Absence Of Hepatic Metastases Research Articles

Outcomes of partially covered self-expandable metal stents with different uncovered lengths in endoscopic ultrasound-guided hepaticogastrostomy: a Japanese retrospective study.

The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO). Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared. Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7 vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS. No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Clinical characteristics and survival trends of patients with metastatic colorectal cancer (mCRC) and peritoneal carcinomatosis who receive metastases surgery in a Spanish cohort.

159 Background: Peritoneal metastases in patients with mCRC are commonly associated with poor outcomes. Some of these patients are candidates to undergo metastases surgery, which may result in better prognosis; however, clinical and molecular characteristics of these patients remain uncertain. Methods: We conducted a retrospective analysis of 166 patients with mCRC and peritoneal metastases in a tumor registry from 2015 to 2021, analyzing the clinical and molecular characteristics, as well as progression-free survival (PFS) and overall survival (OS) of patients who received peritoneal surgery versus those who did not. Results: From the whole population, 65 patients (39%) underwent peritoneal metastases surgery, and several characteristics were more frequent in this subgroup: ECOG 0 (n = 26, OR 2.75, p = 0,0069), age <65 years (n = 43, OR 2.29, p = 0,0162), absence of hepatic metastases (n = 56, OR 3.31, p = 0,0037), single metastatic location (n = 43, OR 3.48, p = 0,0002), normal CEA levels at diagnosis (n = 33, OR 2.02, p = 0,0455) and BRAF mutation (n = 12, OR 3.32, p = 0,0345). Moreover, these patients received more lines of systemic treatment (2.8 vs 2, p = 0,006) and more metastases surgeries (1.7 vs 0.9, p = 0,000). Significant differences in tumor mutational status regardless of BRAF (KRAS, NRAS, MSI, PI3K and HER2), sex and primary tumor location between groups were not found. PFS was longer in patients receiving metastases surgery (median, 13.68 vs 7.76 months; HR for progression 0.64; 95 % confidence interval (CI) 0.46 to 0.89; p = 0,009), as well as overall survival (median NR vs 29.53; HR for death 0.39; 95 % CI, 0.25 to 0.60; p = 0,000). Conclusions: In our cohort, patients with mCRC and peritoneal carcinomatosis who underwent metastases surgery had more frequently less than 65 years, ECOG 0, absence of liver metastases, single metastatic location, normal CEA levels at diagnosis and BRAF mutation. Moreover, this subgroup showed better outcomes with a statistically significant increase in PFS and OS.

Pyrotinib combining with radiotherapy on breast cancer with brain metastasis.

With the extensive application of anti-human epidermal growth factor receptor-2 (HER2) targeted therapy, the prognosis of HER2-positive breast cancer brain metastasis (BCBM) has been improved greatly. Due to the lack of prospective randomized controlled studies; however, the treatment of active brain metastasis (BM) remains a difficulty in clinic. Based upon the retrospective studies, an effective approach of radiotherapy combined with pyrotinib in HER2-positive BCBM treatment was investigated in present research. In all, 29 patients who had active BM in HER2-positive breast cancer (BC) and underwent whole-brain radiotherapy (WBRT) combined with pyrotinib from January 2019 to May 2021 were enrolled. The progression-free survival (PFS), overall survival (OS), clinical benefit rate (CBR), objective response rate (ORR), and drug-related adverse events (AEs) were analyzed among patients undergoing WBRT combined with concurrent or sequence pyrotinib + capecitabine. After the systematic treatments using WBRT combined with pyrotinib + capecitabine, the mPFS and mOS of BM patients were 6.5 months and 15.5 months, respectively. PFS (7.2 vs 6.2 months, p = 0.038) and OS (19.0 vs 14.0 months, p = 0.014) were longer after sequence treatments than those after concurrent treatment. The central nervous system (CNS) ORR of sequence treatment was superior to that of concurrent treatment (80.4% vs 58.6%, p < 0.05). Vomiting (17.2%) and diarrhea (10.3%) were the most common adverse reactions ⩾ grade 3. WBRT combined with pyrotinib is safe and effective for the treatments of active BM in HER2-positive BC. WBRT combined with sequence pyrotinib + capecitabine is more effective and less toxic than concurrent treatment. Therefore, sequence treatment is potentially a preferred regimen for patients with active BM in HER2-positive BC. The size and number of BM lesions, presence or absence of hepatic metastasis, and combination mode of radiotherapy and targeted therapy are independent risk factors for active BM prognosis.

