Higher Complete Resection Rate Research Articles

Value of Tertiary Cytoreductive Surgery in Epithelial Ovarian Cancer: An International Multicenter Evaluation

The value of surgery for recurrent epithelial ovarian cancer (OC) is controversial. The aim of the present study was to evaluate the outcome of EOC-patients who underwent tertiary cytoreductive surgery (TCS) and to identify prognostic markers for complete tumor resection and survival. Retrospective multicenter evaluation of TCS patients treated between 1997 and 2011 in 14 centers across Europe, the United States, and Asia. We evaluated 406 patients (median age, 55years; range, 16-80years). Median time from first to second recurrence was 18months (2-204months). Median follow-up from TCS was 14months (0-182months), and median OS was 26months (95% CI, 19.62-32.38months). Median OS for patients without versus any tumor residuals was 49months (95% CI, 42.5-56.4months) versus 12months (95% CI 9.3-14.7months) (p<0.001). The majority of the patients had an advanced initial FIGO stage III/IV (69%), peritoneal carcinomatosis (51.7%), and absence of ascites (72.2%). A total of 224 patients (54.1%) underwent complete tumor resection. The most frequent tumor dissemination site was the pelvis (73%). Rates of major operative morbidity and 30-day mortality were 25.9% and 3.2%, respectively. Multivariate analysis identified platinum resistance, tumor residuals at secondary surgery, and peritoneal carcinomatosis to be of predictive significance for complete tumor resection, while tumor residuals at secondary and tertiary surgery, decreasing interval to second relapse, ascites, upper abdominal tumor involvement, and nonplatinum third-line chemotherapy significantly affected OS. In this largest known database for TCS, residual tumor retains its high impact on survival even in the tertiary setting of OC. In specialized centers high rates of complete tumor resection can be obtained. Prospective analyses are warranted to define the value of TCS in EOC.

FOLFIRI-3/bevacizumab induction, then capecitabine/bevacizumab maintenance as front-line strategy for metastatic colorectal cancer: A phase II trial.

e14007 Background: Bevacizumab with FOLFIRI or FOLFOX regimen is the standard of care in metastatic colorectal cancer (mCRC). As second line regimen after FOLFOX, FOLFIRI-3 has showed a significantly better PFS in comparison with other irinotecan-based regimen. We therefore evaluated the safety, efficacy and possible predictive factors for FOLFIRI-3 in combination with bevacizumab as initial treatment for mCRC. Secondarily, we evaluated the feasibility of Capecitabine-Bevacizumab maintenance. Methods: We conducted a phase II, multicentric trial of FOLFIRI-3 regimen (irinotecan 100mg/m2 day 1, LV 200mg/m2 day 1, 5-FU bolus 400 mg/m2 day 1 followed by a 36-h 5-FU continuous infusion 2400 mg/m2, irinotecan 100mg/m2 day 3) with bevacizumab (5mg/kg day 1) repeated every 2 weeks, as first-line treatment in mCRC for 6 months, followed by maintenance treatment with bevacizumab (7.5 mg/kg day 1) and capecitabine (1000 mg/m2 day 1 to 14), repeated every 3 weeks. The primary endpoint was objective response rate (ORR). Secondary endpoints were PFS, overall survival (OS), and biologic analysis of potential predictive factors of response to treatment. Results: From October 2007 to July 2009, 61 patients were enrolled for treatment. The ORR was 66.7% (8.3% of complete response and 58.3% of partial response). Stable disease was observed in 25% of patients (disease control rate of 91.7%). PFS was 12 months, and OS was 33 months. Forty patients entered to maintenance phase. Favorable tolerance profile was observed. Median PFS was 14 months, and OS was 36 months. Its efficacy was maintained in patients recently exposed to oxaliplatin. Conclusions: As front-line regimen in mCRC, FOLFIRI3-bevacizumab is maybe the best among irinotecan-5FU-bevacizumab based regimens to obtain objective response rate. PFS and OS are high but it can be secondary to high complete resection rate in our trial. In recently oxaliplatin-exposed patients, FOLFIRI3-bevacizumab regimen should be considered as first line treatment. Capecitabine-bevacizumab maintenance is clearly feasible and its encouraging result should be validated in a large phase III trial.

