Targeted transcriptomic analysis of pancreatic adenocarcinoma in EUS-FNA samples by NanoString technology

Background: Integration of transcriptomic testing into EUS-FNA samples is a growing need for precision oncology in pancreatic ductal adenocarcinoma (PDAC). The NanoString platform is suitable for transcriptome profiling in low yield RNA samples. Methods: Inclusion of patients that underwent EUS-FNA cytological diagnosis of pancreatic ductal adenocarcinoma using 19G and/or 22G needles and subsequent surgical resection. Formalin-fixed, paraffin-embedded (FFPE) cytological and surgical samples underwent RNA extraction and transcriptomic analysis using a custom 52-gene NanoString panel of stromal PDAC features. Cell type abundance was quantified in FFPE specimens and correlated. Results: 18 PDAC patients were included. Mean EUS-FNA passes was 2 + 0.7. All FFPE passed the RNA quality control for genomic analysis. Hierarchical clustering on the global gene expression data showed that genes were differentially expressed between EUS and surgical samples. A more enriched cancer-associated fibroblasts and epithelial-mesenchymal transition transcriptomic profile was observed across surgical specimens whereas immunological biomarkers were more represented in EUS-FNA samples. Cytological examination confirmed a scanty representation of CAF and more immunological cell abundance in cytological samples in comparison to surgical specimens. Conclusion: Targeted transcriptomic NanoString profiling of PDAC samples obtained by EUS-FNA is a feasible approach for pre-surgical molecular analysis although stromal CAF/EMT mRNA biomarkers are underrepresented.

Postoperative day one systemic inflammatory response syndrome is a powerful early biomarker of clinically relevant pancreatic fistula

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication following pancreaticoduodenectomy (PD). There is increasing evidence that very early postoperative factors can be helpful to identify high-risk patients. The aim of this study is to analyze whether postoperative day one (POD1) systemic inflammatory response can be used as an early biomarker of CR-POPF development.

METHODS

All patients undergoing PD from 2014 to 2020 were considered. Variables were extracted from a prospectively held database. Clinical and perioperative variables, including POD1 systemic inflammatory response syndrome (SIRS) and C-reactive protein level were collected. To elucidate the independent role of early CR-POPF biomarkers, multivariate hierarchical logistic regression analyses were planned.

RESULTS

Out of 243, 213 patients were included in this analysis. CR-POPF occurred in 49 (23.0%) patients and 90-day mortality was 1.4%. POD1 SIRS was reported in 65 (30.5%) patients. Following hierarchical logistic regression analyses, CR-POPF was independently associated with body mass index (OR = 2.787, p = 0.003), soft pancreatic texture (OR = 4.258, p = 0.002) and POD1 SIRS (OR = 50.067, p = 0.001).

CONCLUSION

POD1 SIRS is powerfully associated with CR-POPF and therefore it could be used as a tool to optimize postoperative care of PD patients. Further prospective studies are needed to validate these findings.

Telemedicine and intraductal papillary mucinous neoplasms: Analysis of a new follow-up strategy during COVID-19 outbreak

BACKGROUND

The Coronavirus pandemic outbreak in 2019 and the saturation of healthcare system led to an increased use of digital tools for surveillance. In this study we described our experience using telemedicine to follow-up on patients with intraductal papillary mucinous neoplasms during the COVID-19 era and analyze those factors associated to patients' satisfaction.

METHODS

This 1-year retrospective observational study enrolled patients with intraductal papillary mucinous neoplasms followed-up by telemedicine during COVID-19 outbreak. Patients with high-risk features needing on-site physical examination or declining remote follow-up were excluded. A 13-question survey was conducted; demographic, geographic, and employment information was collected. Univariate and multivariate analyses were performed to evaluate those factors associated to patients' satisfaction.

