Francesco D’Angelo

Log Odds of Positive Lymph Nodes (LODDS): What Are Their Role in the Prognostic Assessment of Gastric Adenocarcinoma?

BackgroundNodal status is an important prognostic factor for patients with gastric cancer. Log odds of positive nodes (LODDS) (log of the ratio between the number of positive nodes and the number of negative nodes) are a new effective indicator of prognosis. The aim of the study is to evaluate if LODDS are superior to N stage and lymph nodal ratio (LNR).MethodsPrognostic efficacy of pN, nodal ratio, and LODDS was analyzed and compared in a group of 177 patients with gastric adenocarcinoma who underwent curative gastrectomy.ResultspT, pN, LNR, and LODDS were all significantly correlated with 5-year survival. Multivariate analyses showed significant values as prognostic factor for pN, LNR, and LODDS. A Pearson test demonstrated no significant correlation between LODDS and retrieved nodes. In patients with less than 15 examined nodes, LODDS classification and pN were significantly correlated with survival, whereas LNR classification was not significantly related.ConclusionsLODDS are not correlated with the extension of the lymphadenectomy and are able to predict survival even if less than 15 nodes are examined. They permit an effective prognostic stratification of patients with a nodal ratio approaching 0 and 1. Further studies are needed to clarify their role and if they are capable of guaranteeing some advantages over pN and LNR.

Dedifferentiated Liposarcoma of the Retroperitoneum With Osteosarcomatous Component

We commend Iwasa and Nakashima for their brilliant work on dedifferentiated liposarcoma (DDL). In particular, we really appreciated the differentiations the authors assessed between high-grade (HDDL) and low-grade DDL (LDDL), as well as conventional and comingling types of DDL (where the transition from well-differentiated liposarcoma (WDL) to DDL is abrupt in the former and intermingled in the latter). Furthermore, since LDDL proved to have metastatic capability, we concur with them on the concern of using mitotic count as one of the criteria for dedifferentiation, whereas advocate for retroperitoneal localization as a prognostically unfavorable feature of DDL. Recently, we had to deal with a 69-year-old man affected by a very rare form of DDL, that is, DDL with osteosarcomatous component (ODDL) occurring in the left retroperitoneum. A curative excision of the neoplasm was conducted along with en bloc resection of the greater omentum, spleen, left colon, left adrenal gland, and kidney. The patient did well after the intervention and was scheduled for adjuvant radiochemotherapy with epirubicin and ifosfamide; nevertheless, at 4-month follow-up he developed multiple supracentimetric intraand retroperitoneal metastases. Only 17 cases of ODDL are reported in the world medical literature. Of these, 13 occurred in the retroperitoneum. Retroperitoneal ODDL seems to have a predilection for male patients (8 men, 3 women, undeclared gender in 2 instances) ranging in age from 40 to 61 years; of interest, our patient aged 69 years is the oldest to be affected by retroperitoneal ODDL. Ten patients (77%) were Asian (9 from Japan and 1 from South Korea), whereas only 3 patients were Occidental (2 from the United States and 1 from England); hence, our patient is the second to be recorded in Europe and the first from Italy. The tumor size data were available for 8 cases (range = 7-40 cm craniocaudally), whereas the retroperitoneal side was revealed only in 5 instances (2 lesions were right-sided, 2 were left-sided whereas 1 occupied the entire retroperitoneum). Our patient suffered from a 19 cm × 16 cm left-sided retroperitoneal ODDL. Eleven patients underwent surgical treatment, and a percutaneous biopsy of the lesion was conducted with diagnostic intention for two patients with widespread disease. Macroscopically, ODDL commonly appears as unior multinodular fatty mass with inner well-defined bony component. Histologically, it is composed of WDL intermingled with osteosarcomatous foci; the interface between the 2 components may be gradual, abrupt, or less frequently, mosaic. The most common pattern was that of a high-grade osteosarcomatous dedifferentiation (6 cases), followed by 3 low-grade cases, whereas in the remaining 4 cases this information was unreported. High-grade osteosarcoma was found also in our patient. The longest follow-up reported for a patient previously operated for ODDL and free from disease (only 2 cases) is of 7 years and 11 months; besides these, 1 patient died from cancer, 4 cases developed local recurrence and distant metastases, and in 5 cases this topic was not clearly described. Concerning the prognostic significance, the anatomic location seems to be the most important factor for DDL, with the retroperitoneal compartment imparting the worst behavior; on the contrary, the tumor size, expression of MDM2 and CDK4, and histological grade have led to heterogeneous results. In summary, DDL with osteosarcomatous dedifferentiation represents a very rare and complex form of DDL; the information about its main features come from very few case reports and are extrapolated with difficulty from larger series on DDL. Hence, more dedicated reports are required to better assess the anatomopathobiological features of this disease.