Stauffer Syndrome: A Comprehensive Review of the Icteric Variant of the Syndrome.

Stauffer syndrome is a rare paraneoplastic syndrome classically associated with renal cell carcinoma (RCC). This association gave it the historical name of nonmetastatic nephrogenic hepatic dysfunction syndrome without jaundice. It is a syndrome of unclear pathophysiology characterized by a reversible anicteric elevation of liver enzymes, alkaline phosphatase, erythrocyte sedimentation rate (ESR), thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly in the absence of direct hepatobiliary obstruction or jaundice. A rare atypical variant of this syndrome with jaundice has been recently described in the literature. Thus, it is important to consider both these variants of Stauffer syndrome in the differential diagnosis of unexplained cholestasis in the absence of hepatic metastasis. This may allow early recognition and treatment of an occult malignancy. Herein, we present a comprehensive review of the literature available on the icteric variant of the Stauffer syndrome, outlining its association with various malignancies and the diagnostic challenges it poses. The objective of this review is to help clinicians in its early diagnosis and management.

Radiological markers of treatment responsiveness in patients (pts) with metastatic pancreatic ductal adenocarcinomas (mPDAC) receiving systemic chemotherapy.

403 Background: mPDAC is a deadly disease with dismal survival. Newer systemic therapies including gemcitabine/nab-paclitaxel (GA) and FOLFIRINOX (FF) have resulted in modest increases in median overall survival(mOS). Currently, no good predictors exist to prioritize the use of one regimen over the other. We investigated imaging patterns in patients receiving these two regimens. Methods: A single institution retrospective analysis of pts with mPDAC receiving either GA or FF as the front-line therapy between Jan 2012 - Dec 2014 was conducted. Data included demographics and systemic therapy.Baseline CT evaluated six imaging features; lung metastases, liver metastases, peripancreatic adenopathy, retroperitoneal adenopathy, mesentery/omentum infiltration and ascites. Statistical analysis included Kaplan Meier survival analysis with Chi-square test to compare imaging features that predict mOS or median response duration (mRD). Results: N = 27 pts; median age:GA-66 years( range: 52-76), FF-55 years (range: 40-67); 13 pts (48 %) were women and 24 pts had an ECOG performance status of ≤ 1. 18 pts received GA and 9 received FF. mOS with GA = 6.1 months(m) ( range: 1.9-15.7) and FF = 9.9 m (range: 2.5-24.1). 5/18 (28%) of the GA group and 7/9(78%) of the FF group received subsequent therapies. The presence of peripancreatic adenopathy in GA pts correlated with prolonged mRD (2.2 vs. 0.6 m; p &lt; 0.001) without statistical difference in mOS (8.5 vs. 2.9 m; p = 0.4). In pts receiving FF the absence of hepatic metastasis resulted in a significant mRD (2.3 vs. 0.9 m; p = 0.01) and mOS (7.9 vs. 1.9 m; p = 0.04). The remainder of the radiological features did not show any statistically significant difference. Conclusions: In patients with mPDAC receiving GA or FF in front-line therapy; we observed that metastasis to the liver predicts worse outcome with FF than GA. Interestingly, peripancreatic lymphadenopathy was predictive of longer mRD for GA pts, without difference in mOS. Our pilot data demonstrates the potential of using CT imaging features to predict likelihood of response to different chemotherapy regimens. A larger study is needed to confirm these findings.

Hepatic Metastases is Associated with Poor Efficacy of Erlotinib as 2nd/3rd Line Therapy in Patients with Lung Adenocarcinoma.