RESULTS

Out of 287, a total of 177 patients with intraductal papillary mucinous neoplasms were included: the mean age was 69 (44-87) years and the male/female ratio was 0.78. A total of 80 (45.2%) patients had previously experienced abdominal pain. Most patients (85.3%) were satisfied with telemedicine: at univariate analysis, age ≥70 years (P = .007), retirement (P = .001), and absence of previous abdominal pain (P = .05) were significantly associated with patient satisfaction. At multivariate analysis, the absence of previous abdominal pain was the only factor independently associated with patient satisfaction (odds ratio 5.964, 95% confidence interval 2.21-16.11, P < .001).

CONCLUSION

Telemedicine allows a new follow-up strategy that can be used in selected patients with intraductal papillary mucinous neoplasms. The absence of previous abdominal pain is associated with patient satisfaction during follow-up. Further studies are needed to evaluate safety of remote follow-up in patients with intraductal papillary mucinous neoplasms.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Can we predict recurrence in WHO G1-G2 pancreatic neuroendocrine neoplasms? Results from a multi-institutional Spanish study

INTRODUCTION

Pancreatic neuroendocrine neoplasms (PNEN) are rare tumours and well differentiated PNEN are associated with relatively indolent physiological behaviour. For this reason, only few studies have investigated those factors associated with recurrence in this group of patients. The aim of this study is to analyse whether it is possible to predict tumour recurrence in World Health Organization (WHO) 2017 G1-G2 PNEN patients.

METHODS

This is a retrospective multi-institutional study. Patients submitted to pancreatic resection from 7 Spanish centres were reviewed. Only patients with WHO G1-G2 PNEN were included. Demographic and clinicopathological variables were analysed.

RESULTS

Data from 137 patients were reviewed. Median age was 59.2 (25-84) years. Recurrence of disease occurred in 19 (13.9%) patients. Median DFS was 55 months. At multivariate analysis, tumour size >20 mm, lymphnode metastasis and a new tumour grade 2 incorporating Ki-67 labelling index (LI) > 5% and mitotic index (MI) > 2 were independently associated with recurrence. We developed a risk score model with these three factors. High-risk patients had a significantly lower 5-year disease-specific survival compared to low-risk patients (70% vs 100%).

CONCLUSION

We propose a novel risk score for recurrence based on lymphnode metastasis, tumour size > 20 mm and a new grade 2 based on Ki-67 LI >5% and MI > 2. If 2 factors are present, patients have a higher risk for recurrence and a significantly poorer DSS, and therefore they should be closely monitored during follow-up. The role of adjuvant chemotherapy in these patients needs to be evaluated in clinical trials.

Lymphadenectomy in pancreatic neuroendocrine neoplasms: Why are we still debating?

Pancreatic Neuroendocrine Neoplasms (PNEN) are rare tumours exhibiting very heterogeneous behaviour. For these reasons, studies with high level of evidence are lacking. Whether lymphadenectomy should be performed for PNEN is a matter of debate. In this review, we perform a critical analysis of the available literature regarding the clinical significance of lymphnode metastases, the importance of lymphadenectomy, and the implications on disease-specific survival.

Management of ampullary tumours in children: still a challenge

This study describes the case of the youngest patient ever reported with ampullary adenoma. The incidence of ampullary adenomas in childhood is unknown. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used in adults to assess and treat these lesions, although there are no instruments designed specifically for use in young children. A six-year-old girl was admitted for abdominal pain, vomiting, pruritus and weight loss. Abdominal ultrasound showed biliary tree (8mm) and pancreatic duct dilatation (4mm). Magnetic resonance cholangiopancreatography and computed tomography confirmed these findings, and also showed displacement of the ampulla to the left upper quadrant. An upper endoscopy confirmed a large ampullary adenoma. A laparotomy was performed and a 5cm villous tumour arising from the ampulla was excised. The postoperative course was uneventful. The histology demonstrated adenoma of the ampulla (intestinal type) without low-grade dysplasia. all clinical and radiological parameters are normal at 20 months follow-up. We describe the case of the youngest patient ever reported with ampullary adenoma. Pancreaticoduodenectomy carries high morbidity and mortality rates, and therefore it should be avoided in absence of histologically proven malignancy. We believe that surgical ampullectomy is a safe and oncologically correct procedure until better endoscopic instruments for peadiatric use will be designed.