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR LARGE COLORECTAL TUMORS USING A CROSS‐COUNTER TECHNIQUE AND A NOVEL LARGE‐DIAMETER BALLOON OVERTUBE

Endoscopic submucosal dissection (ESD) in early gastric cancer (EGC), which provides a higher complete resection rate than conventional endoscopic mucosal resection (EMR), has rapidly come into widespread use. However, colorectal ESD is not widely used because of its technical difficulty and complications such as perforation, and the procedure time is longer than that of conventional EMR. Development of safer and more reliable devices as well as technique modifications are therefore required. The aim of our study is to compare safety and efficacy of a new traction method, the cross-counter technique, for large colorectal tumors combined with a balloon overtube. A total of 30 patients with large colorectal tumors were analyzed retrospectively; 15 patients for the cross-counter technique group (CC group) and 15 patients for the no-traction group (NT group). Procedure time, complete resection rate, perforation rate and bleeding rate were assessed. The procedure time was 126 ± 42.2 min and 165 ± 61.3 min in the CC and NT groups, respectively, and there was a significant difference between the two groups (P < 0.05). There were no significant differences in complete resection rate, perforation rate and bleeding rate between the two groups. The cross-counter technique shortened the treatment time in colorectal ESD without any complication.

Su1341 Endoscopic Submucosal Dissection for Large Colorectal Tumors Using a Cross-Counter Technique With a Novel Large Diameter Balloon Overtube

Endoscopic submucosal dissection (ESD) in early gastric cancer which provides a higher complete resection rate than conventional endoscopic mucosal resection (EMR) has rapidly come into widespread use. However, it is not widely used for treatment of colorectal tumors because of its technical difficulty. Since Colorectal ESD requires a very long procedure time and often causes complications such as perforation, development of safer and more reliable devices as well as technique modifications are needed. The aim of this study is to evaluate safety and efficacy of new traction method, the cross-counter technique, for large colorectal tumors with a combination of a novel large diameter balloon overtube.

Practice referral patterns and outcomes in patients with primary retroperitoneal sarcoma in British Columbia

BackgroundWe examined practice referral patterns for primary retroperitoneal sarcoma (PRS) in British Columbia (BC) and associations between the timing of referral to tertiary care and patient outcomes. MethodsUsing ICD-10 coding, the Cancer Agency Information System was used to identify patients with PRS from 2000 to 2009 who had been referred to tertiary care and had undergone a surgical resection. ResultsEighty-two patients were included. Those referred before surgery were significantly more likely to receive a complete resection (P = .0002) and adjuvant radiation (P = .0000) compared with patients referred after surgery. Referral before surgery was associated with a significantly increased overall (P = .0619) and recurrence-free (P = .0400) survival; however, in the multivariate model this was not significant. ConclusionsReferral before surgery is associated with higher rates of complete resection and the use of adjuvant radiation; furthermore, it is associated with prolonged survival in the univariate but not in the multivariate model.

