margin gallbladder tumours are at high risk for DD and targeting these patients may increase the yield of SL.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | | | - T Peter Kingham
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Yuman Fong
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - Leslie Blumgart
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer CenterNew York, NY, USA
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Maker AV, Butte JM, Oxenberg J, Kuk D, Gonen M, Fong Y, Dematteo RP, D'Angelica MI, Allen PJ, Jarnagin WR. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol 2011; 19:409-17. [PMID: 21698501 DOI: 10.1245/s10434-011-1850-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND In selected patients with incidental gallbladder carcinoma (GBCA) diagnosed after laparoscopic cholecystectomy (LC), definitive resection is warranted. Port site excision has been advocated but remains controversial. METHODS Patients with GBCA were identified through institutional/departmental databases. The subset of patients with incidental tumors identified after LC and submitted to definitive surgical therapy were selected. Those subjected to port site resection were compared with patients who underwent resection without port site removal and analyzed for differences in recurrence patterns and survival. RESULTS From 1992 to 2009, 113 patients with incidental GBCA presented for definitive resection after LC; 69 patients had port site resection and 44 did not. In the resected port site group, depth of tumor invasion was T1b = 6, T2 = 35, T3 = 28, and 13 (19%) had port site metastases. Port site disease was seen only in patients with T2 or T3 tumors and correlated with the development of peritoneal metastases (P = 0.01). Median survival of patients with T2/T3 tumors without port site metastases was 42 months compared to 17 months in patients with port site disease (P = 0.005). When only R0 resected patients were compared and adjusted for T and N stage, port site resection was not associated with overall survival (P = 0.23) or recurrence-free survival (P = 0.69). CONCLUSIONS In patients with incidental GBCA, port site metastases were associated with peritoneal disease and decreased survival. Port site resection was not associated with improved survival or disease recurrence and should not be considered mandatory during definitive surgical treatment.
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Affiliation(s)
- Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
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Maker AV, Butte JM, Oxenberg J, Kuk D, Gonen M, Fong Y, Dematteo RP, D'Angelica MI, Allen PJ, Jarnagin WR. Is port site resection necessary in the surgical management of gallbladder cancer? Ann Surg Oncol 2011. [PMID: 21698501 DOI: 10.1245/s10434-011-1850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In selected patients with incidental gallbladder carcinoma (GBCA) diagnosed after laparoscopic cholecystectomy (LC), definitive resection is warranted. Port site excision has been advocated but remains controversial. METHODS Patients with GBCA were identified through institutional/departmental databases. The subset of patients with incidental tumors identified after LC and submitted to definitive surgical therapy were selected. Those subjected to port site resection were compared with patients who underwent resection without port site removal and analyzed for differences in recurrence patterns and survival. RESULTS From 1992 to 2009, 113 patients with incidental GBCA presented for definitive resection after LC; 69 patients had port site resection and 44 did not. In the resected port site group, depth of tumor invasion was T1b = 6, T2 = 35, T3 = 28, and 13 (19%) had port site metastases. Port site disease was seen only in patients with T2 or T3 tumors and correlated with the development of peritoneal metastases (P = 0.01). Median survival of patients with T2/T3 tumors without port site metastases was 42 months compared to 17 months in patients with port site disease (P = 0.005). When only R0 resected patients were compared and adjusted for T and N stage, port site resection was not associated with overall survival (P = 0.23) or recurrence-free survival (P = 0.69). CONCLUSIONS In patients with incidental GBCA, port site metastases were associated with peritoneal disease and decreased survival. Port site resection was not associated with improved survival or disease recurrence and should not be considered mandatory during definitive surgical treatment.