A registry analysis of damage to the deceased donor pancreas during procurement

Surgical injury to the pancreas is thought to occur commonly during procurement. The UK Transplant Registry was analyzed to determine the frequency of pancreatic injuries, identify factors associated with damage, and assess the impact of injuries on graft survival. Twelve hundred ninety-six pancreata were procured from donation after brain death donors, with 314 (19.5%) from donation after circulatory death donors. More than 50% of recovered pancreata had at least one injury, most commonly a short portal vein (21.5%). Liver donation, procurement team origin, hepatic artery (HA) arising from the superior mesenteric artery (SMA), and increasing donor BMI were associated with increased rates of pancreas damage on univariate analyses; on multivariate analysis only the presence of an HA from the SMA remained significant (p = 0.02). Six hundred forty solid organ pancreas transplants were performed; 238 had some form of damage. Overall, there was no difference in graft survival between damaged and undamaged organs (p = 0.28); however, graft loss was significantly more frequent in pancreata with arterial damage (p = 0.04) and in those with parenchymal damage (p = 0.05). Damage to the pancreas during organ recovery is more common than other organs, and meticulous surgical technique and awareness of damage risk factors are essential to reduce rates of procurement-related injuries.

Implications of the index cholecystectomy and timing of referral for radical resection of advanced incidental gallbladder cancer

INTRODUCTION

Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection.

METHODS

The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed.

RESULTS

Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging.

CONCLUSIONS

In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.

Gallbladder perforation: morbidity, mortality and preoperative risk prediction

INTRODUCTION

Gallbladder perforation (GBP) is a life threatening complication of acute cholecystitis occurring in approximately 2-11 % of patients. The aim of this study is to analyse all factors associated with morbidity and mortality and assess the accuracy of preoperative risk prediction scores.

METHODS

Medical records of 1,033 patients who underwent cholecystectomy for acute cholecystitis in our centre between 2002 and 2012 were reviewed. Preoperative, intraoperative and postoperative relevant data were analysed with univariate and multivariate statistical methods to identify all factors associated with postoperative complications and mortality. Accuracy of ASA, POSSUM and APACHE II scores was also compared using receiver-operating characteristics methodology.

RESULTS

137 (12.4 %) patients with gallbladder perforation were identified. Morbidity and mortality rates were 57.7 and 9.5 %, respectively. At multivariate analysis, preoperative albumin (P = 0.007, OR 0.175), open surgery (P = 0.011, OR 37.78) and preoperative sepsis (P = 0.002, OR 51.647) were associated with complications, and preoperative sepsis was the only factor independently associated with hospital mortality (P = 0.007, OR 9.127). Both POSSUM and APACHE II scores were superior to ASA score in risk prediction.

CONCLUSION

Preoperative severe sepsis is the most important factor associated with postoperative morbidity and mortality following GBP, and it can be helpful to identify those patients needing the highest level of care possible.

Microwave liver ablation and dark urine

Microwave assisted liver resection is a useful technique, especially when haemostasis could be difficult to achieve with conventional methods. However, prolonged administration of microwaves can be responsible for intraoperative haemoglobinuria. We describe the first case of acute haemolysis secondary to microwave assisted liver resection.

Simultaneous liver resection and double cardiac valve replacement. A case report

INTRODUCTION

We present a rare case in which both a double cardiac valve replacement was performed as well as a hepatic resection.

PRESENTATION OF CASE

We report the case of a 36 year old patient who presented with intra abdominal bleeding thought to have been caused by a liver haemangioma she also had severe autoimmune cardiac valve disease. She underwent a simultaneous right hepatectomy with cardiac valve replacement.

