Margin-negative Surgical Resection Research Articles

A population-based evaluation of tunica vaginalis mesothelioma: An analysis of the National Cancer Database.

Primary mesothelioma of the tunica vaginalis (TVM) is a rare and poorly understood malignancy with insufficient population-level data to guide management decisions. A retrospective analysis of TVM cases recorded in the National Cancer Database from 2004 to 2015 was performed. Cases were identified using International Classification of Diseases for Oncology histology codes. Associations between demographic, clinical and therapeutic factors were analyzed using Kaplan-Meier survival estimates for overall survival (OS) and Cox proportional hazard modeling. Propensity score matching for receipt of systemic chemotherapy was performed to assess the impact on OS. One hundred fifty-one men with a median age of 65 years (interquartile range [IQR] 51-78) were included. Median OS from diagnosis was 72.5 months (IQR 20.2-Not Reached [NR]) after a median follow up of 34.9 months. Multivariate analysis demonstrated an increased risk of death for patients in the fourth quartile of age (hazard ratio [HR] 5.57, 95% confidence interval [CI] 1.70-18.17, P = 0.004), those with biphasic or fibrous histology (HR 2.59, 95% CI 1.15-6.42, P = 0.04) and positive surgical margins (HR 3.27, 95% CI 1.61-6.63, P = 0.001). There was no significant difference in OS associated with receiving chemotherapy (P = 0.5) even after propensity score matching (P = 0.07). Margin-negative surgical resection is paramount to improving OS. There are insufficient data to recommend for or against adjuvant systemic chemotherapy or RT, although the limited available data does not suggest apparent benefit in terms of OS.

Intrahepatic Cholangiocarcinoma: A Summative Review of Biomarkers and Targeted Therapies.

Simple SummaryIntrahepatic cholangiocarcinoma is the second most common primary liver malignancy. Among patients with operable disease, surgical resection is the cornerstone of therapy. Among the majority of patients who present with advanced disease treatment, systemic or targeted therapy is indicated. Recent advancements have provided more novel therapeutic approaches to a subset of patients with intrahepatic cholangiocarcinoma. Although rare, intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy and the incidence of ICC has increased 14% per year in recent decades. Treatment of ICC remains difficult as most people present with advanced disease not amenable to curative-intent surgical resection. Even among patients with operable disease, margin-negative surgical resection can be difficult to achieve and the incidence of recurrence remains high. As such, there has been considerable interest in systemic chemotherapy and targeted therapy for ICC. Over the last decade, the understanding of the molecular and genetic foundations of ICC has reshaped treatment approaches and strategies. Next-generation sequencing has revealed that most ICC tumors have at least one targetable mutation. These advancements have led to multiple clinical trials to examine the safety and efficacy of novel therapeutics that target tumor-specific molecular and genetic aberrations. While these advancements have demonstrated survival benefit in early phase clinical trials, continued investigation in randomized larger-scale trials is needed to further define the potential clinical impact of such therapy.

Pancreatic solid pseudopapillary neoplasm: a single-institution study.

Solid pseudopapillary neoplasms (SPNs) are a distinct but rare form of low-grade pancreatic neoplasia, accounting for 0.3%-2.7% of all pancreatic tumours. They are most common in young females. Local recurrence and distant metastasis are reported but extremely rare, and are usually resectable with curative intent. We report the clinicopathological features and long-term outcomes of SPNs following surgical resection from a single institution. A total of 1296 patients undergoing pancreatic resection during the 30 years period from 1991 to 2020 were retrospectively reviewed, and those with a confirmed pathological diagnosis of pancreatic SPN on review were included. Twenty-two patients (1.7% of all patients undergoing resection), were identified. Twenty patients (91%) were female. Unlike previous studies, most patients (91%) were symptomatic at diagnosis. On diagnostic CT, cystic components were visible in 16 patients (73%), calcifications were found in two patients (9%), haemorrhage in one patient (5%) and a defined capsule was seen in four patients (18%). Surgical resection was undertaken on all cases, with distal pancreatectomy the most commonly performed (n= 11, 50%). One patient (4.7%) had nodal involvement, nine patients had an incomplete tumour capsule (41%) and seven patients (32%) had tumour extension into the pancreatic parenchyma. Despite this, no patients had disease recurrence at 10 years. One patient died within 5 years of heart failure unrelated to the SPN process; no patients died within 10 years of the disease. We confirm a high proportion of female patients. Interestingly, a high proportion of our cohort was investigated for symptomatic disease. Despite a high proportion of tumours with an incomplete capsule, and extension into the pancreatic parenchyma, our findings indicated that SPN patients have excellent survival after margin-negative surgical resection.

