Geoffrey G. Giacco

Carcinoid tumors of the rectum: effect of size, histopathology, and surgical treatment on metastasis free survival.

The purpose of this study was to determine the clinical course, effects of specific tumor histopathologic characteristics, and extent of surgical treatment on the metastatic rate in patients with rectal carcinoids.

Osseous metastases secondary to renal cell carcinoma

We present the distribution of metastases and clinical course of 252 patients with osseous metastases secondary to renal cell carcinoma. Symptoms of the metastases were the presenting complaint in 48 per cent of patients (including 37 with pathologic fractures); the axial skeleton was the most commonly involved site. Despite earlier reports that nephrectomy lengthened survival for patients with osseous metastases, our data showed this to be true only for patients with a solitary osseous metastasis. Patients with multiple osseous metastases had survival rates no better than patients with soft tissue or mixed lesions-whether or not nephrectomy was performed.

Renal cell carcinoma. A clinicopathologic and dna flow cytometric analysis of 103 cases

Renal cell carcinoma is unpredictable in outcome, although the best predictor is tumor stage, followed by histologic grade. The authors retrospectively assessed the clinicopathologic features and DNA ploidy of 103 cases of renal cell carcinoma, the latter determined by flow cytometry of formalin‐fixed, paraffin‐embedded tissue. The study group comprised 63 men and 40 women (age, 28–80 years; mean, 57 years). Robson stage at diagnosis was Stage I in 52 patients, Stage II in 21, and Stage III in 30. Statistically significant variables in predicting outcome were Robson stage (P < 0.0001), DNA ploidy (P = 0.0008), mitotic rate (MR, P < 0.0001), worst nuclear grade (WNG, P = 0.0009), predominant nuclear grade (P = 0.019), and sex (P = 0.044). Tumor size, cell type, and architectural pattern were also assessed but did not prove to be significant. Statistically significant associations occurred between DNA ploidy and WNG (P < 0.0001), stage (P = 0.0037), and MR (P = 0.015); between WNG and MR (P < 0.0001) and stage (P = 0.0007); and between stage and MR (P = 0.002). Cox proportional hazards regression analysis of all significant variables showed Robson stage, tumor ploidy, and MR to be independent, significant predictors of outcome. If ploidy data had not been available, WNG would have been independently significant. The authors conclude that DNA ploidy analysis provides significant predictive information on renal cell carcinoma.

Clinical, pathologic, and economic parameters of laparoscopic colon resection for cancer

BACKGROUND The appropriateness of laparoscopic colon resection (LCR) as treatment for malignancy has been questioned. METHODS From 1992 to 1997, 91 patients were entered into a prospective study of LCR for cancer. Clinical, pathologic, and economic parameters of LCR were compared in a cohort of patients matched for age, tumor stage, and type of colectomy who underwent open colon resection (OCR) during the same time period. RESULTS With a median follow-up of 26 months, there were no significant differences in survival rate for patients in the LCR, converted colon resection, and OCR groups. There were no port-site recurrences and the number of lymph nodes harvested was similar among the procedures. Hospital stay was significantly shorter if laparoscopic resection was successful. Total hospital costs were similar for LCR and OCR; however, the costs were significantly higher for converted colon resection. CONCLUSIONS LCR is a sound oncologic procedure that can be performed with costs similar to OCR.