DISCUSSION

Management of this challenging case is discussed.

CONCLUSION

We advocate the possibility of performing combined operations where both valve replacement and hepatic resection is required.

Biomarker discovery by plasma proteomics in familial Brugada Syndrome

Brugada Syndrome (BS) is a polygenic inherited cardiac disease characterized by life-threatening arrhythmias and high incidence of sudden death. In this study, two-dimensional gel electrophoresis (2D-PAGE) coupled to mass spectrometry (LC-MS/MS) was used to investigate specific changes in the plasma proteome of BS patients and family members sharing the same gene mutation (SCN5AQ1118X), with the aim to identify novel disease biomarkers. Our data demonstrate that the levels of several proteins were significantly altered in BS patients compared with controls. In particular, apolipoprotein E, prothrombin, vitronectin, complement-factor H, vitamin-D-binding protein, voltage-dependent anion-selective channel protein 3 and clusterin were considerably increased in plasma sample of BS patients, whereas alpha-1-antitrypsin, fibrinogen and angiotensinogen were considerably decreased; moreover, post-translational modifications of antithrombin-III were detected in all affected individuals. On the light of these results, we hypothesize that these proteins might be considered as potential markers for the identification of disease status in BS.

Liver damage during organ donor procurement in donation after circulatory death compared with donation after brain death

Background

During the past decade the number of livers recovered and transplanted from donation after circulatory death (DCD) donors has increased significantly. As reported previously, injuries are more frequent during kidney procurement from DCD than from donation after brain death (DBD) donors. This aim of this study was to compare outcomes between DCD and DBD with respect to liver injuries.

Methods

Data on liver injuries in organs procured between 2000 and 2010 were obtained from the UK Transplant Registry.

Results

A total of 7146 livers were recovered from deceased donors during the study, 628 (8·8 per cent) from DCD donors. Injuries occurred in 1001 procedures (14·0 per cent). There were more arterial (1·6 versus 1·0 per cent), portal (0·5 versus 0·3 per cent) and caval (0·3 versus 0·2 per cent) injuries in the DBD group than in the DCD group, although none of these findings was statistically significant. Capsular injuries occurred more frequently in DCD than DBD (15·6 versus 11·4 per cent; P = 0·002). There was no significant difference between DCD and DBD groups in liver discard rates related to damage.

Conclusion

There were no differences in terms of vascular injuries between DCD and DBD livers, although capsular injuries occurred more frequently in DCD organs. Continuing the trend for increased frequency of DCD liver recovery, and ensuring that there is an adequately skilled surgical team available for procurement, is vital to improving the utilization of DCD livers.

Double bypass for inoperable pancreatic malignancy at laparotomy: postoperative complications and long-term outcome

INTRODUCTION

Between 4% and 13% of patients with operable pancreatic malignancy are found unresectable at the time of surgery. Double bypass is a good option for fit patients but it is associated with a high risk of postoperative complications. The aim of this study was to identify pre-operatively which patients undergoing double bypass are at high risk of complications and to assess their long-term outcome.

METHODS

Of the 576 patients undergoing pancreatic resections between 2006 and 2011, 50 patients who underwent a laparotomy for a planned pancreaticoduodenectomy had a double bypass procedure for inoperable disease. Demographic data, risk factors for postoperative complications and pre-operative anaesthetic assessment data including the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and cardiopulmonary exercise testing (CPET) were collected.

RESULTS

Fifty patients (33 men and 17 women) were included in the study. The median patient age was 64 years (range: 39-79 years). The complication rate was 50% and the in-hospital mortality rate was 4%. The P-POSSUM physiology subscore and low anaerobic threshold at CPET were significantly associated with postoperative complications (p =0.005 and p =0.016 respectively) but they were unable to predict them. Overall long-term survival was significantly shorter in patients with postoperative complications (9 vs 18 months). Postoperative complications were independently associated with poorer long-term survival (p =0.003, odds ratio: 3.261).