Phyllodes tumors of the breast: Adjuvant radiation therapy revisited

BackgroundPhyllodes tumors (PT) are rare entity and surgical resection is the cornerstone of treatment. No standard of care exists regarding adjuvant treatment especially radiation therapy (RT). Patients and methodsWe analyzed all patients with non-metastatic, resected phyllodes tumors who presented to our institution from January 2005 through December 2019. Primary study endpoints included local recurrence free survival (LRFS) and overall survival (OS). ResultsOne hundred and eight patients were analyzed (patients with incomplete treatment and follow up data were excluded). Fifty patients had benign phyllodes, 26 patients had borderline and 32 patients had malignant phyllodes. In the benign group, no significant difference in LRFS was observed between patients who received adjuvant RT (n = 3) and those who did not (5-year LRFS 100% vs. 85% respectively, p = 0.49). The 5 year OS for patients who received RT was 60% vs. 89% for those who did not (p 0.40). In the borderline/malignant group, adjuvant RT significantly improved five year LRFS (90% in the RT group vs. 42% in the no RT group, p = 0.005). The 5 year LRFS in patients treated with margin negative breast conserving surgery and RT was 100% vs. 34.3% in patients who did not receive RT (p 0.022). Patients treated with mastectomy and RT had a 5 year LRFS of 100% vs. 83% for patients who did not receive RT (p 0.24). On multivariate analysis, radiation therapy was independently associated with decreased hazard of local failure (HR 0.21, CI 0.05–0.89, p = 0.03). No difference in OS was found between the RT and no RT groups (5-year OS was 52% vs. 45% respectively, p 0.54). ConclusionThe results of the current study confirm the excellent prognosis of benign phyllodes tumors; warranting no further adjuvant treatment after margin-negative surgical resection. For patients with borderline/malignant phyllodes tumors, adjuvant radiation therapy significantly improved LRFS after margin negative wide local excision; however, patients treated with mastectomy did not attain the same benefit from adjuvant irradiation.

Clinical Analysis of En Bloc Resection for Advanced Temporal Bone Squamous Cell Carcinoma.

Objective En bloc and margin-negative surgical resection seems to offer the best prognosis for patients with temporal bone squamous cell carcinoma (TB-SCC). In this study, we summarize the outcomes of surgical cases of advanced TB-SCC (T3-T4) that were managed in two institutions, with an accompanying description of the surgical procedure that was utilized: modified subtotal temporal bone resection (STBR), which involves the en bloc removal of the temporal bone including or transecting the otic capsule. Design This is a case series study with chart review. Setting The study was conducted at two academic tertiary care medical centers. Participants Chart information was collected for all patients who underwent surgical resection of advanced TB-SCC between July 1998 and February 2019. The resulting dataset contained 43 patients with advanced TB-SCC who underwent en bloc resection during the review period. Tumor staging followed the modified Pittsburgh classification. Disease-specific survival (DSS) rates were calculated according to the Kaplan-Meier method. Main Outcome Measure This study shows disease-specific 5-year DSS rate. Results The 5-year DSS rate of the cases who underwent en bloc resection was 79.7%. En bloc lateral temporal bone resection was employed in a total of 25 cases (DSS: 79.0%). En bloc modified STBR was utilized in 18 cases (DSS: 81.7%). Conclusion En bloc margin-negative resection is a reliable treatment strategy for advanced TB-SCC. Modified STBR can be a treatment option for TB-SCC without marked posterior extension.