BackgroundHepatocyte growth factor (HGF)-mediated mesenchymal-to-epithelial transition factor (MET) gene amplification is a common mechanism for acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs). MET gene amplification has also been associated with hepatic metastases in patients with lung cancer. The aim of this study was to investigate whether hepatic metastases are associated with decreased efficacy of erlotinib in patients with adenocarcinoma.Material/MethodsA cohort of 329 patients with stage IV lung adenocarcinoma, known EGFR mutation status, and who received treatment with erlotinib in the 2nd or 3rd line setting were enrolled into this study over a period of 4 years between January 2011 and January 2015. The cohort was stratified based on the presence or absence of hepatic metastases and the efficacy of erlotinib was defined based on disease control rate (DCR) and progression-free survival (PFS).ResultsHepatic metastases were present in 220 of the 329 enrolled lung adenocarcinoma patients. EGFR-activating mutations (exon 19 deletion or an exon 21 L858R mutation) were identified in 113 (34.3%) patients. The DCR was significantly lower in the hepatic metastases group than in patients without hepatic metastases (39.5% vs. 51.4% P=0.045). In patients with hepatic metastases, median PFS was 2.3 months in the EGFR mutation-positive group versus 1.4 months in the EGFR mutation-negative group (95% CI 1.3–3.3 vs. 1.3–1.5; P=0.055). Of note, erlotinib therapy in patients with hepatic metastases was complicated by elevated alanine transaminase (ALT) levels.ConclusionsHepatic metastasis in patients with lung adenocarcinoma predicts poor response to erlotinib as a 2nd/3rd line therapy. Combination therapy, for example with MET-TKI, may be a good choice for patients with liver metastases with poor prognosis.

A Stauffer's syndrome variant associated with renal cell carcinoma and thrombocytopenia

Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell carcinoma which is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, α-2-globulin, γ-glutamyl transferase, thrombocytosis, prolongation of prothrombin time and hepatosplenomegaly, in the absence of hepatic metastasis and jaundice. In this case report, we report a patient who was admitted with fever, fatigue, abdominal pain, weight loss and pruritus in whom renal cell carcinoma was incidentally found in the right kidney during an initial workup.

The intrathoracic lymph node ratio seems to be a better prognostic factor than the level of lymph node involvement in lung metastasectomy of colorectal carcinoma.

Data on thoracic lymph node involvement (LNI) in lung metastasis of colorectal cancer (CRC) are conflicting, with a 5-year overall survival (OS) ranging from 6 to 40%. We aimed to evaluate whether there are subgroups of patients according to the lymph node ratio (LNR). We retrospectively reviewed the data from 106 patients who underwent a thoracic procedure for CRC lung metastasis with pathologically proven thoracic LNI. In the univariate analysis, the median OS was significantly poorer for a pN2 location of LNI (26 vs 16 months, P = 0.04), LNR ≥50% (30 vs 17 months, P = 0.005), high preoperative CEA (32 vs 16 months, P = 0.02), hepatic metastases (27 vs 11 months, P <0.0001) and disease-free survival < 24 months (32 vs 17 months, P = 0.05). When pN1 and pN2 patients were staged according to the LNR, the median OS was significantly better for an LNR <50% (27 vs 17 months for pN1, 32 vs 12 months for pN2, P = 0.01). In the multivariate analysis, a high preoperative CEA [hazard ratio (HR): 2.256 (1.051-4.841), P = 0.04], pN1 status [HR: 0.337 (0.162-0.7), P = 0.004] and the absence of hepatic metastases [HR: 0.395 (0.180-0.687), P = 0.02] remained significant prognostic factors. There was an upward trend for patients with LNR <50% [HR: 0.565 (0.296-1.082), P = 0.08]. Otherwise, low LNR was significantly associated with a decreased risk of loco-regional recurrence (HR: 0.36, 95% confidence intervals: 0.14-0.96, P = 0.04). The LNR seems to be a more reliable prognostic factor than LNI for CRC lung metastasis. Prospective studies are necessary.