Rectal Carcinoid Tumors: Pitfalls of Conventional Polypectomy

See Resection for Rectal Carcinoid Tumors: Comparision of Polypectomy and Endoscopic Submucosal Resection with Band Ligation by Sang Heon Lee, Seun Ja Park, Hyung Hun Kim, et al., on page 89-94 Endoscopic therapy has been accepted as an appropriate and safe therapeutic option for small (≤10 mm), well-differentiated rectal carcinoid tumors without any signs of infiltration to the muscularis propria, lymphovascular invasion, or lymph node metastases. However, in terms of both complete resection and complications, the best modality of endoscopic therapy is a matter of debate. The article by Lee et al.1 suggests endoscopic submucosal resection with band ligation (ESMR-L) as a feasible method with a lower rate of complication and a higher rate of the complete resection in comparison to conventional polypectomy. Since the incidence of rectal carcinoid tumors is recently on the rise by the widespread performance of screening colonoscopy and the size of the tumors is also becoming smaller when they are incidentally identified, endoscopic therapy such as snare polypectomy is frequently performed in various medical facilities including private clinics.2 However, rectal carcinoid tumors demonstrate various clinical behaviors, from benign to metastatic tumors, although they are relatively slow-growing.3 Therefore, complete resection is important; however, conventional polypectomy has a high possibility of incomplete resection due to slipping during snaring. Furthermore, rectal carcinoid tumors originate from deep mucosal layer and invades submucosal layer; conventional polypectomy is more appropriate for the management of tumors originating from the mucosal layer.4 This article highlights the potential risk of remnant tumors using conventional polypectomy by showing a high rate of incomplete resection (19/55, 34.5%) compared to ESMR-L (2/33, 6.1%). However, this study is limited by its retrospective design, the small number of patients enrolled in the study (33 cases in ESMR-L vs. 55 cases in conventional polypectomy), and participation of only two institutions which differed in their preferred endoscopic resection methods, as mentioned in the article. Accordingly, further multi-center, large-scaled studies for comparing the rate of complete resection and complications among various modalities of endoscopic therapies are warranted. In addition, how to treat remnant tumors left by incomplete resection after primary resection by either conventional polypectomy or ESMR-L deserves consideration. Particularly, because the rate of incomplete resection in even ESMR-L (2/33, 6.1%) is not low enough to be considered safe, residual scars by ESMR-L are wider and deeper than those by conventional polypectomy, and resection of the remnant tumors is not as simple as primary resection because of the submucosal fibrosis of residual tissue, it is questionable how 21 patients with remnant tumors by incomplete resection (two patients in ESMR-L and 19 patients in conventional polypectomy) were treated after confirmation of the positive resection margin. In a recently published article concerning the salvage therapy for remnant rectal carcinoid tumors,5 although all patients with a positive resection margin showed negative endoscopic and histological findings on a biopsy of the scarred tissue during the surveillance by endoscopic follow-up, the pathologic results from all tissues obtained by salvage resection proved to be microscopic margin positive. This implies that a biopsy alone should not be used to confirm the absence of remnant tumors because of false negative results due to embedding of the residual remnant tumor during tissue healing after the primary resection. Thus, cases with a positive resection margin require salvage resection. Thereby, careful selection of an appropriate primary resection method for complete resection is important to avoid salvage therapy of remnant carcinoid tumors. Nevertheless, this article is significant to reaffirming the risk of conventional polypectomy as a modality of endoscopic therapy for rectal carcinoid tumors in terms of incomplete resection and to corroborate the feasibility of ESMR-L as a therapeutic option with a relatively high rate of complete resection and a low rate of complications.

Prolonged Therapy with Imatinib Mesylate before Surgery for Advanced Gastrointestinal Stromal Tumor Results of a Phase II Trial

Purpose. Proven efficacy of imatinib mesylate in gastrointestinal stromal tumour (GIST) has led to its use in advanced disease and, more recently, in adjuvant and neoadjuvant settings. The purpose of this study was to evaluate the optimal neoadjuvant imatinib duration to reduce the morbidity of surgery and increase the possibility of resection completeness in advanced tumours. Patients and Method. Patients with advanced GIST were enrolled into a registered open-label multicenter trial and received imatinib daily for a maximum of 12 months, followed by en bloc resection. Data were prospectively collected regarding tumour assessment, response rate, surgical characteristics, recurrence, and survival. Results. Fourteen patients with advanced GIST were enrolled. According to RECIST criteria, 6 patients had partial response and 8 had stable disease. The overall tumour size reduction was 25% (0–62.5%), and there was no tumour progression. Eleven patients underwent tumour resection, and all had R0 resection. After a median followup of 48 months, 4-year OS and DFS were 100% and 64%, respectively. Conclusion. This prospective trial showed that one year of neoadjuvant imatinib in advanced GIST is safe and associated with high rate of complete microscopic resection. It is not associated with increased resistance, progression, or complication rates.