Discussion on: Adjuvant systemic therapy for intermediate and large gastric gastrointestinal stromal tumors (GISTs): Is there a survival benefit following margin negative surgical resection?

(Presentation given by Dhruv J. Patel, B.S.) Adjuvant systemic therapy for intermediate and large gastric gastrointestinal stromal tumors (GISTs): Is there a survival benefit following margin negative surgical resection?The American Journal of SurgeryVol. 219Issue 3PreviewIn an analysis of 3502 patients from the National Cancer Database who underwent margin-negative resection for nonmetastic gastric gastrointestinal stromal tumor (GIST), those who had small (2.1–5 cm) or intermediate (5.1–10 cm) tumors did not achieve any statistically significant benefit in overall survival after receiving adjuvant systemic therapy compared to observation, regardless of tumor grade. However, patients with large (>10 cm) tumors did achieve a statistically significant benefit in overall survival after receiving adjuvant systemic therapy compared to observation. Full-Text PDF

Surgical Management of Solid Pseudopapillary Neoplasms of Pancreas: A Single-Center Experience of 60 Patients

Background: Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare neoplasms, and the selection of surgical approaches is still under debate. The aim of this study was to analyze the clinicopathological characteristics and surgical outcomes of SPN patients and to compare the short-term and long-term outcomes between conventional operations and parenchyma-preserving operations. Methods: Patients who underwent pancreatic resection for SPNs between February 2010 and May 2019 in Fujian Medical University Union Hospital were identified. Clinicopathological details, perioperative data, and long-term follow-up results were retrospectively analyzed. Results: Sixty patients underwent surgical resection for SPNs during the study period: 48 females and 12 males. The mean age was 32.2 years. All patients underwent margin-negative surgical resection. The median follow-up period was 47 months (range: 3~118 months). One patient developed liver metastases 14 months after the operation and received local ablation therapy. All patients were alive during the follow-up. The incidence of postoperative pancreatic fistula was higher in the parenchyma-preserving surgery group than in the conventional surgery group (40.0 vs. 11.1%, p = 0.034). There was no significant difference in the tumor recurrence rate between the 2 groups. Eight (17.7%) and 6 patients (13.3%) in the conventional surgery group demonstrated endocrine and exocrine pancreatic insufficiency, respectively; furthermore, no patients in the parenchyma-preserving surgery group had endocrine or exocrine pancreatic insufficiency, but the incidences were not significantly different between the 2 groups. Conclusions: Margin-negative surgical resection of SPNs yields a very low rate of tumor recurrence and excellent long-term survival.

Benefit of postoperative radiotherapy for early tumors with single ipsilateral lymph node metastasis.

Indication for postoperative radiotherapy in patients with locally circumscribed tumors (pT1-pT2) and a single ipsilateral lymph node metastasis (pN1) is debatable. The aim of this study was to evaluate the oncological long-term outcome of patients with pT1-pT2 pN1 squamous cell carcinoma (SCC) of the oral cavity, the oropharynx, and the hypopharynx without extracapsular spread (ECS) after a margin-negative surgical resection, who either received or did not receive postoperative (chemo)radiotherapy. Retrospective case series. The oncological outcome of patients with pT1-pT2 pN1 SCC without ECS was evaluated retrospectively. All patients underwent primary tumor resection that included transoral laser microsurgery and neck dissection at an academic tertiary referral center. Of 65 identified patients treated between 1986 and 2015 (18 oral cavity, 30 oropharynx, 17 hypopharynx), 21 (32%) received postoperative radiotherapy, and 44 (68%) were treated by surgery alone. The group of patients receiving postoperative treatment showed a significantly superior 5-year disease-specific (94.4% vs. 73.2%, P = .029) and recurrence-free survival (85.2% vs. 43.2%, P = .002), as well as a higher local control rate (90.2% vs. 64.9%, P = .042). The overall survival was 71.4% vs. 62.6% (P = .53). The mean follow-up was 80.7 months. Patients with locally circumscribed carcinomas and a single ipsilateral ECS-negative lymph node metastasis seem to benefit from postoperative radiotherapy. 4 Laryngoscope, 130:E530-E538, 2020.