Hepatocellular Cancer in a Non-cirrhotic Hepatitis C Patient

Introduction: Cirrhosis is the number one predisposing factor for development of hepatocellular cancer (HCC), but rarely, it has also been observed in hepatitis C patients with no underlying cirrhosis. Surveillance of HCC has been postulated for hepatitis B, hepatitis C, cirrhosis, alcoholic cirrhosis, genetic hemochromatosis, and primary biliary cirrhosis, but there are no guidelines developed for screening of non-cirrhotic hepatitis C patients. A 60-year-old man with past medical history significant for chronic hepatitis C presented to his primary care office with a vague abdominal pain present for the past few months, with early satiety and poor appetite. The patient reported social drinking and denied any past smoking or illicit drug usage. His physical examination was unremarkable except for hepatomegaly, with a liver span of 3-4 cm. Hepatitis C antibody was positive with hepatitis RNA quantitative of 7000,000 IU/mL. Hepatitis B surface antigen, hepatitis B core IgM, and hepatitis A IgM were negative. Alpha-fetoprotein, Ca-99, CEA, and chromogranin were unremarkable. Laboratory work was unremarkable except elevated alkaline phosphatase (ALP) 154 U/L (34-104 U/L), AST 157 U/L (13-39 U/L), and ALT 95 U/L (7-52 U/L). Ultrasound of the abdomen revealed a large left-sided malignant-appearing liver mass. A follow-up triple phase CT (Figures A and B) of the abdomen demonstrated a liver mass 9.3 x 9 x 9 cm in size directly compressing the stomach, with no evidence of peritoneal metastasis and absence of cirrhosis. The patient underwent partial left hepatic lobectomy, segment 2 and 3 lateral segmentectomy with 7-mm tumor free margin, with no evidence of peritoneal metastasis. Intraoperative ultrasound of the liver revealed normal anatomy with the absence of hepatic metastasis. Pathologic analysis of the hepatic mass illustrated moderately differentiated hepatocellular carcinoma consistent with a trabecular pattern without significant fibrosis, absence of fibrous lamellae, and abundant necrosis (Figure C). The patient was thus diagnosed with stage II (T2NxMx) with 9 cm of moderately differentiated hepatocellular cancer. On follow-up, there was a remarkable improvement in his functional status. ALP, AST, and ALT were followed sequentially and the levels normalized to 80 U/L, 40 U/L, and 53 U/L within 4 months. The patient opted for conservative management with 6 monthly follow-ups with CT Abdomen scan for the next 2 years.Figure 1

An unusual presentation of carcinoma stomach.

Symptomatic gastric malignancy usually presents with symptoms which mimic peptic ulcer disease.Usual presenting features include weight loss and abdominal pain. Other symptoms include nausea, vomiting, dysphagia, melena and early satiety. Gastric malignancy presenting with hemetemesis, macular skin lesions of DIC and low backache due to bone metastasis from the primary is rare. Also bone metastasis in gastric cancer in the absence of hepatic metastasis is also rare.

Staufferʼs Syndrome: Another Protean Manifestation of the “Internistʼs Tumor”