Primary Debulking Surgery Versus Neoadjuvant Chemotherapy in Stage IV Ovarian Cancer

Primary debulking surgery (PDS) has historically been the standard treatment for advanced ovarian cancer. Recent data appear to support a paradigm shift toward neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS). We hypothesized that stage IV ovarian cancer patients would likely benefit from NACT-IDS by achieving similar outcomes with less morbidity. Patients with stage IV epithelial ovarian cancer who underwent primary treatment between January 1, 1995 and December 31, 2007, were identified. Data were retrospectively extracted. Each patient record was evaluated to subclassify stage IV disease according to the sites of tumor dissemination at the time of diagnosis. The Kaplan-Meier method was used to compare overall survival (OS) data. A total of 242 newly diagnosed stage IV epithelial ovarian cancer patients were included in the final analysis; 176 women (73%) underwent PDS, 45 (18%) NACT-IDS, and 21 (9%) chemotherapy only. The frequency of achieving complete resection to no residual disease was significantly higher in patients with NACT-IDS versus PDS (27% vs. 7.5%; P < 0.001). When compared to women treated with NACT-IDS, women with PDS had longer admissions (12 vs. 8 days; P = 0.01), more frequent intensive care unit admissions (12% vs. 0%; P = 0.01), and a trend toward a higher rate of postoperative complications (27% vs. 15%; P = 0.08). The patients who received only chemotherapy had a median OS of 23 months, compared to 33 months in the NACT-IDS group and 29 months in the PDS group (P = 0.1). NACT-IDS for stage IV ovarian cancer resulted in higher rates of complete resection to no residual disease, less morbidity, and equivalent OS compared to PDS.

Endoscopic and oncologic outcomes after endoscopic resection for early gastric cancer: 1370 cases of absolute and extended indications

Current guidelines for endoscopic management such as EMR and endoscopic submucosal dissection (ESD) in early gastric cancer (EGC) are in evolution, with broader indication criteria. To determine the clinical outcomes of endoscopic treatment, based on absolute indication and extended indication criteria and endoscopic methods. Retrospective study. Tertiary-care, academic medical center. EMR or ESD was performed on 1627 cases of EGC in 1447 patients from July 1994 to January 2009. EMR and ESD. Clinical outcomes of EGC after EMR or ESD, based on the indication criteria. Although the complete resection rate was higher (95.9% vs 88.4%; P < .001), and the complication rate was lower (6.8% vs 9.8%; P = .054) in the absolute than in the extended indication group, there was no between-group difference in the local recurrence rate (0.9% vs 1.1%; P = .783) at a median follow-up period of 32 months (interquartile range 22-48 months). In the extended indication group, ESD resulted in a significantly higher complete resection rate than EMR (83.0% vs 91.1%; P = .006). Retrospective study. ESD in the extended indication group showed acceptable clinical outcomes with a relatively high complete resection rate and a low local recurrence rate.

