Surgical Resection Status Research Articles

Localized pulmonary histiocytic sarcomas in Pembroke Welsh Corgi.

Nineteen cases of histiocytic sarcomas in Pembroke Welsh Corgi were examined histopathologically. Focal or multiple masses were detected in the lung or in regional lymph nodes, or in both lung and nodes. All neoplastic lesions had common histological features characterized by the proliferation of pleomorphic histiocytic cells combined with various inflammatory cells. Most of the pleomorphic neoplastic cells were immunopositive for human leukocyte antigen (HLA)-DR and Iba-1. The median survival time for all dogs was 133 days. In the present study, several prognostic factors, such as gender, age, single or multiple lesions, lymph node involvement at the time of diagnosis, surgical resection status and additional chemotherapy, were examined, although none of these factors approached statistical significance. Histiocytic sarcoma must be considered in the differential diagnosis of dogs with pulmonary masses, especially in the canine breed.

QL-16 * COST EFFECTIVENESS ANALYSIS OF GLIOBLASTOMA MULTIFORME THERAPIES

BACKGROUND: Standard of care for glioblastoma multiforme (GBM) involves surgical resection plus chemoradiation. We recently published a survival model demonstrating personalized estimates of median survival that vary with patient-specific characteristics. We wished to build an econometric model to assess the costs of therapies for GBM. METHODS: Cost data from publicly available sources were used to construct a cost model based on our personalized predictor of GBM patient survival. We used the model to estimate median survival and cost of therapy for patients of various ages (40-90 years), Karnofsky Performance Scores (50-90), and extents of resection (0-100%). We analyzed surgery plus several adjuvant therapies (steroids, radiotherapy [XRT], temozolamide [TMZ], and XRT + TMZ). Cost effectiveness was calculated as cost per week of survival and cost per quality adjust life year (QALY). RESULTS: For surgery plus steroids, mean survival was 113 days (range 34-291), mean cost was $21,892 (range $15,167-23,782), mean cost per week of therapy was $1,614 (range $572-3,666), and mean cost/QALY was $130,149 (range $33,144-382,305). For surgery + XRT, mean survival was 155 days (range 46-399), mean cost was $35,017 (range $23,702-37,040), mean cost per week of therapy was $1,923 (range $552-4,283), and mean cost/QALY was $155,010 (range $32,009-446,611). For surgery + TMZ, mean survival was 184 days (range 48-476), mean cost was $58,732 (range $33,157-103,840), mean cost per week of therapy was $2,489 (range $1,527-5,440), and mean cost/QALY was $197,842 (range $88,472-472,753). For surgery + XRT + TMZ, mean survival was 253 days (range 76-653), mean cost was $82,018 (range $50,711-143,670), mean cost per week of therapy was $2,542 (range $1,541-4,695), and mean cost/QALY was $202,089 (range $89,283-489,670). CONCLUSION: Cost effectiveness of treatments for GBM is influenced by patient age, functional status, and extent of surgical resection. For many patients the estimated cost/QALY exceeds commonly-stated thresholds for cost-effective care, a finding that may inform future debate on GBM therapy.

Primary neuroendocrine tumors of the thymus: Clinical review of 22 cases.

Primary neuroendocrine tumors of the thymus are rare mediastinum tumors, which present a distinct type of tumor, which exhibit morpholgical and biological neuroendorcine features including the production of numerous biogenic amines. The aim of the present study was to evaluate factors influencing long-term survival in patients with primary neuroendocrine tumors of the thymus. A total of 22 patients exhibiting primary thymic neuroendocrine tumors, who were treated at the Zhejiang Cancer Hospital (Hangzhou, China), between 1995 and 2012 were reviewed. Survival curves were plotted using the Kaplan-Meier method and the Cox proportional hazards model was used for multivariate analysis. The overall five-year survival rate was 45.5% and the median survival time was 59 months in all of the patients. Histological grade (P<0.001), Masaoka-Koga stage (P=0.003) and surgical resection status (P=0.004) were identified to be associated with patient survival time. Furthermore, multivariate analysis identified that the histological grade was an independent prognostic factor, which was applicable to all patients (P=0.009). Therefore, the histological grade and Masaoka-Koga stage, as well as surgical resection status present three prognostic factors in patients exhibiting primary thymic neuroendocrine tumors.