Purpose: A 46 yr man with no past medical history presented with fatigue, left flank pain and 60 lb weight loss for 8 months. He denied any recent alcohol, illicit drug or medication use. Physical examination revealed a palpable mass in the left flank. Most prominent laboratory abnormality were elevated alkaline phosphatase (Alk P) at 731(50- 120 U/l) and γ-glutamyltransferase (GGT) at 261 (3-60 U/l). Serum bilirubin and aminotransferases were normal. Total serum protein was 8.2 g/dl, albumin 2.2 g/dl and total cholesterol 163 mg/dL. Microcytic anemia, thrombocytosis and mildly deranged coagulation parameters were also present. Proteinuria and hematuria were noted on urinalysis. MRI abdomen showed a 17 cm heterogeneous left renal mass involving the left renal vein with para aortic lymphadenopathy suggestive of renal cell carcinoma. Mild hepatosplenomegaly with no focal lesions was noted. There was no intra or extrahepatic biliary dilatation or any evidence of cirrhosis. Immunologic investigations revealed the absence of rheumatoid factor and antineutrophil cytoplasmic, antimitochondrial and antismooth muscle antibodies. Hepatitis and HIV viral serologies were negative, serum free thyroxine was normal and polyclonal gammopathy was observed on protein electrophoresis. The cholestasis was diagnosed as a paraneoplastic phenomenon associated with renal cell cancer (Stauffer's syndrome) and a left radical nephrectomy was attempted. Intraoperatively, the mass was inoperable due to involvement of great vessels. Histopathological examination confirmed the diagnosis of poorly differentiated renal adenocarcinoma. The patient then elected for home hospice. Nonmetastatic nephrogenic hepatic dysfunction syndrome (Stauffer's syndrome) is a unique paraneoplastic manifestation of renal cell carcinoma that usually presents as anicteric cholestasis, though a variant presenting with jaundice has also been described. It is characterized by elevated Alk P, ESR, a-2-globulin, and GGT with thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the absence of hepatic metastasis. The underlying pathophysiology of this paraneoplastic manifestation is assumed to be from interleukin-6 overexpression by the primary tumor. The cholestasis reverses spontaneously after resection of the tumor. This phenomenon has also been reported with leiomyosarcoma, angiosarcoma, malignant histiocytoma, prostate carcinoma, and bronchial adenocarcinoma. It may occasionally be the initial presentation of the underlying neoplasm and if suspected may be lead to an early diagnosis. We conclude that paraneoplastic syndromes especially from renal cell carcinoma should be kept in the differential in evaluating unexplained cholestasis.

Carcinoid syndrome from small bowel endocrine carcinoma in the absence of hepatic metastasis

An 80-year-old male patient presented with abdominal pain, paroxysmal diaphoresis, diarrhoea and vomiting. CT scan revealed a small bowel endocrine carcinoma (or 'carcinoid' tumour), but the absence of hepatic disease. The lesion was excised 'en-bloc'. Intra-operatively, there was wide fluctuation in blood pressure associated with tumour manipulation, with hyper- and hypotension. Carcinoid syndrome usually occurs from gastrointestinal tumours when hepatic metastases occur, causing flushing, diarrhoea, bronchoconstriction and murmurs from cardiac valvular lesions. This patient did not have radiological evidence of hepatic metastasis, but the syndrome could still occur with midgut tumours via local invasion of the retroperitoneal circulation, or by action of substances other than serotonin that do not undergo hepatic metabolism.

Cetuximab efficacy in patients treated routinely in university hospitals

The aim of this study was to evaluate the efficacy and tolerance of cetuximab (Cx) in patients with irinotecan-refractory metastatic colorectal cancer (IRMCRC) treated routinely at five university hospitals. Data from all patients treated with Cx (N=105) during the study period (between January 2004 and September 2005) were included in the analysis. Median number of Cx infusions was 12 (range: 1 to 62). Objective response rate was 24.8%; stable disease in 23.8%; progression in 34.3%; 17.1% of the patients were not evaluable. Digestive and hematological adverse events were grade III in 20% and 12%, respectively, and grade IV in 12% and 11%, respectively. Response rates were higher in patients with acne-like rashes than in patients without (P=0.005). Median time to tumor progression (TTP; intention-to-treat) was 3.9 months (95% CI: 2.6-4.8). Median overall survival after Cx initiation was 8.3 months (95% CI: 6.310.7). Four prognostic factors were significantly associated with a shorter TTP: center (Center 4: HR=2.25, 95% CI: 1.16-4.35, P=0.017); absence of hepatic metastases (HR=2.5, 95% CI: 1.434.37, P=0.001); WHO performance status (HR=1.47, 95% CI: 1.10-1.96, P=0.008); and number of metastatic sites (HR=1.30, 95% CI: 1.05-1.60, P=0.014). This analysis of a random population of IRMCRC patients supports Cx efficacy and feasibility, and is in agreement with the results of the BOND study.