Adjuvant systemic therapy for intermediate and large gastric gastrointestinal stromal tumors (GISTs): Is there a survival benefit following margin negative surgical resection?

BackgroundThe value of adjuvant systemic therapy after margin-negative resection for gastric gastrointestinal stromal tumors (GISTs) remains unclear. MethodsThe National Cancer Data Base was queried to identify patients undergoing margin negative resections for gastric GISTs >2 cm between 2010 and 2015. Patients were stratified by tumor size (small: 2.1–5 cm, intermediate: 5.1–10 cm, large: >10 cm), histologic grade (low: ≤5 mitoses/50 HPF and high: >5 mitoses/50 HPF), and use of adjuvant therapy. Multivariable cox proportional hazard methods were used to compare overall survival (OS). Results3520 patients met inclusion criteria. Adjuvant therapy was associated with a statistical improvement in OS (86% vs. 76%, p = 0.014) for those with large tumors but had no measurable effect in patients with small or intermediate sized tumors. On multivariable analysis, this association was independent of grade. ConclusionsAdjuvant therapy is associated with improved OS for patients with gastric GISTs >10 cm but provides no statistically significant benefit in OS for those with GISTs 2–10 cm

A Review of Pancreatic Cancer: Epidemiology, Genetics, Screening, and Management.

Pancreatic cancer ranks among the causes of cancer-related deaths. The average size of pancreatic cancer during diagnosis is about 31 mm and has not changed significantly over the past 30 years. Poor early diagnosis of a tumour has been attributed to the late-presenting symptoms. Over the years, improvement in the diagnosis of pancreatic cancer has been observed, and this can be linked to advancement in imaging techniques as well as the increasing knowledge of cancer history and genetics. Magnetic Resonance Imaging, Endoscopic Ultrasound, and Computer Topography are the approved imaging modalities utilised in the diagnosing of pancreatic cancer. Over the years, the management of patients with pancreatic cancer has seen remarkable improvement as reliable techniques can now be harnessed and implemented in determining the resectability of cancer. However, only about 10% of pancreatic adenocarcinomas are resectable at the time of diagnosis and will highly benefit from a microscopic margin-negative surgical resection. Overall, the failure of early tumour identification will result in considerable morbidity and mortality.

Clinical and Pathological Features of Solid Pseudopapillary Neoplasms of the Pancreas: A Nationwide Multicenter Study in Japan.

The aim of this study was to evaluate the clinicopathological features of solid pseudopapillary neoplasms (SPNs). In this retrospective study, 288 SPNs were analyzed. Overall, 214 patients (74%) were female. Distant metastases occurred in 4 patients, and splenic vein tumor thrombus occurred in 1 patient. Although imaging findings showed large (>2.0 cm) SPNs with clear, regular border, and heterogeneous internal structure, small SPNs appeared as almost entirely solid. Surgical resection was performed in 278 cases. The 5-year survival rate was 98.8%. Six patients had tumor recurrence after the initial resection. The detection rate in typical pathological findings was low for small SPNs. Tumor extension to the pancreatic parenchyma was detected in greater than 70% of the cases. Tumor invasion to adjacent organs was detected in 13 cases. One was given a diagnosis of apparent high-grade malignant transformation. The proportion of male cases was higher than that in previous studies, and there were statistically significant differences in the onset age and tumor diameter between male and female patients. Therefore, women seemed to have an early occurrence of SPNs, suggesting a difference in the developmental stage between men and women. Images and pathological findings of SPNs varied according to tumor size. Our findings indicated that SPN patients have excellent survival after margin-negative surgical resection.