CONCLUSIONS

P-POSSUM and CPET are associated with postoperative complications but the possibility of using them for risk prediction requires further research. However, postoperative complications following double bypass have a significant impact on long-term survival and this type of surgery should therefore only be performed in specialised centres.

Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy

Background

Postoperative complications are increased in patients with reduced cardiopulmonary reserve undergoing major surgery. Pancreatic leak is an important contributor to postoperative complications and death following pancreaticoduodenectomy. The aim of this study was to determine whether reduced cardiopulmonary reserve was a risk factor for pancreatic leak.

Methods

All patients who underwent pancreaticoduodenectomy between January 2006 and July 2010 were identified from a prospectively held database. Data analysis was restricted to those who underwent cardiopulmonary exercise testing during preoperative assessment. Pancreatic leak was defined as grade A, B or C according to the International Study Group on Pancreatic Fistula definition. An anaerobic threshold (AT) cut-off value of 10·1 ml per kg per min was used to identify patients with reduced cardiopulmonary reserve. Univariable and multivariable analyses were performed to identify other risk factors for pancreatic leak.

Results

Some 67 men and 57 women with a median age of 66 (range 37–82) years were identified. Low AT was significantly associated with pancreatic leak (45 versus 19·2 per cent in patients with greater cardiopulmonary reserve; P = 0·020), postoperative complications (70 versus 38·5 per cent; P = 0·013) and prolonged hospital stay (29·4 versus 17·5 days; P = 0·001). On multivariable analysis, an AT of 10·1 ml per kg per min or less was the only independent factor associated with pancreatic leak.

Conclusion

Low cardiopulmonary reserve was associated with pancreatic leak following pancreaticoduodenectomy. AT seems a useful tool for stratifying the risk of postoperative complications.

Kidney damage during organ recovery in donation after circulatory death donors: data from UK National Transplant Database

During the last 10 years, kidneys recovered/transplanted from donors after circulatory death (DCD) have significantly increased. To optimize their use, there has been an urgent need to minimize both warm and cold ischemia, which often necessitates more rapid removal. To compare the rates of kidney injury during procurement from DCD and donors after brain death (DBD) organ donors. A total of 13 260 kidney procurements were performed in the United Kingdom over a 10-year period (2000-2010). Injuries occurred in 903 procedures (7.1%). Twelve thousand three hundred seventy-two (93.3%) kidneys were recovered from DBD donors and 888 (6.7%) from DCD donors. The rates of kidney injury were significantly higher when recovered from DCD donors (11.4% vs. 6.8%, p < 0.001). Capsular, ureteric and vascular injuries were all significantly more frequent (p = 0.002, p < 0.001 and p = 0.017, respectively). Discard because of injury was more common after DCD donation (p = 0.002). Multivariate analysis demonstrated procurement injuries were significantly associated with DCD donors (p = 0.035) and increased donor age (<0.001) and donor body mass index (BMI; 0.001), donor male gender (p = 0.001) and no liver donation (0.009). We conclude that procurement from DCD donors leads to higher rates of injury to the kidney and are more likely to be discarded.

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future.

Unusual case of abdominal pain following liver transplant: causality or casualty?

This is an unusual case of chronic abdominal pain following two liver transplants with at least three potential causes: traumatic neuroma, intussusception of the small bowel of the Roux loop and biliary cast. Surgical removal of the latter two factors led to resolution of the pain. The management of the clinical case is discussed.

A wrong diagnosis of recurrent perineal hernia

We describe a case of a patient who had several operations for recurrent perineal hernia. She eventually had an abdominal surgical debulking for aggressive angiomyxoma.