Chromatin CKAP2, a new proliferation marker, as independent prognostic indicator in breast cancer.

BackgroundThe level of proliferation activity is a strong prognostic or predictive indicator in breast cancer, but its optimal measurement is still in debate, necessitating new proliferation markers. In the present study, the prognostic significance of the CKAP2-positive cell count (CPCC), a new proliferation marker, was evaluated, and the results were compared with those for the mitotic activity index (MAI).MethodsThis study included 375 early-stage breast cancer samples collected from two institutions between 2000 and 2006. Immunohistochemical staining was performed using a CKAP2 monoclonal antibody. Cox proportional hazard regression models were fitted to determine the association between the CPCC and relapse-free survival (RFS) amongst three groups formed on the basis of the CPCC or MAI value: groups 2 and 3 showing the middle and highest values, respectively, and group 1 the lowest.ResultsAfter adjustment for age, T stage, N stage, HER2 status, estrogen receptor status, progesterone receptor status, institution, and year of surgical resection, the CPCC was associated with a significantly worse RFS {hazard ratio [HR] = 4.10 (95% CI: 1.64–10.29) for group 2; HR = 4.35 (95% CI: 2.04–10.35) for group 3}. Moreover, its prognostic significance was similar to or higher than that based on the MAI {HR = 2.05 (95% CI: 0.94–4.65) for group 2; HR = 2.35 (95% CI: 1.09–5.10) for group 3}. In subgroup analyses, the CPCC showed a prognostic significance in the luminal A and triple-negative subgroups, but not in the HER2-positive subgroup.ConclusionsChromatin CKAP2 is an independent prognostic marker for RFS in early-stage breast cancer, and could potentially replace the MAI in clinical evaluation of proliferation activity. Additionally, our study results suggest that the prognostic significance of proliferation activity differs among the various subgroups of breast cancer.

Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in Peritoneal Carcinomatosis from Rectal Cancer

Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment most likely to achieve prolonged survival in peritoneal carcinomatosis (PC). Yet the efficacy of HIPEC in rectal patients is controversial because of the retroperitoneal location of the primary tumor. Therefore, we reviewed our experience in patients with PC from a rectal primary tumor. A retrospective analysis of a prospective database of 950 HIPEC procedures was performed. Performance status, age, albumin level, prior surgical score, resection status, morbidity, mortality, and survival were reviewed. A total of 13 and 204 patients with PC from rectal and colon cancer, respectively, were identified. Median follow-up was 40.1 and 88.1months, respectively. Eastern Cooperative Oncology Group (ECOG) score was zero or one for 92% of patients with rectal cancer and 83% for colon, while R1 resection was achieved in 54 and 51%. The 30-day mortality was 5% for colon cancer. There were no deaths in the rectal group. The morbidity for the colon and rectal groups was 57 and 46%, respectively, with a 23% 30-day readmission rate. In univariate analysis, age, ECOG, prior surgical score, albumin level, and node and resection status were not statistically significant in predicting survival for the rectal cancer patients. Median survival for the rectal and colon groups was 14.6 versus 17.3months, while the 3-year survival was 28.2 versus 25.1%. Our data demonstrate similar 3-year survival for patients with rectal and colon cancer PC treated with CS/HIPEC. This can be attributed to patient selection bias. Selected rectal cancer PC patients should not be excluded from an attempted cytoreduction and HIPEC.

Search for Distinctive Markers in DNT and Cortical Grade II Glioma in Children: Same Clinicopathological and Molecular Entities?

