Caterina Boso

Trends in management and prognosis for esophageal cancer surgery: twenty-five years of experience at a single institution.

OBJECTIVE To investigate trends in results of esophagectomies to treat esophageal cancer at a single high-volume institution during the past 25 years. DESIGN AND SETTING Retrospective cohort study in a university tertiary referral center. PATIENTS AND METHODS Patients with cancer of the thoracic esophagus or esophagogastric junction seen from 1980 through 2004 were included (N = 3493). Three time periods were defined: 1980-1987, 1988-1995, and 1996-2004. MAIN OUTCOME MEASURES Clinical presentation, tumor characteristics, and morbidity, mortality, and survival rates among patients with esophageal cancer undergoing esophagectomy. RESULTS The ratio of squamous cell carcinoma to adenocarcinoma decreased from 3.3 to 1.7 (P <.001) during the study period, in parallel with an increase in the number of patients with tumors in the lower esophagus/esophagogastric junction. An increasing proportion of patients who underwent resection received neoadjuvant treatment (chemotherapy/chemoradiotherapy), and 1978 patients underwent esophagectomy. The R0 resection rate increased from 74.5% to 90.1% (P <.001). In addition, an increasing proportion of patients had early-stage tumor in the resected specimen. In-hospital postoperative mortality decreased from 8.2% to 2.6% (P <.001), and the 5-year survival rate significantly improved from 18.8% to 42.3% (P <.001) for all patients who underwent resection. Pathological tumor stage, completeness of the resection, time period, sex, tumor histological type, and tumor location influenced the prognosis of patients with esophageal cancer undergoing esophagectomy. CONCLUSIONS A change in location and histological type of esophageal cancer has occurred during the past 25 years. Earlier diagnosis, a multidisciplinary approach, and refinements in surgical technique and perioperative care have led to a significant reduction in postoperative mortality rate and improved long-term survival among patients with cancer of the thoracic esophagus or esophagogastric junction.

Outcome of patients receiving photodynamic therapy for early esophageal cancer

PURPOSE Photodynamic therapy (PDT) has shown remarkable activity in a variety of human cancers. In the present study, we report the effects of PDT on inoperable early-stage esophageal cancer. METHODS AND MATERIALS Sixty-two patients were treated with an argon dye laser (630 nm wavelength, 300-800 mW of power, energy dose of 200-300 J/cm) after intravenous injection of 5 mg/kg of hematoporphyrin derivative. Eighteen patients (29.5%) had in situ carcinoma (Tis), 30 (48.5%) had T1-stage cancer, 7 (11%) had T2-stage cancer, and 7 (11%) had recurrent disease in the anastomotic area after previous surgery without evidence of invasion outside the lumen. Patients with residual disease after two rounds of PDT received definitive radiotherapy. Patients were evaluated for response to therapy and survival. The follow-up time ranged from 3 to 90 months (median, 32 months). RESULTS The complete response (CR) rate was 37% (23 of 62) in patients who received PDT alone and 82% (51 of 62) in those who also received radiotherapy. The CR rate after PDT alone was statistically higher (p = 0.04) for patients who had Tis/T1 lesions (21 of 48; 44%) than for those with T2-stage disease (2 of 7; 28%) or recurrent tumors (0 of 7; 0%). Fifty-two percent of patients who had CR following PDT alone did not suffer local tumor recurrence. The median local progression-free survival times after PDT and additional radiotherapy (in cases with incomplete response) was 49 months for Tis- and T1-stage lesions, 30 months for those with T2-stage disease, and 14 months for patients with locally recurrent disease. Patients who completely responded to PDT had a median overall survival (OS) of 50 months, which was significantly longer (p < 0.003) than that of patients not responding to PDT. Toxicity was minimal; we recorded three cases of esophageal stenosis (7%) and one case of tracheo-esophageal fistula (2.5%) after combined PDT and radiotherapy. CONCLUSION PDT is an effective regimen for early esophageal cancer, giving a CR rate of about 40%, long-term local control and favorable overall survival. Additional radiotherapy in cases of incomplete response to PDT is effective and potentially curative in another 45% of cases.

Stanford V Regimen plus Consolidative Radiotherapy Is an Effective Therapeutic Program for Bulky or Advanced-Stage Hodgkin’s Disease

Since September 1996, 48 untreated patients with bulky or advanced-stage Hodgkin’s disease received the 12-week Stanford V chemotherapy regimen followed by consolidation radiotherapy at a dose of 36 Gy to bulky mediastinal disease and 30.6 Gy to the initial sites of disease ≧3 cm in transverse diameter. After the combined therapy, 46 of 48 (96%) achieved complete remissions. With a median follow-up of 48 months, the 5-year overall survival was 95% and freedom from progression 86%.There were no treatment-related deaths. All but one premenopausal female patient (who received pelvic and inguinal irradiation) recovered normal menses. Until now no case of secondary leukemia or myelodysplasia was observed. Our results confirm that the Stanford V regimen with consolidation radiotherapy is safe and effective in patients with bulky or advanced-stage Hodgkin’s disease, achieving very high remission and overall 5-year survival rates. Longer follow-up is necessary to evaluate the extent of all complications.

Fatal HBV-related liver failure during lamivudine therapy in a patient with non-Hodgkin's lymphoma.