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Affiliation(s)
- Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
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Butte JM, Do RK, Shia J, Gönen M, D'Angelica MI, Getrajdman GI, Allen PJ, Fong Y, Dematteo RP, Klimstra DS, Jarnagin WR. Liver angiomyolipomas: a clinical, radiologic, and pathologic analysis of 22 patients from a single center. Surgery 2011; 150:557-67. [PMID: 21621235 DOI: 10.1016/j.surg.2011.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 03/22/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver angiomyolipomas (AML) are mesenchymal neoplasms with an uncertain clinical behavior. The spectrum of presentation, imaging and histologic features, and outcomes were analyzed in all patients treated at Memorial Sloan-Kettering Cancer Center. METHODS Demographics, disease, pathologic, treatment, and outcome-related variables for consecutive patients were reviewed retrospectively. All imaging studies obtained at presentation were reexamined, categorized, and compared using Fisher and Wilcoxon tests. RESULTS Between 1989 and 2010, 238 patients with AML were seen and 22 (9.3%) had liver involvement (exclusive = 17; combined with kidney = 5). The median age was 53 years; 18 were females, and 15 had symptoms. AML was not suspected at initial presentation in any patient. Fat-containing neoplasms on imaging were larger (P = .03), with more heterogeneous enhancement compared with fat-poor neoplasms (P = .001), but none of the imaging/histologic features correlated with outcome. Thirteen patients underwent resection (R0 = 9), 4 were observed, 2 received chemotherapy, 2 embolization, and 1 embolization plus intra-arterial chemotherapy. Two patients treated with R0-resection recurred and 2 treated with chemotherapy progressed, but no patient died of AML-related causes. At a median follow-up of 36 months, 7 patients were free of disease, 13 were alive with disease, 1 died of an unrelated cause, and another was lost to follow-up. CONCLUSION AMLs are rare neoplasms with an indolent course in most patients. Subtypes based on fat content are recognized, but clinical behavior does not seem to be different. Recurrence after resection is not associated with disease-related mortality. Resection may be unnecessary in selected asymptomatic patients if the diagnosis can be established definitively.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Yopp AC, Shia J, Butte JM, Allen PJ, Fong Y, Jarnagin WR, DeMatteo RP, D'Angelica MI. CXCR4 expression predicts patient outcome and recurrence patterns after hepatic resection for colorectal liver metastases. Ann Surg Oncol 2011; 19 Suppl 3:S339-46. [PMID: 21584832 DOI: 10.1245/s10434-011-1774-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to determine if the expression of the chemokine receptors, CXCR4 and CCR7, and the chemokine ligand, CXCL12, in completely resected colorectal cancer hepatic metastases are predictive of disease-specific survival, recurrence-free survival and patterns of recurrence. METHODS Immunohistochemical analysis of CXCR4, CCR7 and CXCL12 expression within resected hepatic metastases was performed and correlated with clinicopathological variables, disease-specific survival, recurrence-free survival and patterns of recurrence. RESULTS Seventy-five patients who underwent partial hepatectomy with curative intent were studied. CXCR4 expression (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 1.4-9.1) and clinical risk score >2 (HR 2.3, 95% CI 1.1-4.7) were independently associated with disease-specific survival by multivariate analysis. The 5-year estimated disease-specific survival rates for positive and negative CXCR4 tumor expression were 44 and 77%, respectively (P = 0.005). CXCR4 expression (HR 2.2, 95% CI 1.2-4.2) and clinical risk score >2 (HR 1.9, 95% CI 1.1-3.4) were independently associated with recurrence-free survival by multivariate analysis. The five year estimated recurrence-free survival rates for positive and negative CXCR4 tumor expression were 20 and 50%, respectively (P = 0.004). Neither CXCL12 nor CCR7 expression in tumors predicted disease-specific survival or recurrence-free survival. Forty-nine patients (65%) developed recurrent disease after initial hepatectomy. Negative CXCR4 tumor expression was associated with favorable recurrence patterns amenable to salvage resection and/or ablation. CONCLUSIONS Negative CXCR4 expression in resected colorectal cancer hepatic metastases is independently associated with improved disease-specific and recurrence-free survival and favorable patterns of recurrence.
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Affiliation(s)
- Adam C Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Butte JM, Brennan MF, Gönen M, Tang LH, D'Angelica MI, Fong Y, Dematteo RP, Jarnagin WR, Allen PJ. Solid pseudopapillary tumors of the pancreas. Clinical features, surgical outcomes, and long-term survival in 45 consecutive patients from a single center. J Gastrointest Surg 2011; 15:350-7. [PMID: 20824369 DOI: 10.1007/s11605-010-1337-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 08/18/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Solid pseudopapillary tumors of the pancreas (SPT) are rare neoplasms, and the natural history is poorly defined. The aim of this study was to define the natural history and compare patient and tumor factors between patients with malignant and non-malignant disease. METHODS Data for all patients with SPT who underwent surgical exploration at MSKCC between 1987 and 2009 were collected and analyzed. Patient, tumor, treatment, and survival variables were examined. Malignant tumors were defined as any tumor that was locally unresectable, metastatic, or recurrent. Differences between groups were analyzed by Fisher's exact, chi-squared, Wilcoxon, and log-rank tests. RESULTS Forty-five patients had an SPT during the study period. Median age was 38 years (10-63) and 38 (84%) were women. At the time of diagnosis, 38 were symptomatic, with the most common symptom being abdominal pain (n = 35). The most frequent imaging characteristic was a solid and cystic tumor (n = 29), most commonly located in the tail of the pancreas (n = 23). Resection of the primary tumor (n = 41) (41/2,919 = 1.4% of all resections) included distal pancreatectomy in 26, pancreatoduodenectomy in 11, central pancreatectomy in two, and enucleation in two. Nine patients had malignant disease defined by a locally unresectable tumor in three, liver metastases in three, locally unresectable tumor and liver metastases in one, local recurrence and liver metastases in one, and local recurrence in another. Patients with malignant disease presented with larger tumors (7.8 vs. 4.2 cm) (p < 0.005). After median follow-up of 44 months, 34 patients were without evidence of disease, four patients were alive with disease, three patients died of disease, and four patients died of other causes. CONCLUSIONS These results demonstrate that SPT occurs in young women, and the majority of patients will experience long-term survival following resection. The only feature associated with malignant disease was tumor size at presentation. The majority of patients are alive at last follow-up, and a low percentage experienced disease recurrence or death from disease.