Dysembryoplastic Neuroepithelial Tumours (DNT) are benign brain lesions arising during childhood that are characterized by early onset partial seizures, no neurological deficit and cortical location. Pathological diagnosis is easy when the glioneuronal element is present. Its absence might lead to the diagnosis of non-specific DNT or low-grade glioma (LGG). The aim of this retrospective study was to analyse clinicopathological and molecular features of a series of cortical tumours, in order to find diagnostic and prognostic markers to better custom treatment next. Twenty four children with cortical neuroepithelial tumour were included. Clinical and radiological data were collected. Histological diagnosis was reviewed for all patients. 1p19q and p53 status were obtained by FISH and immunohistochemistry respectively. IDH1-2 gene mutations were assessed by DNA sequencing. CGH-array was performed in 6/24 samples. We recorded 13 DNT and 11 cortical LGG. Median age at surgery was 11.5 years. Overall survival was 100% and event-free survival at 10 years was 70%. No tumour displayed chromosomal alteration or 1p19q deletion or p53 expression. Only one patient with grade-II oligoastrocytoma had an IDH1 mutation. No statistical difference was found between the two populations in terms of age, sex, tumour location, type of surgical resection, disease progression and clinical status at last follow-up. Only the occurrence of septations on preoperative MRI was significantly associated with pathological features of DNT. Patients with DNT and cortical LGG share excellent outcome. Our genetic analysis could not distinguish DNT from LGG. In particular, CGH-array analysis was strictly normal in both tumor types. In attempt to find molecular markers, diagnosis of these lesions remains difficult when the glioneuronal element is lacking.

Steroid‐sparing effects of angiotensin‐II inhibitors in glioblastoma patients

The standard of care in patients with glioblastoma (GBM) relies on surgical resection, radiation therapy (RT), and temozolomide. Steroids are required in almost all patients to reduce peritumoral edema, but are associated with numerous side effects. Vascular endothelial growth factor (VEGF) is a key driver of peritumoral edema and angiogenesis in human GBM. Recently, angiotensin-II inhibitors were reported to reduce VEGF secretion and tumor growth in some animal models. To investigate whether angiotensin-II inhibitors might have a similar effect in humans and before undertaking a prospective study, we retrospectively investigated a series of 87 consecutive, newly diagnosed GBM patients, treated in a single center. Amongst these patients, 29 (33%) were already treated before RT for high blood pressure (HBP), 18 of them (21%) with an angiotensin-II inhibitor. In all patients, performance status, surgical procedures, and steroid dosages were documented. Patients treated with angiotensin-II inhibitors, but not other antihypertensive drugs, required half of the steroids of the other patients during radiotherapy (P = 0.005 in multivariate analysis, considering other antihypertensive treatments, surgical resection, and performance status). This effect of angiotensin-II inhibitors was also significant at the beginning of radiotherapy (P = 0.03 in multivariate analysis). Treatment with angiotensin-II inhibitors had no effect on survival (16.2 vs. 17.9 months for the treated and the non-treated group, respectively, P = 0.77). Angiotensin-II inhibitors might display significant steroid-sparing effects in brain tumor patients. Given the morbidity associated with steroids, this finding might have important practical consequences in these patients and warrants a randomized study.

Serum YKL-40 is a marker of prognosis and disease status in high-grade gliomas

The objective of this study was to evaluate whether longitudinal levels of serum YKL-40 correlate with disease status or survival in adults with gliomas. Patients with histologically confirmed gliomas were eligible for this longitudinal study. Serum samples were collected prospectively and concurrently with MRI scans at multiple time points during the course of the disease. YKL-40 levels determined by ELISA were correlated with radiographic disease status and survival. We performed a multivariate survival analysis including well-known prognostic factors such as age, performance status, and extent of surgical resection. Three hundred and forty-three patients with gliomas (41 low-grade, 105 anaplastic, and 197 glioblastoma) were accrued. Two-year survival from registration was 29% for glioblastomas, 62% for anaplastic gliomas, and 83% for low-grade gliomas. A total of 1740 serum samples were collected, and 95.6% of samples had matching MRI scans. Serum YKL-40 level was significantly lower in patients with no radiographic disease compared with patients with radiographic disease in both the anaplastic glioma (P= .0008) and the glioblastoma (P= .0006) cohorts. Serum levels of YKL-40 in patients with low-grade gliomas were not associated with radiographic disease status. Increases in YKL-40 were independently associated with worse survival in anaplastic gliomas (hazard ratio [HR] = 1.4, P= .01) and glioblastomas (HR = 1.4, P< .0001). Longitudinal increases in serum YKL-40 are associated with increased risk of death in patients with glioblastomas and anaplastic gliomas. YKL-40 is also a putative indicator of disease status in these patients.