Treatment Outcomes for Pleomorphic Lobular Carcinoma In Situ of the Breast.

Pleomorphic lobular carcinoma in situ (PLCIS) is an uncommon high-grade in situ lesion that shares morphologic features of both classic lobular and ductal carcinoma in situ. Data on the natural history of pure PLCIS are limited, and no evidence-based consensus guidelines for management exist. From our prospectively maintained institutional pathology and breast surgery databases, we identified all patients with a diagnosis of PLCIS on core needle biopsy (CNB) or excisional biopsy from 2004 to 2017. Patient, tumor, treatment, and outcome data were abstracted to analyze upstage rates and treatment outcomes. We identified 18 patients with pure PLCIS: 15 diagnosed on CNB, 2 diagnosed at operation for atypia on CNB, and 1 diagnosed after excisional biopsy without preceding CNB. Of the 15 patients with PLCIS on CNB, 3 (20%) were upgraded to invasive cancer on surgical excision. Overall, 7 patients were treated with mastectomy (all margin-negative) and 11 with lumpectomy (one with a focally positive margin). Eight patients received adjuvant therapy: six endocrine therapy, one radiation therapy, and one received both. Among patients with a final diagnosis of PLCIS, two ipsilateral recurrences were observed at follow-up: one invasive lobular carcinoma at 87months and one PLCIS at 16months postoperatively. PLCIS on CNB mandates surgical resection as 20% of patients may be upgraded to invasive cancer, and outcomes following pathologic margin-negative surgical resection were excellent with only one invasive recurrence observed. Larger-scale investigation with longer follow-up is needed to define a role for adjuvant therapy and to develop evidence-based treatment guidelines.

Abstract 1870: Fluorescence-guided soft tissue sarcoma surgery using a cetuximab-imaging probe conjugate

Abstract BACKGROUND: Soft tissue sarcomas (STS) are a heterogeneous group of solid malignancies whose treatment includes margin-negative resection. Large tumor size and anatomic constraints make margin assessment challenging. Fluorescence-guided surgical resection can help delineate intraoperative margins; preclinical studies demonstrate improved oncologic outcomes in other malignancies using cancer-specific imaging probes. Recent literature describes cathepsin activated probes selective for STS, but no studies using disease-specific chemotherapeutic agents conjugated to imaging probes. This novel strategy has potential to decrease unnecessary healthy tissue resection and improve oncologic outcomes by reducing margin-positive resections. Epidermal growth factor receptor (EGFR) is overexpressed in multiple subtypes of STS and is a potential target for fluorescence-guided surgery. Recent studies show fluorescently labeled cetuximab, an FDA-approved, anti-EGFR antibody, to be safe and useful for margin assessment in other malignancies. Our aim was to evaluate its potential for STS, examining tumor-targeting specificity of two drug-probe conjugates, and comparing them to the described cathepsin-activated probes. We hypothesize the drug-probe conjugates would successfully target STS, with superior tumor specificity. We also aimed to determine the smallest tumor detectable by our conjugate. METHODS: Athymic nude mice with subcutaneous HT1080 fibrosarcoma tumors were injected with one of five probes: IRDye800CW fluorescent probe conjugated to either cetuximab (anti-EGFR) or DC101 (anti-VEGFR2), IRDye800CW conjugated to an isotype control (IgG), or a cathepsin-activated probe (IntegriSense 750 and Prosense 750). Fluorescence imaging was performed daily with open- and closed-field systems. Tumor-to-background ratios (TBR), signal washout times and normalized signal averages were evaluated. On day 9, smallest resectable game evaluation was performed to assess sensitivity for detecting residual post-resection tumor RESULTS: At day 9 post-injection, the TBR of the cetuximab-IRDye800CW group (11.1) was significantly greater than Integrisense750 (6.88, p=0.005), the IgG-IRDye800CW control (4.44, p=0.00005), Prosense750 (2.35, p=0.00009), and DC101-IRDye800CW (1.87, p=0.00003). During in vivo imaging, cetuximab-IRDye800CW outperformed all other agents by several folds of contrast enhancement. The smallest resectable game evaluation demonstrated 1mm3 fragment detection using the cetuximab-IRDye800CW probe. CONCLUSIONS: This study demonstrates superiority of cetuximab-IRDye800CW for disease-specific imaging in a subcutaneous animal model of STS. The novel strategy of coupling improved margin-negative surgical resection with established chemotherapy has considerable translational significance and is an avenue for exploration with other drugs used to treat STS. Citation Format: Nicole K. Behnke, Jason M. Warram, Andrew C. Prince. Fluorescence-guided soft tissue sarcoma surgery using a cetuximab-imaging probe conjugate [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1870. doi:10.1158/1538-7445.AM2017-1870