Endoscopic Mucosal Resection: Not Your Father's Polypectomy Anymore

Endoscopic mucosal resection (EMR) is a continuously evolving technique that has revolutionized the diagnosis, staging, and treatment of superficial neoplasms throughout the digestive tract. As a minimally invasive technique, it offers an alternative to operative resection and mucosal ablation. For neoplasms limited to the mucosa, EMR compares equivalently with operative resection for R0 status (no residual neoplasia) and favorably for morbidity and mortality. In contrast with mucosal ablation, EMR delivers a more precise and predictable depth of tissue effect and, most important, provides the resected specimen for histopathologic analysis. EMR was pioneered in Eastern Asia as a technique for resection of early gastric cancers. Incrementally, the tools and techniques for EMR have evolved to be employed around the globe for eradication of superficial lesions throughout the esophagus, stomach, small bowel, and colon. Owing to improvements in endoscopic detection and recognition, more sessile, flat, depressed, and even subepithelial lesions are being identified for which endoscopic resection is being adopted. Moreover, the implementation of surveillance strategies for various gastrointestinal conditions, such as Barrett’s esophagus, has fostered image guided detection and eradication of premalignant and early malignant lesions, incorporating EMR for diagnosis, staging, and therapy. This review focuses on the techniques, applications, and limitations of EMR for lesions throughout the digestive tract.

The role of sleeve resections in advanced nodal disease

The aim of this study was to compare the short-term and long-term results of sleeve resections depending on limited nodal disease (N0/N1, LND) and advanced nodal disease (N2/N3, AND) for non-small cell lung cancer (NSCLC) at a single institution. We retrospectively reviewed our prospective database of all NSCLC patients undergoing sleeve resections between January 1999 and December 2008. Patients' characteristics, morbidity, mortality, locoregional recurrence, distant recurrence, and survival were analyzed corresponding to LND and AND. The indication was NSCLC for 170 sleeve resections (LND: n=120; AND: n=50) out of 213 consecutive sleeve resections. Both groups were statistically equal with regard to age (LND 61.8±12.4 vs AND 60.8±9.6 years), gender, co-morbidities, type of sleeve resection (bronchial vs bronchovascular), number of dissected lymph nodes (LND 40.0±12.4 vs AND 36.7±14.0), histology and completeness of resection (LND 96.7% vs AND 98.0%), respectively. More patients had induction chemotherapy in AND group (p=0.049). The short-term results were equal on the subject of morbidity rate (LND: 34.2%, AND: 44.0%), secondary pneumonectomy (LND: 1.7%, AND: 4.0%), and mortality rate (LND: 5.0%, AND: 6.0%), respectively. LND was associated with a better 5-year-survival rate (LND: 67%; AND: 42%) and mean survival (LND: 80.8 months; AND: 37.7 months; p=0.014). In the long-term follow-up, more distant metastases were detected in AND group (26.0% vs 14.2%, p=0.079) in contrast to identical locoregional recurrence (LND: 1.7%; AND: 0%). In the event of metastazing, the mean time to the development of distant metastases was similar (LND: 19.1 months; AND: 12.4 months; p=0.2). Lymph node involvement is a negative prognostic factor concerning long-term survival. Sleeve resections in AND do not result in higher morbidity and mortality. But even in AND, sleeve resections are associated with promising long-term survival and extraordinary local control of the disease as a result of high complete resection rates. High rate of distant failure warrants further investigation for the systemic control of the disease.

Incidence and management of high grade glioma in Māori and non-Māori patients

A retrospective analysis of 301 patients was undertaken between 1993 and 2003 to evaluate the relationship of ethnicity with incidence, treatment and survival in patients undergoing surgery for high grade glioma (HGG) in New Zealand. There was no difference in age standardised incidence of HGG in Māori compared to non-Māori patients; 4.2/100,000 person years (95% confidence interval [CI] 2.6–6.9) versus 4.1 (95% CI 3.6–4.6). Māori were more likely to have complete tumour resection (odds ratio 3.59 (95% CI 1.01–12.76)) but waited 1.32 (95% CI 0.98–1.79) times longer for radiotherapy. Median survival was 29 weeks with poorer survival in Māori compared to non-Māori (hazard ratio 1.55 [95% CI 0.95–2.55]). We concluded that the incidence of HGG in Māori is similar to non-Maori. However, Māori with HGG have higher rates of complete resection but wait longer for radiotherapy and may have poorer overall survival than non-Māori.