Extremity Soft Tissue Sarcoma in a Series of Patients Treated at a Single Institution

To improve understanding of what is adequate in local treatment of extremity soft tissue sarcomas (ESTS), to maximize the ratio between local control, limb preservation and prognosis. Nine hundred ninety-seven consecutive patients affected by primary ESTS were reviewed. Size, depth, histotype and grade of the tumor, margin status (R0, R1, R2) of surgical resection, and adjuvant treatments were analyzed. Univariable and multivariable analysis were carried out. For the subgroup of R1 resection the presence/absence of the tumor at the inked surface and the presence/absence of an anatomic barrier were also considered. Five- and 10-year mortality estimates (95% confidence interval) were 0.29 (0.20-0.38) and 0.38 (0.28-0.49) in R1 cases, and 0.16 (0.13-0.19) and 0.19 (0.16-0.23) in R0 cases (P = 0.0003). Size, grade, depth, and histologic subtype were also significant predictor of mortality. Significant determinants for local relapse were surgical margins, radiation therapy, and histologic subtype. In the subset of R1 resections trends towards a better local control for R1 negative cases and histology other than myxofibrosarcoma were identified. Significant determinants for distant metastases were size, grade and histologic subtype of the tumor but not surgical margins. Quality of surgical margins independently predicted local control and survival. The effect on survival was directly mediated by local recurrence to proximal sites invading the abdomen/thorax, and this may indeed be the main way by which quality of surgery directly impacts the final prognosis of ESTS patients.

Étude de sept cas de méningiomes à cellules claires et revue de la littérature

Clear cell meningioma (CCM) is a rare variant of meningioma, which is important to distinguish because of its aggressive behaviour. Sixty-eight cases have been previously described in the literature. In this retrospective study, we report seven cases of CCM operated in our institution between 1994 and 2008. Seven CCM cases were retrieved from the files of our pathology department. Clinical and radiological data were reviewed. A standard histological study was realized and immunohistochemistry was performed with epithelial membrane antigen (EMA), cytokeratin KL1, progesterone receptors, Ki-67 (MIB-1), S100 protein. Patients' age ranged from 2 to 70 years (median age: 36 years), with a female predominance (5/7 patients). Three patients belonged to the same family, probably affected by neurofibromatosis type 2. CCM occurred in various locations: medullary region (two), sphenoid wing (two), ponto-cerebellar angle (two), tentorium (one). The tumour could be fully resected in three cases. Follow-up ranged from 3 months to 15 years: recurrence occurred in four patients, three of whom eventually died from the disease. In our series, the frequency of CCM (0,6% of all meningiomas operated on in our institution) and its histological aspects are almost identical to those observed of the literature. We discuss the predictive value of proliferation index (MIB-1) and the role of patient status and quality of surgical resection in the evolution. Our study supports the fact that MCC course is less favourable than meningioma WHO grade I, even in the absence of anaplastic area, high mitotic activity, or necrosis. In this series, MIB-1 index was of no interest identifying patients with or without recurrence.

Angiogenesis and expression of estrogen and progesterone receptors as predictive factors for recurrence of meningioma

Meningiomas are benign tumors, with low rate of recurrence after surgery. The most important factor predicting recurrence is the extent of surgical resection; other factors have been studied with conflicting results. Angiogenesis, an important substratum for growth and spread of neoplasic cells, and the expression of estrogen and progesterone receptors (ER, PR), could play a role in the recurrence of meningioma. We evaluated 42 patients with meningioma diagnosis (confirmed by histopathology) treated exclusively by surgery between January 1995 and December 1999, and compared the recurring and non-recurring groups after a ten-year follow-up period. Recurrence was associated with several factors including vascular density (VD), cell proliferation index (CPI), ER, PR, and cyclin E (CE) tissue expression, as evaluated by immunohistochemistry. Complete surgical resection was achieved in 41% of patients. Recurrence of meningioma was found in 17 patients (40%). Median + or - standard deviation (SD) of recurrence time was 32 + or - 5 months. When recurrence versus no recurrence was compared, mean + or - SD of VD and CPI were 9 + or - 3.6 and 607.6 + or - 233 (40x/10 fields) respectively. Tissue expression was positive for ER, PR, and CE in 28, 62 and 91% of patients, respectively. The sole significant recurrence-associated factors were extent of resection (P = 0.003) and VD (P = 0.004). ER, PR, and CE-tissue expression were not statistically significant. The most important factor associated with meningioma relapse was vascular density, independently of hormonal status and extent of surgical resection. Patients with a high risk of recurrence could benefit from additional treatment.