Solid pseudopapillary neoplasm of the pancreas: Management and long-term outcome

BackgroundSolid pseudopapillary neoplasm (SPN) of pancreas is a rare pancreatic neoplasm with a low metastatic potential. Our aim was to study the clinical–pathological characteristics, and long-term outcome of this tumor. MaterialsRretrospective single center study of patients operated for SPN of pancreas. Clinical and pathological data were collected. ResultsFrom 1995 to 2016, 1320 patients underwent pancreatic resection. SPN was confirmed in 32 cases (2.46%), including 29 (90.6%) female and three (9.4%) male, with a mean age of 28.4 ± 12.2 years. SPN was the most common pathology among female patients under age of 40 (72.4%). Abdominal pain was the most frequent presenting symptom (48%), whereas none of the patients presented with jaundice. Mean tumor diameter was 5.9 cm (range, 0.9–14 cm). All patients underwent margin-negative surgical resection. Two patients demonstrated gross malignant features, including liver metastases at presentation (n = 1), and adjacent organ and vascular invasion (n = 1). Microscopic malignant features were present in thirteen patients (40.6%). Recurrence occurred in the retroperitoneal lymph nodes (n = 1, 7 years post resection) and in the liver (n = 2, 1 and 5 years post resection). Mean follow-up was 49.2 months (range, 1–228 months). Five and 10-year disease-free survival was 96.5% and 89.6% respectively. ConclusionsSPNs are low-grade tumors with a good prognosis. Margin-negative surgical resection is curative in most patients. However, almost 15% of patients demonstrate malignant features including invasion of adjacent organs or metastatic disease. Patients with malignant disease are still expected to have long survival, and aggressive surgical approach is advocated.

Neoadjuvant FOLFIRINOX and/or gemcitabine/nab-paclitaxel for advanced pancreatic adenocarcinoma.

473 Background: Neoadjuvant chemotherapy is increasingly being utilized for locally advanced (LAPC)/borderline resectable pancreatic cancer (BRPC); however, long term follow up data is sparse. At our institution, we use FOLFIRINOX as the regimen of choice. Gemcitabine (Gem) and nab-Paclitaxel (Abraxane) is utilized in patients not suited for FOLFIRINOX or if they have poor radiographic response and/or develop significant toxicities to FOLFIRINOX. The aim of this study was to report our institutional experience with neoadjuvant therapy for patients with advanced pancreatic cancer. Methods: A retrospective review was performed of all patients with BRPC or LAPC who received FOLFIRINOX (or a modified regimen), Gem/nab-Paclitaxel, or both prior to surgical resection. FOLFIRINOX was typically given for 4 – 6 cycles while gem/nab-Paclitaxel was given for 2 cycles. Results: From January 2011 to December 2015, 39 patients were identified who met the study criteria. Eight patients received FOLFIRINOX alone (median age 62), 20 patients received FOLFIRINOX + Gem/nab-Paclitaxel, and 11 received only Gem/nab-Paclitaxel (median age 72). Eighteen patients (46%) completed the intended cycles of chemotherapy. Twenty two patients had a radiologic and/or biomarker response. Exploration was performed in 25 of 39 (64%) patients of whom 20 (51%) underwent curative resection. Of the 20 resected patients, there were no post-operative deaths. The median tumor size, median lymph node ratio, and R0 resection rates were 2.4 cm, 0, and 85% for the entire cohort. Median follow up was 20.7 months. The median overall survival for the resected cohort was not reached vs 13.5 months in the no resection group; two year overall survival for the resection vs. no resection groups was 87% vs 16% (p < .001). Conclusions: FOLFIRINOX and/or Gemcitabine/nab-Paclitaxel as neoadjuvant therapy for LAPC/BRPC is fairly well tolerated, leads to appreciable rates of margin negative surgical resection, and a significant overall survival advantage.