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Affiliation(s)
- Jean M Butte
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Butte JM, Waugh E, Meneses M, Parada H, De La Fuente HA. Incidental gallbladder cancer: analysis of surgical findings and survival. J Surg Oncol 2010; 102:620-5. [PMID: 20721958 DOI: 10.1002/jso.21681] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Incidental gallbladder cancer (IGBCA) has risen worldwide and its prognosis depends on complete radical cholecystectomy (CRC). This study evaluated surgical findings during re-operation and survival of patients with IGBCA. METHODS Demographics, surgical treatment, staging, and survival data for all IGBCA patients who underwent surgery at Instituto Oncológico Fundación Arturo López Pérez (FALP) between 2000 and 2008 were analyzed. Differences between groups were analyzed by Student's t-test, Mann-Whitney, chi-square, or Fisher log-rank tests. RESULTS Forty-nine patients were studied (38 women/11 men, median age = 58 years). Pathology reports from cholecystectomy showed that 32 patients had a T2 tumor and 12 had positive resection margin. Thirty-six patients underwent surgical re-exploration and 20 underwent CRC; 10 with (+) residual disease and 10 with (-). For patients with at least T1b tumor, median survival was 28 months and 5-year disease-specific survival (DSS) was 29%. The 3-year DSS was 64% for CRC (-), 30% for CRC (+), and 8% for non-resected cases (P < 0.007). The 3-year DSS was better for patients with stage Ib than those with stages II and IV (P < 0.007). CONCLUSIONS Patients with IGBCA have a high chance of intra-abdominal metastases or local residual disease. In CRC patients, intra-abdominal metastases were associated with a worse prognosis.
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Affiliation(s)
- Jean M Butte
- Department of Gastrointestinal Surgery, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
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Butte JM, Kerrigan N, Waugh E, Meneses M, Parad H, Visscher A, Becker F, De la Fuente H. [Complications and mortality of extended gastrectomy for gastric cancer]. Rev Med Chil 2010; 138:1487-1494. [PMID: 21526296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Extended gastrectomy allows a complete tumor excision in patients with advanced gastric cancer. AIM To compare the surgical results of extended (ER) and non-extended gastrectomy (NER) among patients with gastric cancer, and determine factors associated with complications and mortality. MATERIAL AND METHODS Review of medical records of patients with gastric cancer who underwent complete resection between 2002 and 2008 in an oncological hospital. Demographics, patient-related and therapeutic features were compared between groups, and independent factors were established with multivariate analysis. RESULTS Seventy four patients, (44 men, median age 62 years) underwent an ER and 103 patients, (56 men, median age 61 years) a NER. Specifically, ER included splenectomy alone in 27 patients, splenectomy associated with other procedure in 24, partial esophagectomy in 18, distal pancreatectomy in 13, hemicolectomy in 8, total esophagectomy in 7, partial hepatectomy in 4, and adrenalectomy in 1. Postoperative complications were observed in 19 patients treated with an ER (26%) and in 11 patients treated with a NER (11%), p < 0.05. Serious complications were higher in patients who underwent an ER compared with NER (6 patients (8%) vs. 4 (4%), respectively) p < 0.05. In the same way, mortality was higher in patients treated with ER when it was compared with NER (4 patients (5%) vs two (2%), respectively), p < 0.05. ER and serum albumin levels were independent factors associated to a higher risk of mortality and rate of complications. CONCLUSIONS ER was associated with a higher rate of general and severe complications, and mortality.