Retrospective analysis of long-term defunctioning stoma complications after colorectal surgery

OBJECTIVE

Defunctioning stoma is a common surgical procedure, but the choice of stoma remains controversial. The preference for colostomy or ileostomy depends on the type of surgery and on the surgeon who performs the procedure. Stoma reversal is often performed a few weeks after colorectal resection but few studies have analysed the long-term complications of different types of stoma. This study aims to determine which type of stoma is associated with a lower rate of long-term complications.

METHOD

A retrospective study of patients undergoing colorectal surgery from 1998 to 2004 with stoma creation after was conducted. Only patients followed up by our enterostomal therapist for a minimum of 3 months were included. Both emergency and elective procedures were considered. All stoma-related complications were recorded. Kruskal-Wallis and Mann-Whitney U-test were used for statistical analysis (Reviewer 2, n. 5).

RESULTS

132 patients were considered suitable for the analysis. Patients were divided into loop ileostomy (44), loop colostomy (77) and end colostomy (11) group. Mean age was 68 years. Mean follow up was 4 months (range: 3-23). The overall complication rate was 60%. The most common complication included dermatitis, parastomal hernia, leakage and stenosis. The stoma with the lowest complications rate was end colostomy (P = 0.026). Age <68 years was significantly associated with less complications (P = 0.01). Indication for surgery, emergency procedure, gender, morbidity and preoperative site were not significant factors.

CONCLUSION

In this long term follow-up study, end colostomy and younger patients had a lower incidence of complications. A large prospective trial is needed to confirm our results.

Tumor regression in mesorectal lymphnodes after neoadjuvant chemoradiation for rectal cancer

AIMS

The histological modification produced by neoadjuvant chemoradiation on primary rectal cancer has been investigated by many authors, and a prognostic value of tumor regression grade (TRG) has been identified. Tumor regression grade on metastatic mesorectal lymphnodes has been never evaluated. The purpose of this study is to analyse the TRG on mesorectal lymphnodes (lymphnode regression grade, LRG) after preoperative chemoradiation in rectal cancer patients and to determine the correlation with TRG of primary tumor.

METHODS

Surgical specimens from 35 patients who underwent chemoradiation were included. LRG on mesorectal lymphnodes was assessed by immunohistochemistry. Response to treatment was evaluated by a 5-point LRG based on the ratio of residual tumor to fibrosis.

RESULTS

Complete pathologic response (LRG 1) was observed in 18 patients (51%). In 4 patients (11%) no regression was observed (LRG 5). In 4 cases only reactive lymphnodes were found. LRG on lymphnodes significantly correlated with TRG on primary tumor (p<0.05).

CONCLUSIONS

Neoadjuvant chemoradiation determines a tumor regression on mesorectal lymphnodes as on primary tumor; further studies are needed to evaluate the prognostic value of LRG.

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation

BACKGROUND

Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation.

METHODS

Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient's clinical response after chemoradiation and distance from the anal verge.

RESULTS

A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group.

CONCLUSIONS

The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.

Prognostic factors after surgery for locally recurrent rectal cancer: an overview

PURPOSE

Local recurrence of rectal cancer occurs in a considerable group of patients who have undergone radical treatment for primary tumour. The treatment of choice is surgical resection but the prognosis remains poor, as a negative margin excision is possible in only a small subset of patients. A review of prognostic factors for locally recurrent rectal cancer (LRRC) after surgery is presented.

METHODS

We systematically reviewed the literature for reports on prognostic factors after surgical excision of LRRC. These reports were identified through a review of the Medline database from 1982 to 2004.

RESULTS

This review highlights the most important prognostic factors for LRRC patients treated with surgery. Data are grouped on the basis of the prognostic factors investigated.

CONCLUSIONS

R0 resection seems to be the only reliable prognostic factor; however, symptoms, pre-operative CEA doubling time, performance status and pre-operative radiotherapy can help patient selection before surgery. The results of this review provide the basis for improved outcome, aiming to assess patients who would benefit from reoperation.