.Wereportthecaseofa59-year-oldmanadmittedtoourdepartmenton2August2006withfever,fatigueandjaundice.InDecember2005thepatientwasfirstdiagno -sedwithstageIIBbulkydiffuselargeBcelllymphoma,CD20+withanaaIPIof1.Atthetimeofdiagnosis,hehadsplenomegalyandhepatomegaly;laparoscopicspleenandliverbiopsyresultedinahistologicaldiagnosisofsplenicinfiltrationofnon-Hodgkin’slymphoma(NHL)inacontextofchronichepatitis(withmildactivity,gradeG2),suggestiveofviralinfection.Stagingwascompletedwiththoracicandabdomi-nalCTthatevidencedaspleniclesionof13x14x16cmalongwithliverinvolvementwithsmallnodulesinthefourthsegmentandseveralmesenteric,hepatichilumandparaaorticinvolvedlymphnodes.SerologyrevealedthepatienttobeachronicHBVcarrier(HbsAgpositive).ThepatientwasHbeAgnegativeandanti-HBcpositivewithahighHBVDNAtiterof5,017,954IU/mL.CoexistinghepatitisCorhepatitisDviruswasexcludedbeforechemotherapy.Thelevelofaspartateaminotransferase(AST)was60U/L(normal10-45U/L),alanineaminotransferase(ALT)was50U/L(normal10-50U/L),whiletheremainingroutinebiochemicalexaminationsincludingbiliru -bin,albumin,plateletandWBCcountswerewithinnormalranges.ViralsequencingoftheHBVstraindidnotrevealthepresenceofmutationsassociatedwithresistanceto lamivudine. Lamivudine treatment 100 mg/day was started together with achemotherapyregimenconsistingofcyclophosphamide,doxorubicin,vincristine,prednisoneandrituximab(CHOP-R)givenfor8cycles.PETCTafterchemotherapyshowedremissionoftheneoplasticdiseasebutasplenicresidual,sothepatientwasgivenadditionalradiotherapytothesplenicarea(lastcourseon7July2006).Athisadmissiontoourdepartment,thepatient’shematologicalpanelwasnormalbutliverbiochemistryrevealedserumASTtobe3,878U/L,ALT4,364U/L,totalbilirubin137.1 mol/L,alkalinephosphatase138U/L,andalbumin35.5g/L.Othernonviralcausesofacutehepatitiswereexcluded.HBVDNAwas95,528IU/mL.Thepatientwasstillonlamivudinetreatment.ViralsequencingoftheHBVstrainrevealedthepresenceofacombinedL180MandM204Imutation,whichisassociatedwithre -si tan ce o lmv ud

Post Transplant Lymphoproliferative Disorders After Liver Transplantation

Post-transplant lymphoproliferative disorder (PTLD) is a clearly recognized and potentially life threatening complication after solid organ or bone marrow transplantation. It comprises a spectrum of diseases ranging from infectious mononucleosis and lymphoid hyperplasia to highly aggressive lymphoma. The disease has increased clinical importance in view of the constantly rising number of organ transplant recipients and the development of more potent and specific immunosuppressive drugs.

Endoscopic treatment of early bronchial cancer: our experience with photodynamic therapy (PDT)

The role of photodynamic therapy (PDT) in the treatment of small cancers has been established in several clinical studies. Here, we report on the efficacy of PDT for early inoperable or recurrent non-small-cell lung cancer (NSCLC). Methods and Materials: From June 1989 to November 2004, 40 patients with 50 NSCLC were treated with PDT. Twelve cases were inoperable for medical reasons and were staged as T1N0M0, and 28 had recurrent in situ carcinoma. Patients with residual disease after PDT received definitive radiotherapy and/or brachytherapy. Follow-up ranged from 6 to 167 months (median 43.59). Twenty of the 40 patients received i.v. injections of hematoporphyrin derivative (5 mg/kg), the other 20 had injections of porfimer sodium (Photofrin, 2 mg/kg). An argon dye laser (630 nm wavelength, 200-300 J/cm2) was used for light irradiation in 24 of the 40 patients, a diode laser (Diomed, 630 nm wavelength, 100- 200 J/cm2) in the other 16. Results: PDT obtained a 72% complete response (CR) rate (36/50 treated lesions), that is 27 CR among the 37 Tis carcinomas and 9 among the 13 T1 cases. Kaplan-Meier curves showed a mean overall survival (OS) of 75.59 months (median 91.4 months). Two- and 5- year OS rates were 72.78% and 59.55%. The mean and median survival rates for patients with Tis stage were 86.5 and 120.4 months, respectively (standard error 9.50) and for patients with T1 disease they were 45.78 and 35.71 months, respectively; the difference was statistically significant (P< 0.03). No severe early or late PDT-related adverse events were recorded. Conclusions: PDT is effective in early primary or recurrent NSCLC, resulting in a CR rate of 72%. The incorporation of PDT in standard clinical practice, in combination with radiotherapy, warrants further investigation.

Radiotherapy alone in the treatment of clinical stage I-IIA, nonbulky, Hodgkin's disease: Single-institution experience on 73 patients staged with lymphangiography and laparoscopy

From 1985 to 1998, at the Regional Cancer Center of Padua, patients with Hodgkin’s disease (HD) routinely underwent a clinical staging procedure including lymphangiography and laparoscopy with multiple liver and spleen biopsies. Patients with IA and IIA nonbulky HD were treated with radiotherapy alone. The aim of this study is to analyze the efficacy of radiotherapy as radical treatment in this group of patients, and the role of lymphangiography and laparoscopy in the selection of patients with abdominal disease located to the spleen, liver, or the pelvic lymphatic chains. From January 1985 to January 1998, 94 previously untreated patients with biopsy-proven HD underwent clinical staging procedures consisting of history, physical examination, routine laboratory tests, chest radiography, total-body computed tomography scan, and bone marrow biopsy and were considered in stage I-IIA nonbulky. In addition, all patients underwent bipedal lymphangiography, which was positive in 12 (12.8%). Of the 82 patients with negative lymphangiography, 9 (11%) showed disease below the diaphragm at laparoscopy with multiple random spleen and liver biopsies. Of the remaining 73 patients, 32 were male and 41 were female with a median age of 29 years (range: 14–72 years).