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Affiliation(s)
- Jean M Butte
- Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
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Butte JM, Visscher A, DE LA Fuente H, Meneses M, Carrasco AM, Amaral H, Waugh E. [Esophageal melanoma: report of two cases]. Rev Med Chil 2010; 138:77-81. [PMID: 20361155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Esophageal melanomas correspond to 0.1 to 0.2% of esophageal tumors. We report two patients with the disease. The first patient is a 51 year-old woman pre-sentingwith dysphagia and weight loss. An upper gastrointestinal endoscopy showed a polypoid ulcerated lesion in the middle third of the esophagus. The pathological study ofthe biopsy disclosed a malignant melanoma. The patient was subjected to an esophagectomy with a satisfactory postoperative evolution. Four months later, liver metastases were detected and the patient died eleven months after the operation. The second patient is a 59 year-old mole that consulted by dysphagia. An endoscopy showed a pigmented esophageal lesion whose pathological diagnosis was a malignant melanoma. The patient was subjected to an esophagectomy and sixteen months after surgery there was no evidence of relapse.
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Affiliation(s)
- Jean M Butte
- Servicio de Cirugía Digestiva Oncológica, Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
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Butte JM, Becker F, Visscher A, Waugh E, Meneses M, Court I, Parada H, DE LA Fuente H. [Adenocarcinoma of the esophagogastric junction: retrospective analysis of 39 patients]. Rev Med Chil 2010; 138:53-60. [PMID: 20361151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND The long-term survival of adenocarcinoma of the esophago-gastric junction is poor and depends on the possibility of performing a complete surgical excision and the absence of lymph node involvement. AIM To report surgical results and survival of patients with adenocarcinoma of the esophago-gastric junction. MATERIAL AND METHODS Retrospective review of medical records of patients with adenocarcinoma of the esophago-gastric junction, subjected to a curative surgical procedure between 2000 and 2008. Deaths that occurred within 60 days of the operation were considered operative mortality. Tumor stage was determined using TNM and Siewert pathological classifications. RESULTS Thirty-nine patients aged 40 to 80years (27 men), were operated. According to Siewert classification, seven patients had type I, six type II and 26 type III tumors. Twenty-two patients were subjected to a total gastrectomy with partial excision of distal esophagus and mediastinal reconstruction, 10patients were subjected to a trans-hiatal esophagectomy and seven to a total esophagogastrectomy. According to postoperative staging, five patients were in stage I, 12 in stage II, nine in stage III and 13 in stage IV. Median, three and five year's survival figures were 21.4 months, 33 and 25%, respectively. Lymph node and perineural involvement was associated with a lower survival. Well differentiated and stage I tumors had a better survival. Multivariate analysis showed that the presence of a type III tumor, N3 lymph node involvement and vascular permeation were independent predictors' ofa lower survival. CONCLUSIONS Among patients with adenocarcinoma of the esophago-gastric junction, type III tumors, lymph node involvement and vascular permeations are associated with a lower survival.
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Butte JM, Torres J, Viviani P, Duarte I, Crovari F, Guzmán S, Cabrera R, Pedemonte J, Llanos O. [Long term survival of patients operated for early gastric cancer]. Rev Med Chil 2009; 136:1424-30. [PMID: 19301773 DOI: 10.4067/s0034-98872008001100008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early gastric cancer involves mucosa and submucosa, independent of lymph node involvement. Radical gastrectomy is the standard treatment. AIM To assess long term survival of patients operated for an early gastric cancer. MATERIAL AND METHODS Retrospective review of medical and pathology records of patients subjected to a gastrectomy for an early gastric cancer, between 1975 and 2002. All were treated using a standardized protocol and staged according to 2002 TNM classification of the American Joint Committee of Cancer (AJCC). Demographic and pathologic features, operation performed and long term survival were recorded. Survival was analyzed using Kaplan-Meier method. RESULTS The series is comprised by 64 males and 41 females aged 61 +/- 1 years. Tumor was located in the upper third of the stomach on 33 subjects and a total gastrectomy was performed in 53. Pathology showed an intestinal type adenocarcinoma in 82 and a diffuse type in 23. In patients with involvement of mucosa and submucosa, 24 +/- 14 and 22 +/- 14 lymph nodes were excised, respectively. Lymph node involvement was present in 8% and 22% of patients with involvement of mucosa and submucosa, respectively. Five years survival was 94% and 78% in patients without and with lymph node involvement, respectively. Survival among patients in stage IA and IB was 94% and 76%, respectively. Multivariate analysis showed that the lymph node involvement was an independent mortality risk factor. CONCLUSIONS Total gastrectomy in patients with early gastric cancer is associated with a good survival. Lymph node involvement is a mortality risk factor.