Use of ifosfamide, carboplatin, and etoposide chemotherapy in choroid plexus carcinoma

Choroid plexus carcinomas (CPCs) are rare pediatric tumors with a generally poor prognosis. Although the role of surgery is well recognized, the role of adjuvant chemotherapy and radiation therapy remains unclear. In this paper, the authors' goal was to assess the role of second-look surgery and neoadjuvant ifosfamide, carboplatin, etoposide (ICE) chemotherapy in the management of CPC and to study neurocognitive outcome. The authors performed an institutional retrospective review of patients in whom CPC was diagnosed between 1985 and 2006 at the Hospital for Sick Children in Toronto. Fourteen patients (7 boys and 7 girls) were included. The median age at diagnosis was 18.6 months (range 1.1-65.3 months). Four patients had evidence of metastatic disease at diagnosis. Two of the 14 patients underwent gross-total resection during initial surgery; 12 of the patients received neoadjuvant chemotherapy, 10 of whom underwent second surgery. In total, of 12 patients who received chemotherapy with a curative intent, 11 underwent a greater than 95% resection. Neoadjuvant ICE chemotherapy was given prior to second surgery (median 4 cycles, range 2-5 cycles) and was continued after second resection for a median total of 7 cycles (range 4-16 cycles). No tumor progression was observed during chemotherapy prior to second surgery. Five patients subsequently experienced tumor progression/relapse. At a median follow-up of 6.9 years (range 1.9-18.5 years), 8 patients are alive. None of the survivors received radiation therapy. However, 6 of 8 display significant neurocognitive and/or sensorial deficit. In this experience, second surgery following neoadjuvant ICE chemotherapy led to a high rate of complete or near-complete resection. Chemotherapy appears to facilitate second-look surgery, in particular through a reduction of intraoperative blood loss. Despite radiation avoidance, the majority of survivors experienced significant neurocognitive impairment.

Endoscopic submucosal dissection for colorectal tumors

Endoscopic submucosal dissection (ESD) is a state-of-the-art method that enables resection of larger tumors than those resectable by conventional endoscopic mucosal resection (EMR). However, the individual role of each method in the treatment of colorectal tumors remains undetermined. To consider the respective indications of ESD and EMR for colorectal tumors, we analyzed the results of the two treatments retrospectively. Tumors treated by ESD (44 tumors) were significantly larger, more often located in the rectum and more often coexistent with cancer than those treated by EMR (512 tumors). EMR was used in the majority of adenomas, and showed high rates of both one-piece resection (OPR) and complete resection (CR) for adenomas less than 20 mm. However, for adenomas and cancers greater or equal to 20 mm, the CR rate for EMR was significantly lower than that for ESD because of the incidence of OPR with a positive lateral margin (16% vs 0% with ESD vs EMR). Histopathology (cancer), size (> or =20 mm) and macroscopic type (laterally spreading tumors) were shown to be significant risk factors for that incidence. For tumors with these factors, ESD showed a higher CR rate than did EMR. However, ESD required longer operating times and tended to have a higher rate of perforation compared with EMR. ESD was aborted halfway in seven cases due to technical difficulties and perforation. ESD and EMR have different characteristics as treatment for colorectal tumors. Careful evaluation of the lesion and of the balance between benefits and risks are mandatory before selecting either of these treatments for colorectal tumors.

Endoscopic Submucosal Dissection for Early Gastric Cancer and Gastric Adenoma: 3-Years Experience in a Single Center