Stauffer’s syndrome variant with cholestatic jaundice

Cholestasis is a common feature of several malignant diseases, including pancreatic, hepatic, gallbladder, and ampullary carcinomas. It is usually secondary to main bile duct obstruction or widespread hepatic metastasis, but it can also be a paraneoplastic syndrome of other underlying malignancies. Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell carcinoma (RCC) that is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, alpha-2-globulin, and gamma-glutamyl transferase, thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the absence of hepatic metastasis and jaundice. A rare variant of this syndrome with jaundice has recently been described in 3 cases in the literature. We report a patient who presented with abdominal pain and cholestatic jaundice in whom RCC was incidentally found during initial workup. Jaundice and liver dysfunction resolved completely after surgical resection of the tumor. This case illustrates the protean manifestations of RCC, and the importance of considering Stauffer's syndrome and its variant in the differential diagnosis of anicteric and icteric cholestasis, which may allow early recognition and treatment of an underlying malignancy.

Acinar Cell Carcinoma of the Pancreas: A Case Associated With the Lipase Hypersecretion Syndrome

Acinar cell carcinoma is a rare primary tumor of the pancreas that exhibits evidence of acinar differentiation in the form of enzyme production, in addition to having characteristic histologic features. A case is presented that demonstrates the uncommon lipase hypersecretion syndrome, characterized by subcutaneous fat necrosis caused by lipase secreted by the tumor cells. The presence in this case of the syndrome in the absence of hepatic metastases is unusual and perhaps is explained by the large size of the primary tumor (17 cm). The tumor exhibited the typical hypercellular pattern, with a solid and acinar architecture. An unusual degree of nuclear pleomorphism was focally noted. Enzyme production by the tumor cells was demonstrated immunohistochemically with stains for trypsin, chymotrypsin, and lipase, and electron microscopic analysis revealed zymogen granules. The patient lived 18 months after surgical resection, which is a typical course for acinar cell carcinoma, an aggressive tumor with a slightly better prognosis than ductal adenocarcinoma of the pancreas.

PYOGENIC LIVER ABSCESSES SECONDARY TO CARCINOMA OF THE SIGMOID COLON-A CASE REPORT AND REVIEW OF THE LITERATURE-

We report a case of multiple pyogenic liver abscesses. The patient was a 47-year-old woman with liver abscesses secondary to sigmoid colon cancer. The liver abscesses disappeared after antimicrobial treatment and sigmoidectomy. Histological examination of the resected specimen disclosed circumferential colon cancer and inflammatory adhesion to the bladder and the ileum with formation of small abscesses around the tumor. No evidence of ascending biliary infection, sepsis, nor diverticular disease in the colon were observed. Detailed reports of coloreetal cancer presenting with liver abscesses in the absence of hepatic metastases are extremely rarc. Clinical findings of patients reported to date in the context of literature review are discussed.

Carcinoid syndrome in the absence of hepatic metastases: correlation of CT and In-111 octreotide imaging

A 49-year-old man was hospitalized for investigation of a 2-year history of flushing and diarrhea. His urinary 5-hydroxyindoleacetic acid level was elevated. CT scanning showed no evidence of hepatic metastases and equivocal masses in the mesentery and right pelvis. In-111 octreotide imaging confirmed focal increased uptake in the midabdomen, right iliac fossa, and lower right pelvis at 24 and 48 hours. At laparotomy, soft tissue masses were resected from the mesentery, lower right pelvis, and small bowel in the right iliac fossa. One of the tumor masses was contained within a Meckel’s diverticulum in the terminal ileum. No liver abnormality was found. All resected masses showed classical carcinoid histologic signs. Symptoms resolved immediately after surgery. FIGURE 1Fig. 1: A CT image at the level of the umbilicus shows an equivocal soft tissue mass within the mesentery. This could easily be mistaken for an unopacified loop of the small bowel.FIGURE 2Fig. 2: A CT image of the pelvis shows a possible soft tissue mass (arrowhead) just medial to the opacified distal right ureter.FIGURE 3Fig. 3: An In-111 octreotide scan at 24 hours shows normal uptake in the liver and spleen. Abnormal uptake is present in the midabdomen, corresponding to the mesenteric soft tissue mass on seen on the CT.FIGURE 4Fig. 4: (A) An In-111 octreotide scan at 24 hours shows additional foci in the right iliac fossa and adjacent to the right superolateral wall of the bladder. (B) A CT scan shows no abnormality of the terminal ileum.