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Affiliation(s)
- Jean M Butte
- Departamento de Cirugía Digestiva, Pontificia Universidad Católica de Chile, Santiago, Chile
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Butte JM, Redondo F, Waugh E, Meneses M, Pruzzo R, Parada H, Amaral H, De La Fuente HA. The role of PET-CT in patients with incidental gallbladder cancer. HPB (Oxford) 2009; 11:585-91. [PMID: 20495711 PMCID: PMC2785954 DOI: 10.1111/j.1477-2574.2009.00104.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2009] [Accepted: 06/16/2009] [Indexed: 12/12/2022]
Abstract
INTRODUCTION After a cholecystectomy, incidental gallbladder cancer (IGC) requires accurate imaging studies to determine the actual extent of the disease to properly tailor subsequent treatment. The aim of this study was to evaluate the utility of (18)F-fluorodeoxyglucose positron emission tomography-computed tomography ((18)FDG PET-CT) to provide optimal pre-treatment staging in patients with IGC. MATERIAL AND METHODS Between January 2006 and August 2008, all patients with IGC and at least muscular layer invasion were studied with (18)FDG PET-CT. The examination was considered positive when the standardized uptake values (SUV) were >/=2.5. In all instances patients were offered to undergo definitive exploration and possible radical resection. RESULTS The series included 32 patients, 26 women and 6 men, with a median age of 57 years (range 30-81 years). The examination was performed at a median time of 6 weeks after cholecystectomy (range 2-52 weeks). (18)FDG PET-CT was negative in 13 patients and positive in 19 patients: 9 with localized potentially resectable disease (PRD) and in 10 with disseminated disease. Of the 13 patients with negative PET-CT, 9 refused surgery and 4 underwent formal exploration: 3 patients were resected with no disease identified in the final pathology report (FPR) and 1 was not resected as a result of peritoneal carcinomatosis. Of the 9 with PRD, 4 patients refused reoperation and 5 underwent exploration: 3 were resected with residual disease noted in the FPR and 2 did not undergo resection because of dissemination. Two patients with disseminated disease were reoperated and in both instances disseminated disease was confirmed. The median survival for the entire group was 20.3 months (range 1.6-32.9 months). The median survival for those patients with negative PET-CT was 13.5 months (range 5.6-32.9 months), 6.2 months (range 1.6-18.7 months) for localized potentially resectable disease and 4.9 months (range 2-14.1 months) for disseminated disease (P < 0.003). CONCLUSIONS For patients presenting with stage T1b or greater IGC, the use of (18)FDG PET-CT will help reduce the number of patients undergoing non-therapeutic re-exploration and may help to determine the likely prognosis. (18)FDG PET-CT might be a useful tool for the selection of patients for potentially curative treatment.
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Affiliation(s)
- Jean M Butte
- Instituto Oncológico Fundación Arturo López Pérez Santiago, Chile
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Concha MR, Mertz VF, Cortínez LI, González KA, Butte JM. Pulse Contour Analysis and Transesophageal Echocardiography: A Comparison of Measurements of Cardiac Output During Laparoscopic Colon Surgery. Anesth Analg 2009; 109:114-8. [DOI: 10.1213/ane.0b013e3181a491b8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Butte JM, Marín L, Meneses M, De la Fuente H, Pruzzo R, Redondo F, Parada H, Amaral H, Waugh E. Thyroid metastases from gallbladder cancer. J Gastrointest Surg 2009; 13:1389-91. [PMID: 19023633 DOI: 10.1007/s11605-008-0743-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 10/28/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gallbladder cancer is an aggressive malignancy and radical resection is the only curative therapy available. Metastatic disease in the thyroid is rarely seen; however, different studies have confirmed that the most common primary tumor source is the kidney. CASE REPORT Thyroid metastases from tumors originating in the gastrointestinal tract have been reported. We report a patient with gallbladder cancer (T2N1M0) treated with radical resection and postoperative chemoradiation who developed thyroid metastases.