[Cerebellar metastasis from pancreatic adenocarcinoma: report of a clinical case]

We describe a case of a metacronous cerebellar metastasis from pancreatic adenocarcinoma occurred in a 67 years old male. Central nervous system metastases from pancreatic carcinoma are mostly autoptic findings. To our knowledge, this is the first case reported in literature of cerebellar metastasis from pancreatic cancer; furthermore, this case calls attention on vomit presentation that could be erroneously attributed to an abdominal relapse. Due to the increasing frequency of central nervous system metastases observed in recent years in other types of cancer, some authors speculate that this event could represent a consequence of the prolonged natural history as the result of improved survival.

[Xanthogranulomatous pyelonephritis and renal carcinoma. Report of a clinical case and review of the literature]

Xanthogranulomatous pyelonephritis is a rare disease of the kidney; renal parenchyma is replaced by lesions radiologically simulating clear cell carcinoma. We present a case of a 62-year-old diabetic woman observed at our institution for the appearance of back pain and dysuria. A CT scan revealed a large lesion of left kidney with psoas muscle infiltration and the patient undrwent a nephrectomy. Histology surprisingly showed a xanthogranulomatous pyelonephritis. Though recent reports demonstrated the feasibility of conservative management of XGP with antibiotics, the use of pre-operative biopsy is still limited by the risk of seeding and the high false-negative results. How to distinguish xanthogranulomatous pyelonephritis from renal cancer?

[Signet-ring cell carcinoma of the Vater's ampulla: report of a clinical case]

We report the case of a sixty-six year-old man admitted at our hospital with a suspected malignant tumor of the ampulla of Vater. The patient underwent a Pylorus-preserving pancreatico-duodenectomy. Histology showed a signet-ring cell carcinoma of the ampulla of Vater. This case is the 13th report in the literature of a signet-ring cell carcinoma of the ampulla of Vater.

[Pancreatic tumor: unusual onset of Von-Hippel Lindau syndrome]

The Von-Hippel Lindau (VHL) disease is a rare genetically determined syndrome. Clinical course depends on the occurrence of multiple tumors as central nervous system tumors, phaeochromocytoma and renal cell carcinoma. We describe the second case in the literature reporting about a patient affected by a pancreatic neuroendocrine tumor as the first clinical sign of VHL disease. It has been showed that only a strict follow-up can effectively improve survival. Based on the present case, the follow-up of patients affected by VHL syndrome should routinely include functional tests and imaging exams of the pancreas.

Sacral nerve neuromodulation improves physical, psychological and social quality of life in patients with fecal incontinence

There are several therapeutic options for fecal incontinence but often they do not achieve good results in the long run. This study dealt with sacral nerve modulation, a new therapeutic option. Twenty-one patients underwent pudendal nerve evaluation (PNE) at our institution. Nine patients were affected by both fecal and urinary incontinence, 3 had fecal incontinence and anal pain, 5 had fecal incontinence and pelvic floor dyssynergia, and 4 had isolated fecal incontinence. They underwent morphological, functional and psychological tests prior to PNE, showing no sphincter rupture, almost normal anal pressures, impaired rectal sensation and deficient psychological pattern. All patients underwent at least two nerve evaluations. Four of 21 patients (19%) were selected to receive a permanent sacral electrode, as PNE seemed to have improved their symptoms by >75%. A median follow-up of 15 months (range, 6-24 months) showed that this method decreases weekly episodes of incontinence and increases maximal squeeze pressure. We demonstrated an increase in basal pressure in 3 of 4 patients (all with isolated fecal incontinence). Rectal sensation threshold decreased in three patients; urge threshold decreased in two patients and increased in two patients, but in each patient we got a stabilization. We evaluated the quality of life by applying the Short Form Health Survey test (SF-36). All 4 patients showed a significant increase in the scores of physical, emotional and social role functioning after the permanent implant. In conclusion, sacral nerve modulation may improve physical, physiological and social quality of life in selected groups of incontinent patients without gross sphincter lesions and with impaired rectal sensation.