Duodenal-Jejunal Flexure GI Stromal Tumor Frequently Heralds Somatic NF1 and Notch Pathway Mutations

Purpose GI stromal tumors (GISTs) are commonly associated with somatic mutations in KIT and PDGFRA. However, a subset arises from mutations in NF1, most commonly associated with neurofibromatosis type 1. We define the anatomic distribution of NF1 alterations in GIST. Methods We describe the demographic/clinicopathologic features of 177 patients from two institutions whose GISTs underwent next-generation sequencing of ≥315 cancer-related genes. Results We initially identified six (9.7%) of 62 GISTs with NF1 genomic alterations from the first cohort. Of these six patients, five (83.3%) had unifocal tumors at the duodenal-jejunal flexure (DJF). Two additional patients with DJF GISTs had non-NF1 (KIT and BRAF) genomic alterations. After excluding one DJF GIST with an NF1 single nucleotide polymorphism, four (57.1%) of seven sequenced DJF tumors demonstrated deleterious NF1 alterations, whereas only one (1.8%) of 55 sequenced non-DJF GISTs had a deleterious NF1 somatic mutation (P < .001). One patient with DJF GIST had a germline NF1 variant that was associated with incomplete penetrance of clinical neurofibromatosis type 1 features along with a somatic NF1 mutation. Of the five DJF GISTs with any NF1 alteration, three (60%) had KIT mutations, and three (60%) had Notch pathway mutations (NOTCH2, MAML2, CDC73). We validated these findings in a second cohort of 115 GISTs, where two (40%) of five unifocal NF1-mutated GISTs arose at the DJF, and one of these also had a Notch pathway mutation (EP300). Conclusion Broad genomic profiling of adult GISTs has revealed that NF1 alterations are enriched in DJF GISTs. These tumors also may harbor concurrent activating KIT and/or inactivating Notch pathway mutations. In some cases, germline NF1 genetic testing may be appropriate for patients with DJF GISTs.

Borderline resectable pancreatic cancer: an evolving concept

We read with interest the article entitled “Borderline resectable pancreatic cancer: conceptual evolution and current approach to image-based classification” published in the Annals of Oncology, in April 2017, by Gilbert et al (1). The review extensively discusses the major controversies concerning borderline resectable pancreatic cancer (BRPC): lack of universally agreed definition, variance in institution-by-institution practice, and lack of

Granulomatous Reaction Within the Thyroid Metastases of a Renal Cell Carcinoma

Metastases of non-thyroid malignancies to the thyroid gland have been reported in 1.4% to 3% of patients undergoing thyroid surgery for thyroid malignancy. We report a case of thyroid metastases from renal cell carcinoma in a 57-year-old man, who underwent a left nephrectomy 11 years earlier for a renal cell carcinoma. The histological examination demonstrated a CD-10 positive and thyroglobulin and thyroid transcription factor-1 negative tissue, with numerous noncaseating gigantocellular granulomas. These findings are interesting for the possible role of the immune response in metastatic localizations.

Localization of a Colovesical Fistula Using a Retrograde Guide-Wire: Report of a Case

We describe an unconventional method of localizing a colovesical fistula by using a guide-wire, successfully carried out in a 45-year-old man with recurrent dysuria, pneumaturia, and suprapubic tenderness. First, we performed a cystoscopy to establish the fistulous tract in the bladder and passed the guide-wire through it. Next, we performed a colonoscopy, and the guide-wire was identified and brought out through the anus. This created a wire loop through the fistula. The transparietal cathether enabled us to detect the exact fistulous tract at laparotomy, making it possible to resect the inflamed colon and identify and resect the fistulous opening on the vesical wall. This technique allowed for a safer resection and a shorter operation time.

Can pancreatic cancer be detected by adrenomedullin in patients with new-onset diabetes? The PaCANOD cohort study protocol

Introduction: Pancreatic cancer is a leading cause of cancer-related death. Its diagnosis is often delayed and patients are frequently found to have unresectable disease. Patients diagnosed with new-onset diabetes have an 8-fold risk of harboring pancreatic cancer. Adrenomedullin has been claimed to mediate diabetes in pancreatic cancer. New screening tools are needed to develop an early diagnosis protocol. Methods: Patients aged 45-75 years within 2 years of first fulfilling the ADA criteria for diabetes will be prospectively enrolled in this study. Sepsis, renal failure, microangiopathy, pregnancy, acute heart failure and previous malignancies will be considered as exclusion criteria. Results: 440 patients diagnosed with new-onset diabetes will be enrolled and divided into 2 groups: one with high adrenomedullin levels and one with low adrenomedullin levels. Patients will undergo 3 years’ follow-up to detect pancreatic cancer development. Conclusions: Identifying a marker for pancreatic cancer among high-risk patients such as new-onset diabetics might lead to the identification of a subpopulation needing to be screened in order to enable early diagnosis and treatment of a highly lethal tumor. Trial registration: This trial was registered at ClinicalTrials.gov on May 25, 2015 under registration number NCT02456051.

Inferior vena cava resection with prosthesis replacement for recurrent leiomyosarcoma (with video)

Inferior vena cava (IVC) leiomyosarcoma (LY) is a rare tumor with poor prognosis and recurring in one third of patients, radical surgery represents the only chance of cure. Whether caval flow has to be re-established with IVC reconstruction is a matter of debate as well as neoadjuvant therapy. We herein present a case of recurrent IVC LY managed with caval resection and reconstruction with polyethylene terephthalate (PET) prosthesis and left lateral liver resection for suspected metastases. Although the patient experienced a prosthesis occlusion and transient renal failure, at 24 months’ follow-up is recurrence free with a normal renal function and no sign of lower limbs edema.