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Affiliation(s)
- Jean M Butte
- Instituto Oncológico Fundación Arturo López Pérez, Rancagua, 878, Santiago, Chile
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Amaral H, Pruzzo R, Redondo F, Gil MC, Pizarro A, de la Fuente H, Butte JM, Coudeu TMI. [Detection of neuroendocrine tumors by positron emission tomography-computed tomography with 68Ga-DOTATATE: report of one case]. Rev Med Chil 2009; 137:537-541. [PMID: 19623420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We report a 74-year-old male with liver metastases from a neuroendocrine tumor (NET) of unknown origin. Conventional imaging studies with ultrasound, computed tomography colonoscopy and Positron emission tomography-computed tomography (PET/CT) with 18Fluor odeoxyglucose did not identify the site of origin of the primary tumor. The patient was submitted for a PET/CT scan with a new radiopharmaceuticai, the somatostatin analogue 68Ga-DOTATATE. This new technique demonstrated increased focal uptake at the ileocecal valve. This lesion and other two liver metastases were surgically removed. The histopathology and immunohistochemistry analysis confirmed the diagnosis of NET (carcinoid). This case illustrates the advantages of the PET/CT scan with 68Ga-DOTATATE.
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Norero E, Jarufe N, Butte JM, Norero B, Duarte I, Torres J, Pinedo G, López F, Guerra JF, Ibáñez L, Zúñiga Á, Guzmán S, Martínez J. Resultados del tratamiento quirúrgico de las metástasis hepáticas por cáncer colorrectal. Rev Med Chil 2009. [DOI: 10.4067/s0034-98872009000400006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Amaral H, Pruzzo R, Redondo F, Gil MC, Pizarro A, de la Fuente H, Butte JM, Coudeu TI. Una nueva modalidad diagnóstica para la detección de tumores neuroendocrinos con 68Ga-DOTATATE PET/CT: Caso clínico. Rev Med Chil 2009. [DOI: 10.4067/s0034-98872009000400012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Norero E, Jarufe N, Butte JM, Norero B, Duarte I, Torres J, Pinedo G, López F, Guerra JF, Ibáñez L, Zúñiga A, Guzmán S, Martínez J. [Outcome of surgical treatment of liver metastasis from colorectal cancer]. Rev Med Chil 2009; 137:487-496. [PMID: 19623414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Surgical resection is the only treatment associated with long-term cure in patients with liver metastasis from colorectal cancer, achieving a 30% to 40% five years survival. AIM To evaluate the results of liver resection for metastatic colorectal cancer in our centre. PATIENTS AND METHODS Retrospective study. Epidemiological, perioperative and follow up data of patients undergoing liver resection for metastatic colorectal cancer between January 1990 and July 2007 were assessed. We compared the results between two periods; period 1 (1990-1997) and period 2 (1998-2007). RESULTS Sixty six patients aged 61+/- 12 years (46 males) underwent 75 resections. An anatomical excision was performed in 54 (72%) cases, a right hepatectomy in 18, an extended right hepatectomy in 11, a left hepatectomy in 1, and a segmentectomy in 24. In 24 (32%) patients the liver resection was simultaneous with the colorectal cancer resection. Operative time was 221+/-86 min. Hospital stay was 11+/-5 days. Postoperative morbidity was 35% and surgical mortality was 0%. Resection margin was free of tumor in 53 (80%) patients. Five years overall and hepatic disease-free survival was 38% and 23%, respectively. In period 2, more anatomical resections than in period 1 were performed (77% and 55%, respectively, p =0.04), without an increase in complications (35% and 34%, respectively; p =ns), but with a better five years survival (45% and 21 %, respectively, p =0.04). CONCLUSIONS Five years survival for excision of liver metastatic colorectal cancer in our center is similar to that reported abroad. During the second period there has been a trend toward more extensive resections which was associated with a better survival, without an increase in complications or mortality .
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Affiliation(s)
- Enrique Norero
- Departamento de Cirugía Digestiva, División de Cirugía, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Butte JM, Meneses M, Waugh E, Parada H, De La Fuente H. Ileal intussusception secondary to small bowel metastases from melanoma. Am J Surg 2009; 198:e1-2. [PMID: 19268910 DOI: 10.1016/j.amjsurg.2008.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 12/30/2022]
Abstract
A 54-year-old man on palliative treatment for disseminated cutaneous malignant melanoma presented with abdominal pain and abdominal distention. A computed tomography scan showed an area in the distal ileum suggesting intussusceptions. In an exploratory laparotomy, a 10-cm mass was found comprised of the distal ileum that had intussuscepted secondary to the small bowel metastases of melanoma. A palliative resection of 2 segments of the small bowel was performed.
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Affiliation(s)
- Jean M Butte
- Department of Digestive Surgery, Instituto Oncológico Fundación Arturo López Pérez, Rancagua 678, Santiago, Chile.