Background/Aims: Endoscopic submucosal dissection (ESD) enables en-bloc complete resection of various gastrointestinal tumors compared with conventional endoscopic mucosal resection (EMR), and has been promising treatment option of early gastric cancer (EGC). This study aimed to evaluate clinical outcome of ESD for EGC and gastric adenoma using insulation-tipped diathermic knife. Methods: From April 2005 to June 2008, 884 patients (452 EGC and 432 gastric adenomas) were enrolled prospectively after ESD in Seoul National University Hospital. Follow-up endoscopies were performed in 3, 6, 12, 18 months, and then annually. Complete resection rate, complications, concordance of diagnosis in between the pre-treatment forcep-biopsy and pathologic mapping of ESD specimen and synchronous or metachronous lesions during follow-up were evaluated. Results: The median follow-up duration was 13.4 ± 9.7 months (range 3-39 months). The en bloc resection rate was 100%, complete resection rate was 91.1%(801/884) on the pathologic mapping and 96.4% (703/729) in 3-month follow-up endoscopy. Perforation occurred in 1.1% (10/884) and bleeding was noticed in 3.6% (32/884). There was no complication requiring operation or procedure related mortality. Gastric adenoma in the pre-treatment biopsy were finally proven as EGC with pathologic mapping in 22.5% (119/529) of cases. During the follow-up, 2% (9/432) of adenoma cases were retreated for the remnant lesion with argon-plasma coagulation (APC) or additional ESD. Additional surgical resection was performed in 5.1% (23/452) of EGC patients due to a residual lesion, tumor invasion more than deep submucosal layer, lymphatic invasion or undifferentiated carcinoma. Among the 23 surgically resected cases, there was residual carcinoma in 17.4%(4/23) and lymph node metastasis in 21.7% (5/23). One case revealed synchronous lesion at a different location from the initial ESD site (4.3%, 1/23). During follow-up period, 160 synchronous lesions (18.1%) within 1 year and 20 metachronous lesions (2.3%) were reported. No distant or lymph node metastasis was found during the follow-up. Conclusions: ESD shows high complete resection rate and more accurate pathologic diagnosis of EGC and gastric adenoma, and close follow-up is warranted for detection of synchronous or metachronous lesion.

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT-ESD group (57.6 +/- 31.9 min vs 21.1 +/- 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. The long-term outcome needs to be evaluated in the future.

A Highly Active and Tolerable Neoadjuvant Regimen Combining Paclitaxel, Carboplatin, 5-FU, and Radiation Therapy in Patients with Stage II and III Esophageal Cancer

BackgroundThe present phase II study aimed to assess the feasibility and efficacy of a new paclitaxel-based neoadjuvant chemoradiation regimen followed by surgery in patients with stage II–III esophageal cancer.MethodsFrom January 2002 to November 2004, 50 patients with a potentially resectable stage II–III esophageal cancer received chemotherapy with paclitaxel, carboplatin, and 5-FU in combination with radiotherapy 45 Gy in 25 fractions. Surgery followed 6–8 weeks after completion of neoadjuvant treatment.ResultsPatient characteristics: male/female: 44/6, median age 60 years (34–75), median WHO 1 (0–2), adenocarcinoma (n = 42), squamous cell carcinoma (n = 8). Toxicity was mild, and 84 % of the patients completed the whole regimen. Forty-seven patients underwent surgery with a curative intention (transhiatal n = 44, transthoracic n = 3).Pathologic complete tumor regression was achieved in 18 of 47 operated patients (38%). R0 resection was achieved in 45 of 47 operated patients (96%). There were four postoperative deaths (8.5). Postoperative complications were comparable with other studies. After a median follow-up of 41.5 months (21–59) estimated 3- and 5-year survival on an intention-to-treat basis was 56 and 48%. Estimated 3-year survival in responders was 61%, in nonresponders 33%.ConclusionThis novel neoadjuvant chemoradiation regimen for treatment of patients with stage II–III esophageal cancer is feasible. Results are encouraging with a high pathologic complete tumor regression and R0 resection rate and an acceptable morbidity and mortality. Preliminary survival data are very promising.