Redefining the R1 resection in patients with pancreatic ductal adenocarcinoma.

Most cases of pancreatic ductal adenocarcinoma (PDAC) are lethal. Margin-negative surgical resection is a mainstay of treatment and the only chance of a cure. Differences in pathological reporting, surgical technique, definitions of resection margin, and group stratification all affect outcome analyses. Furthermore, there are controversial issues influencing the clinical interpretation of resection margin after pancreatectomy. There is no standardized definition of margin involvement in resected specimens of PDAC. The non-standardized pathologic approach explains the wide range of positive resection margin rates (13-71%) that have previously been reported. A standardized pathologic evaluation needs to be developed for proper assessment of resection margin after oncologic pancreatectomy. This manuscript reviews the current controversial issues in assessing resection margin in order to enhance understanding of the current status and potential role of pathological evaluation in patients with PDAC.

Gastric Schwannoma: A Rare but Important Differential Diagnosis of a Gastric Submucosal Mass

Schwannomas are generally slow growing asymptomatic neoplasms that rarely occur in the GI tract. However, if found, the most common site is the stomach. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, and 60–70% of them occur in the stomach. Owing to their typical presentation as submucosal neoplasms, gastric schwannomas and GISTs appear grossly similar. Accordingly, the differential diagnosis for a gastric submucosal mass should include gastric schwannomas. Furthermore, GI schwannomas are benign neoplasms with excellent prognosis after surgical resection, whereas 10–30% of GISTs have malignant behavior. Hence, it is important to distinguish gastric schwannomas from GISTs to make an accurate diagnosis to optimally guide treatment options. Nevertheless, owing to the paucity of gastric schwannomas, the index of suspicion for this diagnosis is low. We report a rare case of gastric schwannoma in 53-year-old woman who underwent laparoscopic partial gastrectomy under the suspicion of a GIST preoperatively but confirmed to have a gastric schwannoma postoperatively. This case underscores the importance of including gastric schwannomas in the differential diagnosis when preoperative imaging studies reveal a submucosal, exophytic gastric mass. For a gastric schwannoma, complete margin negative surgical resection is the curative treatment of choice.

Is there a role for adjuvant therapy in resected adenocarcinoma of the small intestine

Background. The benefit of adjuvant therapy for resected small bowel adenocarcinoma has not been proven. We undertook a retrospective analysis to evaluate the benefit of adjuvant therapy in a clearly defined patient population with curatively resected small bowel adenocarcinoma. Material and methods. We identified 54 patients with small bowel adenocarcinoma who underwent margin-negative surgical resection and were evaluated after surgery at the University of Texas, M. D. Anderson Cancer Center between 1990 and 2008. Disease-free survival (DFS) and overall survival (OS) were estimated. Results. Median age was 55 years and primary tumor site was duodenum in 67%, jejunum in 20%, and ileum in 13%. Thirty patients (56%) received adjuvant therapy consisting of systemic chemotherapy with or without radiation in 28 and radiation alone in two. Patients who received adjuvant therapy had significantly higher tumor stage and rate of lymph node involvement. Five-year DFS and OS did not differ between treatment groups. In multivariate analysis, the use of adjuvant therapy was associated with improved DFS (HR 0.27; 95% CI 0.07–0.98, P = 0.05) but not OS (HR 0.47; 95% CI 0.13–1.62, P = 0.23). In patients with a high risk of relapse (defined as a lymph node ratio ≥10%), adjuvant therapy appeared to improve OS, P = 0.04, but not DFS, P = 0.15. Discussion. The use of adjuvant therapy for curatively resected small bowel adenocarcinoma was associated with an improvement in DFS. This finding strongly supports further investigation of adjuvant chemotherapy in this tumor type.