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Butte JM, Waugh E, Meneses M, Pruzzo R, Carvallo C, Redondo F, Suárez C, Parada H, Amaral H, de La Fuente H. Carcinoma hepatocelular variedad fibrolamelar metastásico en menores de 20 años: Reporte de 2 casos tratados con intención curativa y revisión de la literatura. Rev Med Chil 2009. [DOI: 10.4067/s0034-98872009000300011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Butte JM, Waugh E, Meneses M, Pruzzo R, Carvallo C, Redondo F, Suárez C, Parada H, Amaral H, de La Fuente H. [Fibrolamellar liver carcinoma: report of two cases and review of the literature]. Rev Med Chil 2009; 137:394-400. [PMID: 19621182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Fibrolamellar hepatocellular carcinoma (FLC) is a rare histologic variant of hepatocellular carcinoma that appears most commonly in teenagers and young adults. The diagnosis is often made incidentally and surgical resection is the only curative treatment. Here we report two cases of incidental FLC involving a 19 year-old male, initially diagnosed with screening abdominal ultrasound, and a 14 year-old female that presented with abdominal pain. Diagnostic workup consisted of abdominal PET/CT and MR1 Imaging studies and tissue diagnosis was confirmed with percutaneous liver biopsy. Both patients were treated with radical liver resection/tumor excision. However, tumor recurrence was observed in both during short-term follow-up. The male patient was treated successfully with surgical treatment however the female patient succumbed top regression of disease.
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Affiliation(s)
- Jean M Butte
- Instituto Oncológico Fundación Arturo López Pérez, Santiago,Chile
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Concha MR, Mertz VF, Cortínez LI, González KA, Butte JM, López F, Pinedo G, Zúñiga A. The Volume of Lactated Ringer's Solution Required to Maintain Preload and Cardiac Index During Open and Laparoscopic Surgery. Anesth Analg 2009; 108:616-22. [DOI: 10.1213/ane.0b013e3181923a38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Butte JM, Torres J, Duarte I, Guzmán S, Llanos O. [Gastric adenocarcinoma appearing 32 years after the resection of a gastric lymphoma. Report of one case]. Rev Med Chil 2008; 136:1317-1320. [PMID: 19194630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association of gastric lymphoma and gastric adenocarcinoma in the same patient is uncommon. We report a 76 year-old male with a previous history of massive upper gastrointestinal bleeding who required a subtotal gastrectomy with Billroth II reconstruction in 1974. Pathology demonstrated a gastric lympho-histiocytic non-Hodgkin's lymphoma. The patient received complementary radiotherapy and was followed with annual endoscopies for 23 years. In 2006, he presented with fatigue. An upper gastrointestinal endoscopy showed an ulcerated and proliferative lesion at the gastric stump. Biopsy demonstrated a gastric adenocarcinoma. Gastric stump resection with lymph node dissection was performed. Pathology of the excised specimen showed a moderately differentiated tubular adenocarcinoma of the gastrojejunal anastomoses which infiltrated up to the subserosa. Additionally lymphatic permeations were observed and 10 of the 16 excised lymph nodes were invaded by the tumor.
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Affiliation(s)
- Jean M Butte
- Departamento de Cirugía Digestiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Butte JM, Torres J, Duarte I, Guzmán S, Llanos O. Adenocarcinoma gástrico treinta y dos años post linfoma gástrico. Rev Med Chil 2008. [DOI: 10.4067/s0034-98872008001000013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
INTRODUCTION The characteristics and results of radical gastrectomy for gastric cancer in elderly patients are controversial. Aim. To analyze the clinicopathologic characteristics and the results of gastrectomy for cancer in a group of patients > or = 75 year old. MATERIAL AND METHOD A series of 442 patients who underwent surgery for gastric cancer was divided into group A (< 75 years old) and group B (> or = 75 years old). The clinicopathologic characteristics, results of gastrectomy, and long-term survival were compared. RESULTS The mean age was 62 +/- 13 years. There were 361 patients in group A and 81 patients in group B. Tumoral location in the upper third of the stomach was more frequent in group A than in group B (36.8% vs 24.7%), while localization in the lower third of the stomach was more frequent in group B than in group A (50.6% vs 29.4%) (p < 0.05). Total gastrectomy was performed in 66% of patients in group A and in 38% of those in group B (p < 0.05); 27.3 +/- 3.5 nodes were resected in group A and 19.5 +/- 0.7 in group B (p < 0.05). No differences were found in the frequency of complications (16%) or in overall operative mortality between the two groups. However, mortality in total gastrectomy was higher in group B (6.4%) than in group A (3.8%) (p < 0.05). No differences in 5-year survival were found between the two groups (44.3% in group A and 44.4% in group B). CONCLUSIONS In patients aged more than 75 years old, tumors were more frequently located in the distal third of the stomach. Age above 75 years does not seem to be a prognostic factor and long-term results depend more on disease stage.