Surgical resection of primary and metastatic hepatic malignancies following portal vein embolization

Portal vein embolization (PVE) has been used to induce hypertrophy in future liver remnants (FLRs) in preparation for major hepatic resection. We report our initial experience with PVE and identify potential predictors of unresectability following PVE. Patients with primary and metastatic hepatic malignancies (n = 20) who underwent PVE between 2004 and 2008 were categorized by surgical resection status and clinicopathologic factors were compared. The cohort had the following histologies: colorectal adenocarcinoma (45%, n = 9), hepatocellular carcinoma (20%), cholangiocarcinoma (20%), and other (15%). Seven patients (35%) had previous liver-directed or regional therapy; 55% subsequently underwent successful liver resection, whereas 45% were deemed unresectable. Patients who underwent successful resection had tumor shrinkage after PVE compared to unresectable patients (% change in maximal tumor diameter, -6% vs. +45%, respectively; P = 0.027) and had a lower rate of baseline liver function test abnormality (0% vs. 56%, respectively; P = 0.004). Resected patients had an 83% 5-year overall survival. Baseline liver dysfunction may predict subsequent unresectable hepatic disease following PVE and tumor progression after PVE appears to increase the likelihood for finding unresectable hepatic disease. Select patients should be considered for PVE with careful surveillance during the period of FLR hypertrophy.

Effect of Age on Survival of Clinical Stage I Non-Small-Cell Lung Cancer

Elderly patients with early-stage lung cancer are less likely to undergo tumor resection because of concerns about their ability to tolerate surgery or perceived limited life expectancy. The objective of this study was to evaluate the impact of age and competing risks on outcomes of elderly patients with stage I non-small-cell lung cancer (NSCLC). We identified 27,859 cases of histologically confirmed, stage I NSCLC from the Surveillance, Epidemiology, and End Results registry. Patients were grouped by age (<60, 61-69, 70-79, >or=80 years) and surgical resection status. Relative survival rates were compared amongst treatment groups by age strata to determine the potential impact of surgery and the contribution of competing risks to overall mortality. Patients aged <60, 61-69, 70-79, and >or=80 years represented 20%, 32%, 37%, and 11% of cases. The rate of surgical resections declined from 95% of patients <60 years, to 79% of patients aged >or=80 years. While 5-year relative survival rates were somewhat lower among males >or=80 years compared with those <60 years (63.5% versus 69.2%), there were no significant differences in relative survival among resected women or unresected patients, regardless of sex. Most deaths in unresected patients were attributed to lung cancer across all age groups. Elderly patients who undergo resection achieve relative survival rates that are comparable to their younger counterparts. In unresected patients, lung cancer is the major source of mortality, even in the oldest age groups, suggesting that elderly patients with stage I lung cancer should receive aggressive surgical management when possible.

Akt/protein kinase B overexpression as an accurate prognostic marker in adult diffuse astrocytoma

Akt/Protein kinase B (PKB) is a common downstream molecule of Ras signaling essential for cell survival. In an attempt to find a novel prognostic marker of diffuse astrocytoma, we performed an immunohistochemical analysis of Akt/PKB with regard to patient survival and regrowth patterns. Twenty-four adult patients with diffuse astrocytoma were similarly managed without early post-operative radiotherapy and followed up for a median period of 7.5 years. They were analysed by immunohistochemistry for Akt/PKB expression as well as p53 protein accumulation, epidermal growth factor receptor (EGFR) expression, and MIB-1 labeling index. The prognostic significance of each molecular covariate was tested by multivariate analysis using Cox's proportional hazard model including age, performance status, and extent of surgical resection. Akt/PKB overexpression significantly correlated with both shorter overall survival (OS) and progression-free survival (PFS) (p = 0.0110). All the Akt/PKB-positive patients with post-operative residual tumours experienced tumour recurrences, whereas only a small fraction of the Akt/PKB-negative individuals had recurrences (p = 0.0070). Invasive recurrence into surrounding brain occurred only in the Akt/PKB-overexpressed tumours. In contrast, MIB-1 labeling index correlated only with OS, while p53 protein accumulation correlated only with PFS. The Cox's proportional hazard model identified Akt/PKB overexpression as a significant prognostic factor for shorter PFS (p = 0.0117). These results show that Akt/PKB overexpression would be suggestive of malignant progression and invasive regrowth of diffuse astrocytoma, and it can serve as a novel prognostic marker for this tumour.