Survival in patients with large-bowel cancer

Five-year survival data were obtained in 97 percent or 1105 of 1140 new patients with histologically confirmed colorectal adenocarcinoma during a 12-month period in 1981 and 1982, as part of a large comprehensive population-based study of colorectal cancer incidence, etiology, and survival, The Melbourne Colorectal Cancer Study. Fifteen percent of patients were Dukes' A stage, 32 percent were Dukes' B, 25 percent were Dukes' C, and 29 percent were Dukes' D. At five years after diagnosis, the observed survival rate was 36 percent and the adjusted rate was 42 percent. Dukes' staging was a highly discriminating factor in survival (P less than 0.001). Survival rates were better in women than in men and better for patients with colon cancer than for patients with rectal cancer. Survival by Dukes' staging was not affected by colon subsite or by the tumor being the first and single tumor, metachronous tumor, or synchronous tumor. The survival of younger patients was better for Dukes' stages A, B, and C, and worse for Dukes' D. Survival was worse in the presence of bowel perforation in Dukes' C and D stages. Within Dukes' D (incurable cases), survival was best in the absence of hepatic metastases, slightly worse when only hepatic metastases were present, and poorest in the presence of both hepatic and extrahepatic metastases. Statistical modeling of survival determinants other than staging indicated that cell differentiation had the largest effect (survival decreasing with poor cell differentiation), followed by site (survival worse for rectal cancer than colon cancer), then age (survival better for younger patients), while bowel perforation had the smallest effect on survival.

Outcome of lymph node involvement in patients with the Zollinger-Ellison syndrome.

Prognosis of gastrinoma patients with metastases to lymph nodes only is uncertain, and the true nature of isolated nodal gastrinomas remains controversial. The purpose of this study was to determine the outcome of such patients and whether nodal gastrinomas may occur as primary lesions. Eleven patients with nodal involvement but without hepatic metastases are reported (mean follow-up of 129 months). Primary gastrinomas were located in the duodenum in seven (Group 1) and not identified in four (Group 2). In Group 1, five patients remained eugastrinemic after excision of all gross tumors and gastrectomy (n = 4) or pancreaticoduodenectomy (n = 1), one patient had residual disease and died of other causes (survival of 88 months), and one patient had MEA-I syndrome with multiple gastrinomas (follow-up of 126 months). In Group 2, three patients became eugastrinemic after nodal excision and total gastrectomy (mean follow-up of 212 months) and may represent primary nodal gastrinomas, and in one patient, liver metastases developed and the patient died. Four deaths occurred in a 27-year period, but only one was tumor-related. There was no significant difference in 20-year survival rates between the two groups (85% vs. 75%). It is concluded that 1) lymph node gastrinomas are usually metastatic from primary duodenal lesions, 2) although rare, nodal gastrinomas may occur as primary lesions, and 3) in the absence of hepatic metastases, lymph node gastrinomas, whether primary or metastatic, have a good prognosis and should not deter aggressive surgical treatment.

Malignant peritoneal mesothelioma. A clinical and laparoscopic study of ten cases.

A retrospective study of 10 cases of malignant peritoneal mesothelioma from two centers is reported. All cases were initially diagnosed between 1967 and 1986 utilizing laparoscopy and the histologic interpretation of laparoscopic biopsy samples. Subsequently, the original diagnosis was confirmed by two independent pathologists employing both histological and histochemical techniques. In five cases immunohistochemical studies were also performed. The clinical findings and course of the disease were similar to other reported series. Laparoscopic findings of mesothelioma were indistinguishable from metastatic peritoneal neoplasms. However, the presence of homogeneous spreading of nodules, plaques, or fleshy masses on both parietal and visceral peritoneum; the absence of direct or indirect signs of other abdominal neoplasms; and the absence of hepatic metastases or the possible presence of nodules or plaques on Glisson's capsule without any parenchymal involvement, when observed, allowed the laparoscopist to suspect the disease in four of 10 cases. Laparoscopy may be useful in detecting mesothelioma. The diagnosis is mainly morphological, but even morphology has its inherent limitations. Further studies are necessary to improve the diagnostic accuracy of this tumor.