Resectability of Presymptomatic Pancreatic Cancer and Its Relationship to Onset of Diabetes: A Retrospective Review of CT Scans and Fasting Glucose Values Prior to Diagnosis

The timeline of progression of pancreatic cancer from resectable to unresectable disease is unknown. New-onset diabetes often occurs in pancreatic cancer. It is unclear if the cancer is resectable at the onset of diabetes. We (a) determined the resectability of pancreatic cancer on abdominal CT scans done prior to clinical diagnosis and (b) correlated resectability with onset of diabetes. All CT scans done at diagnosis or before pancreatic cancer diagnosis were reviewed and pancreatic changes classified as normal, potentially resectable, or unresectable pancreatic cancer. Fasting blood glucose values obtained at and prior to diagnosis were available in 18 patients. The date of onset of diabetes and the interval between onset of diabetes and diagnosis of cancer were noted. Thirty patients fulfilled inclusion criteria. Prior to diagnosis, 28 patients had 38 CT scans done at a median of 18 months (range 1-41) before cancer diagnosis. At cancer diagnosis, only 7/30 patients could undergo margin-negative surgical resection. CT scans done >/=6 months prior to diagnosis showed either a normal pancreas (N = 20) or a resectable mass (N = 6); none had unresectable cancer. The mean interval between onset of diabetes and diagnosis of pancreatic cancer was 10 months (range 5-29 months). At the onset of diabetes, 3 patients had normal pancreas, 6 had resectable, and 4 had unresectable pancreatic cancer. Pancreatic cancer is frequently undetectable or resectable on CT scans done >/=6 months prior to clinical diagnosis. At onset of diabetes, pancreatic cancers are generally resectable.

Comparison of stages I–II thymoma treated by complete resection with or without adjuvant radiation

Background Adjuvant radiation after resection of Masaoka stage II thymoma is widely advocated, but the evidence supporting it is controversial. Studies addressing this issue generally report few patients and lump all patients beyond stage I together in the analysis. Methods We retrospectively compared outcomes of stage I and II thymomas treated by resection alone with thymomas treated by resection plus radiation. Histology was re-reviewed to confirm pathologic staging and resection margin status. Results Between February 1992 and 2002, we performed 167 resections for thymoma. Of these, 70 patients were believed to have tumors in stage IIb or less intraoperatively, and all of these patients underwent complete resection. We reviewed the histopathology of 62 of 70 patients. Thirty thymomas demonstrated less than complete transcapsular microscopic invasion (stage I) and 40 thymomas demonstrated microscopic transcapsular invasion or macroscopic invasion into surrounding fatty tissue (stage II). Forty-seven patients underwent surgery without postoperative mediastinal radiotherapy. Dosages in the 23 radiated patients (3 stage I and 20 stage II) consisted of 45 to 55 Gy. Median follow-up was 70.3 months. Stage II patients who were radiated (n = 20) and those who were not radiated (n = 20) consisted of identical proportions in stages IIa and IIb. Two patients recurred (1 unradiated stage I patient and 1 radiated stage IIb patient). Overall 5-year survival rate was 91%. All who died were free of recurrence at time of death. Log-rank test showed no difference in Kaplan Meier survival curves ( p = 0.32) between the radiated and unradiated groups. Conclusions These data support the contention that margin-negative surgical resection alone is sufficient treatment for both stages I and II thymoma.