Liver Resection for Intrahepatic Cholangiocellular Carcinoma: When is it Worthwhile?

SocieteInternationale de Chirurgie 2008 Intrahepatic cholangiocarcinoma (ICC) accounts for 10- 20% of primary liver malignancies, with an increasing incidence in western countries during recent years. In general, prognosis is poor, with a reported median survival of less than 9 months after diagnosis in the majority of patients with unresectable disease (1). Aggressive resection is the mainstay of surgical treatment for ICC, offering patients the best chance for prolonged survival (2, 3). However, comparison of survival data in the literature is difficult due to the often inhomogeneous selection criteria and the small number of cases. In patients with resectable ICC, achieving a negative margin is considered the most important variable associ- ated with outcome and long-term survival (2). In this issue of the World Journal of Surgery, Nakagohri et al. (4) report 56 patients who underwent surgical resection for ICC during a 15-year period in a single institution. R0 resection was achieved in 75% of patients with a 5-year survival of 39%. Interestingly, long-term survival was possible even in patients with R1 resection, and 2 of 14 patients with positive margins survived more than 5 years. Similar results have recently been reported by others (3) and sug- gest that some patients may benefit from liver resection despite having pathologically involved resection margins. In recent years, in addition to resection margin status, numerous other prognostic factors have been investigated. In several studies, the negative prognostic influence of tumor-positive lymph nodes, microvascular or macrovas- cular infiltration, and multifocal tumor growth have been demonstrated (2, 3). Based on multivariate analysis, Nak- agohri et al. report that the presence of intrahepatic metastases was the only significant independent risk factor other than surgical resection status for ICC. In fact, no patient with intrahepatic metastases survived more than 10 months. This poor prognosis after resection of ICC with intrahepatic metastases could be considered a contraindi- cation for operative intervention, and underlines the need for improved selection of patients eligible for hepatic

Lymph node metastases in soft tissue sarcomas—a single center analysis of 1,597 patients

The aim of this study was to examine the clinical course of patients with the rare finding of regional lymph node metastasis (RLNM) from soft tissue sarcoma. Data from 28 out of 1,597 consecutive soft tissue sarcoma patients with RLNM were from the patients' charts and interviewing patients and general practitioners. Survival, including possible influencing factors, was statistically calculated. RLNM was seen in 21.4% for epithelioid sarcoma and 17.6% for clear cell sarcoma. All other entities presented RLNM rates below 10%. At follow-up after an average of 9.6 years, only three patients were alive with no evidence of disease. Survival was independent from surgical resection status of the primary tumor and the RLNM as well as from adjuvant radiation and chemotherapy. Tumor entity as well as the length of the time period from primary to RLNM affect survival. Surgical treatment as well as radiation and chemotherapy may improve survival in selected cases but probably have their value much more in terms of local disease control and improvement life quality of patients who probably already suffer from an aggressive systemic disease at time of nodal involvement.

672 patients with acinar cell carcinoma of the pancreas: a population-based comparison to pancreatic adenocarcinoma