Induction Chemoradiation and Surgical Resection for Superior Sulcus Non–Small-Cell Lung Carcinomas: Long-Term Results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160)

Traditional treatment for superior sulcus non-small-cell lung cancers (SS NSCLC), radiation plus surgery, yields a 50% rate of complete resection and a 30% 5-year survival. On the basis of improved outcomes in other subsets of stage III NSCLC, this trial tested the feasibility of induction chemoradiotherapy for SS NSCLC. Patients with T3-4, N0-1 SS NSCLC received two cycles of cisplatin and etoposide concurrently with radiation (45 Gy). Patients with stable or responding disease underwent thoracotomy. All patients received two more cycles of chemotherapy. Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed by Cox regression analysis. From April 1995 to November 1999, 110 eligible patients (76 men, 34 women) were entered onto the study (78 T3, 32 T4 tumors). Induction therapy was completed by 104 (95%) patients. Of 95 patients eligible for surgery, 88 (80%) underwent thoracotomy, two (1.8%) died postoperatively, and 83 (76%) had complete resection. Pathologic complete response (CR) or minimal microscopic disease was seen in 61 (56%) resection specimens. Five-year survival was 44% for all patients and 54% after complete resection, with no difference between T3 and T4 tumors. Pathologic CR led to better survival than when any residual disease was present (P = .02). Disease progression occurred mainly in distant sites. This combined-modality approach is feasible and is associated with high rates of complete resection and pathologic CR in both T3 and T4 tumors. Local control and overall survival seem markedly improved relative to previous studies of radiation plus resection.

Morphoeic basal cell carcinoma of the face

The morphoeic (or sclerosing) basal cell carcinoma (mBCC) is the most aggressive subtype, as it spreads into the dermis beyond the clinically visible or palpable borders, making complete excision difficult. Our aim was to identify variables in the surgical management that might increase the rate of complete resection, so we made a retrospective study of 97 mBCCs. One-stage procedures (frozen section analysis) had a higher rate of complete resection (63 of 69, 91%) than two-stage procedures (permanent section analysis) (19 of 28, 68%, p<0.05). The false negative rate of frozen section analysis was 9%. Experienced surgeons had more complete excisions and a lower rate of operative re-excisions. The use of frozen section analysis is an effective way of judging invasion of margins by mBCC. The estimation of tumour margins and the treatment of mBCC requires substantial clinical experience.

Phase II Trial of Neoadjuvant Chemotherapy Using Alternating Doublets in Non-Small-Cell Lung Cancer

PurposeLung cancer is an epidemic disease in developing countries. Incorporation of new active drugs in the neoadjuvant treatment of operable patients might lead to improved outcomes. Postchemotherapy mediastinal-based treatment decisions allow for in vivo testing of activity and could help to determine the ideal local treatment. Patients and MethodsThis phase II trial enrolled patients with documented non–small-cell lung cancer, clinically staged IB-IIIA, and considered candidates for surgical resection. Patients received 3 cycles of neoadjuvant chemotherapy with alternating doublets: cisplatin/gemcitabine; gemcitabine/vinorelbine, and cisplatin/vinorelbine. After neoadjuvant treatment, clinical restaging was performed. Patients without evidence of progression underwent mediastinoscopy. Those with negative mediastinal nodes were taken to surgery whereas those with positive nodes were treated with radiation therapy. ResultsBetween January 2001 and August 2002, 30 patients were included. The median age was 56 years, 66% of the patients were men, 43% of the patients had adenocarcinoma, and 34% had squamous cell carcinoma. Clinical staging was IB in 9 patients (30%), IIB in 7 (23%), and IIIA in 14 (47%). Median tumor size was 6.5 cm (range, 3–11 cm). Twenty-three patients (77%) had clinical response to neoadjuvant chemotherapy. Eight of 12 patients (67%) with N2 disease had clinical downstaging. Twenty-two patients (73%) were taken to surgery. Complete resection rate was achieved in 21 patients (70%). Treatment was well tolerated. ConclusionLocalized non–small-cell lung cancer is very sensitive to chemotherapy. Postchemotherapy mediastinal-based treatment decision led to a high complete resection rate, even in patients with large tumors. This strategy deserves further investigation.