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Affiliation(s)
- Jean M Butte
- Departamento de Cirugía Digestiva, División de Cirugía, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Butte JM, Torres J, O'Brien A, Jarufe N, Llanos O. [Intraductal papillary mucinous neoplasm of the pancreas]. Rev Med Chil 2008; 136:517-527. [PMID: 18769796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian-like struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diagnostic, therapeutic and pathological characteristics of this disease.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Biopsy, Fine-Needle
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Carcinoma, Papillary/diagnosis
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary/surgery
- Diagnosis, Differential
- Female
- Humans
- Male
- Middle Aged
- Pancreatectomy
- Pancreatic Ducts/diagnostic imaging
- Pancreatic Ducts/pathology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Prognosis
- Radiography
- Survival Rate
- Ultrasonography
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Affiliation(s)
- Jean M Butte
- Departamento de Cirugía Digestiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Butte JM, Torres J, O'Brien A, Jarufe N, Llanos O. Neoplasia mucinosa intraductal del páncreas. Rev Med Chil 2008. [DOI: 10.4067/s0034-98872008000400014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Butte JM, Devaud N, Jarufe NP, Boza C, Pérez G, Torres J, Pérez-Ayuso RM, Arrese M, Martínez J. Sleeve gastrectomy as treatment for severe obesity after orthotopic liver transplantation. Obes Surg 2008; 17:1517-9. [PMID: 18219781 DOI: 10.1007/s11695-008-9432-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.
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Affiliation(s)
- Jean M Butte
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Abstract
Colonic composite tumors are uncommon masses composed of endo- and exocrine cells. Treatment is similar to that of adenocarcinomas. We report the case of a 44-year-old woman who consulted for abdominal pain. A computed tomography (CT) scan showed a tumor at the splenic flexure bowel and 2 hepatic nodules, suggesting metastases. Preoperative biopsies confirmed an adenocarcinoma. The patient underwent surgery, which confirmed the CT findings. Extended right colectomy was performed, followed by an ileal-sigmoid anastomosis, resection of a diaphragm segment, and resection of both hepatic metastases. The patient made a good postoperative recovery. Histological analysis showed moderately differentiated tubular adenocarcinoma combined with a poorly differentiated neuroendocrine carcinoma and metastases in 25 of 28 lymph nodes. The 2 hepatic metastases showed areas of poorly differentiated neuroendocrine carcinoma. The patient is currently asymptomatic and is undergoing chemotherapy.
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Affiliation(s)
- Jean M Butte
- Departamento de Cirugía Digestiva, División de Cirugía, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile
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Butte JM, Valbuena JR, Huete A, Martínez J. Education and imaging. Hepatobiliary and pancreatic: hepatocellular carcinoma without cirrhosis. J Gastroenterol Hepatol 2007; 22:2359. [PMID: 18031401 DOI: 10.1111/j.1440-1746.2007.05228.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- J M Butte
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Butte JM, San Francisco IF, Pacheco F, Solar A, Crovari FJ, Jarufe NP. Arteriovenous malformation of the pancreas: report of a case. Surg Today 2007; 37:604-7. [PMID: 17593483 DOI: 10.1007/s00595-006-3459-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Accepted: 11/19/2006] [Indexed: 11/28/2022]
Abstract
Arteriovenous malformation (AVM) of the pancreas (AVMP) is uncommon and generally asymptomatic; therefore, few cases have so far been reported. The symptoms of AVMP include gastrointestinal bleeding, pain, and portal hypertension. Definitive diagnosis is confirmed by angiographic study, and surgery is the only effective treatment. We report a case of AVMP confirmed by computed tomography, magnetic resonance imaging, and angiographic study of the abdomen, in a patient who presented to us with epigastric pain. He underwent a pancreaticoduodenectomy, following which his symptoms resolved.
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Affiliation(s)
- Jean M Butte
- Department of Gastrointestinal Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile
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Butte JM, Torres J, Henríquez IM, Pinedo G. Appendicular mucosal intussusception into the cecum secondary to an intramural mucinous cystoadenoma of the appendix. J Am Coll Surg 2006; 204:510. [PMID: 17324789 DOI: 10.1016/j.jamcollsurg.2006.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2006] [Revised: 07/11/2006] [Accepted: 07/20/2006] [Indexed: 11/16/2022]
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