Acinar cell carcinoma (ACC) is a rare cancer of the pancreas accounting for approximately 1% of nonendocrine tumors. Because no large series of patients with ACC exist, our understanding of this disease comes mainly from small retrospective reports and anecdotal experience. Our goal was to evaluate a large population-based cohort of patients with ACC and compare their demographic factors and outcomes to those of patients with pancreatic adenocarcinoma (PA). Using the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2003), we identified all patients with ACC or PA. The demographic factors, tumor characteristics, resection status, and long-term survival were compared between the 2 groups. A total of 672 patients with ACC and 58,526 with PA were identified. The mean age at the time of diagnosis was significantly lower for ACC than PA (56 years vs 70 years, P < .001). Compared with patients with PA, patients with ACC were more likely to be male (54% vs 48%, P = .007) and white (85% vs 81%, P = .03). Based on SEER clinical staging, patients with ACC were less likely to have unstaged disease (8% vs 18%). Of the 616 patients with staged ACC, 16% had localized disease, 26% had regional disease, and 58% had distant disease. In the 47,896 staged patients with PA, 10% had localized disease, 33% had regional disease, and 57% had distant disease (P < .0001 compared to ACC). Based on clinical extent of disease, 81% of patients with locoregional ACC and 70% of patients with locoregional PA were resectable. However, only 69% of ACC patients with locoregional disease and 27% of PA patients with locoregional disease underwent surgical resection. The overall 5-year survival was 42.8% for ACC (median, 47 months) and 3.8% for PA (median, 4 months, P < .0001). Patients with unresected ACC had a 5-year survival rate of 22% compared to 2% in patients with unresected PA (P < .0001). Surgical resection significantly improved survival. The 5-year survival was 72% in resected ACC and 16.3% in resected PA (P < .0001). Multivariate Cox proportional hazards regression model results suggested patients with ACC were less likely to die (hazard ratio = 0.241; 95% confidence interval, 0.22-0.27) than patients with PA after controlling for gender, race, stage, SEER region of diagnosis, and surgical resection status. Consistent with anecdotal reports and previous retrospective studies, ACC is a more indolent disease than PA. Patients with ACC tend to present at a younger age, are more likely to have resectable disease, and are much more likely to undergo potentially curative resection. The long-term survival for patients with ACC is significantly better when compared to the long-term survival of patients with PA.

A case of intraroot cauda equina cavernous angioma: clinical considerations

Case report and literature review. Intradural-extramedullary cavernoma is a rare condition with only 23 cases reported in the literature. Most cases described adhere to spinal root or spinal cord. We report an example of this rare entity located within the sheets of one cauda equina nerve root. Rome, Italy. The authors report clinical, radiological, surgical, and pathological features of intraroot cavernoma with a literature review. Patient was operated. One year after surgery, he was healthy. Lumbar intradural cavernous angioma may present with sciatalgia, low-back pain, neurological deficit, or, more rarely with subarachnoid hemorrhage or hydrocephalus. They are treated successfully with surgical resection but preoperative status is a predicting factor for outcome. Sometimes the sacrifice of the spinal root is inevitable because, as in present case, the cavernous angioma is included in the nerve root. These lesions are rare and benign lesions. It is important for neurosurgeons to be aware of the existence of this entity to avoid preoperative misdiagnosis with tumor.

Current management of locally advanced pancreatic cancer

Almost 30% of patients with pancreatic cancer present with large, locally advanced tumors in the absence of distant metastases. Because surgical resection is frequently contraindicated by vascular invasion, locally advanced pancreatic cancer has a dismal prognosis with a 6-10-month median survival. Recent advances in the multimodality treatment of other gastrointestinal malignancies have not altered the management of patients with locally advanced pancreatic cancer, a clinical dilemma reflected by the number of nonrandomized trials and anecdotal reports addressing this difficult disease. Our review summarizes the current status of aggressive surgical resection and neoadjuvant chemoradiation for locally advanced pancreatic cancer and suggests a treatment algorithm for patients with this disease based upon published clinical evidence.

Long-term outcome of lung cancer patients treated with surgical resection: A report of 210 cases

To study the prognostic factors in patients with lung cancer after curative resection. A retrospective study was conducted on 210 cases of clinicopathological survival data of lung cancer patients who underwent surgical resection from January 1987 to December 1999. Nine conventional prognostic factors were analyzed by COX model. The overall 3-, 5- and 10-year survival rates were 37.4%, 30.1% and 23.5% respectively. Univariate analysis showed that regional lymph nodes status (N), primary tumor status (T), histological type of lung cancer, the type of operation and curability of surgical resection were significantly related to disease specific survival. Multivariate analysis showed that regional lymph nodes status, primary tumor status and curability of surgical resection were the three independent predictors of long term outcome. The hazard ratio of death was 2.42 for patients with N2-3 vs N0-1( P =0.000 1), 3.50 for patients with T2-4 vs T1( P =0.033 0) and 1.77 for patients with incomplete resection vs complete resection ( P =0.022 4). Primary tumor status, regional lymph nodes status and curability of surgical resection are the three important prognostic factors of lung cancer. In order to improve long-term survival of lung cancer patients, it is very important to operate in the earlier stage of tumor, to extensively dissect intra-pulmonary and ipsilateral mediastinal lymph nodes and to avoid incomplete resection.