Predictors of recurrence after local excision and postoperative chemoradiation therapy of adenocarcinoma of the rectum

Background: Local excision of rectal cancer preserves anal continence, bladder function, and normal sexual function. However, local recurrence after excision remains a significant problem. To further define the indications for local excision, we analyzed possible factors predictive of recurrence after local excision of rectal cancer.Methods: The charts of all patients undergoing local excision of adenocarcinoma of the rectum between 1985 and 1995 at a single institution were reviewed. Patients with metastatic disease at the time of excision and patients treated preoperatively with chemoradiation therapy were excluded. All available slides were reviewed by a single pathologist, who assessed the depth of invasion; the presence or absence of vascular invasion, lymphatic invasion, perineural invasion, and lymphocytic infiltrate; the mucinous status; and the degree of differentiation. Using the log-rank test and Cox proportional hazards model, univariate and multivariate analyses were performed to identify predictors of recurrence.Results: Ninety patients underwent local excision, 46 transanally and 44 using a Kraske approach. The breakdown of patients by tumor stage was as follows: Tis, 13%; T1, 41%; T2, 30%; T3, 15%; and Tx, 1%. Sixty-eight percent of patients with T1 tumors were treated with postoperative radiotherapy; all patients with T2 or T3 tumors were treated postoperatively with or without 5-fluorouracil. The median duration of follow-up was 51 months. The median tumor diameter was 2.5 cm (range, 0.4 to 7 cm), and the median distance of the tumor from the anal verge was 4.5 cm (range, 1 to 10 cm). The 4-year actuarial local disease-free survival rate broken down by tumor stage was as follows: Tis, 100%; T1, 95%; T2, 80%; and T3, 73%. The median time to local recurrence was 23 months (range, 7 to 61 months). Multivariate analysis showed that only tumor stage and margin status were predictors of local recurrence.Conclusions: Local excision and postoperative radiotherapy result in adequate local control of early stage (Tis and T1) adenocarcinoma of the rectum. Higher rates of recurrence were seen in patients with T2 and T3 tumors, especially in those with positive margins.

Role of nuclear grading in stage I renal cell carcinoma

Through a retrospective histologic analysis of 55 cases of Stage I renal cell carcinoma, we evaluated the usefulness of the nuclear grading system (Fuhrman, Lasky, Limas) in identifying those tumors that will eventually metastasize and kill the patient. The difference in five-year survival rates between patients with combined nuclear grade 1-3 tumors (n = 50, 91%) and grade 4 tumors (n = 5, 9%) was significant (P less than 0.0046). Other predictors of death due to renal cell carcinoma included: tumor size greater than 8 cm (P less than 0.001) and mitoses greater than one per 10 high-power field (P less than 0.01). Within Stage I tumors, therefore, nuclear grade is an important morphologic variable for predicting long-term survival. Identification of nuclear grade 4 neoplasms may become prognostically indispensable to determine the metastatic potential of early-stage tumors and thereby to institute appropriate systemic therapy.

Outcome After Curative Resection for Locally Recurrent Rectal Cancer

PurposeFew biologic markers have been studied as prognostic factors in recurrent rectal carcinoma patients. We sought to determine the influence of clinical, pathologic, and biologic (p53, bcl-2, and ki-67) variables on survival after curative resection of locally recurrent rectal cancer.MethodsRetrospective review of patients with locally recurrent rectal cancer who received surgery with curative intent.ResultsFrom 1988 to 1998, 134 patients with locally recurrent rectal cancer underwent operative exploration. Curative resection was performed in 85 patients. Median follow-up was 43 (range, 1.3–149) months. On multivariate analysis, negative predictors of overall survival included an elevated carcinoembryonic antigen level (P = 0.02; hazard ratio 2.41; 95 percent confidence interval, 1.19–4.89) and an R1 resection margin (P = 0.01; hazard ratio, 2.81; 95 percent confidence interval, 1.27–6.21). In 26 patients for whom biologic variables were available, p53, bcl-2, and ki-67 did not significantly impact disease-specific survival or overall survival. Five-year disease-specific survival, overall survival, and pelvic control rates were 46, 36, and 51 percent respectively. Of the 50 patients who relapsed, time to second local recurrence was longer than time to development of metastasis (median, 16.5 vs. 9 months). Median survival for patients with metastatic recurrence was 26.l vs. 41.5 months for those with a subsequent local recurrence alone.ConclusionsApproximately two-thirds of patients with locally recurrent rectal cancer can be resected for cure. Preoperative carcinoembryonic antigen and an R0 resection margin were the only significant predictors of overall survival. p53, bcl-2, and ki-67 did not impact survival outcomes.

Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center.

It is common belief that carcinoma of the pancreas has an inherent and unique ability to induce a hypercoagulable diathesis that leads to clinically significant thrombosis. We evaluated 130 consecutive patients with adenocarcinoma of the pancreas to document the incidence and the predisposing factors related to the postulated increased association of thromboembolic disorder (TED) and pancreatic carcinoma. Only nine such patients (6.9%) demonstrated TED complications of the classical Trousseau syndrome. In these instances, the location of the tumor and its mucin-producing potential were significant predisposing factors. In our series, TED was usually associated with tumors of the body and tail, which had a greater likelihood to be mucinogenic as compared with those localized to the head of the pancreas. Routine tests for hemostasis were not helpful in predicting the development of TED except, perhaps, for decreased platelet counts. Therefore, we believe that the relationship between cancer of the pancreas and TED should be de-emphasized since it is neither unique nor especially common to pancreatic carcinoma and since it may be frequently encountered in other varieties of visceral malignancies of the cancer patient population.

Clinicopathologic Behavior of Gastric Adenocarcinoma in Hispanic Patients: Analysis of a Single Institution's Experience Over 15 Years

PURPOSE To determine the clinicopathologic behavior of gastric adenocarcinoma in Hispanics by comparing Hispanic and non-Hispanic patients treated at a single cancer center. PATIENTS AND METHODS Medical records of patients with invasive gastric cancer treated from 1985 to 1999 were reviewed. Diagnoses were pathologically confirmed. Differences in categorical variables were assessed using the chi(2) test. Logistic regression was used for multivariate analyses. Median survival was estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to assess the impact of covariates. RESULTS Of 1,897 patients, 301 (15.9%) were Hispanic. Hispanics were significantly younger at diagnosis than non-Hispanic whites (53.1 +/- 14.4 years v 59.4 +/- 12.7 years, respectively; P < .005) or African Americans (57.6 +/- 15.3 years, P < .005). Hispanics were less likely to have proximal gastric cancers compared with whites (38.9% v 59.5%, respectively; P < .005). Hispanics were more likely to have mucinous/signet-ring type histology (42.5%) than whites (27.4%) and African Americans (32.5%; P < .005). Hispanics were more likely to require total gastrectomy (51%) compared with whites (38%), African Americans (38%), and Asians (36%; P = .039). Among patients with metastases at diagnosis, Hispanics were less likely to have liver metastasis than whites (30% v 44%, respectively; P = .009) but more likely to have peritoneal metastasis than whites and African Americans (54% v 41% and 47%, respectively; P = .002). In Cox analyses, Asian race, earlier stage, papillary/tubular histology, distal location, and younger age were favorable predictors of survival. CONCLUSION Hispanic ethnicity does not impact survival in gastric adenocarcinoma. However, histology, metastasis pattern, tumor localization, and other clinical parameters differ sufficiently to warrant further investigation into the epidemiology, pathogenesis, and molecular biology of gastric cancer in this population.

Palliative total gastrectomy and esophagogastrectomy a reevaluation

In the interval from 1941–1981 when 1887 patients with gastric cancer were seen at The University of Texas System Cancer Center M. D. Anderson Hospital and Tumor Institute, 151 curative and 45 palliative total gastrectomies or esophagogastrectomies were performed. Over the same interval, 21 patients with extent of primary and metastatic tumor roughly comparable to that seen in the palliative resection group were treated by exploration only or, infrequently, by attempted bypass. In individual patients subtle differences in extent of disease as well as differences in philosophy of the operating surgeon regarding the value of palliative resection undoubtedly contributed to the procedure selected. Survival after curative resection was greater than after palliative resection which in turn was greater than survival after exploration bypass (P ⩽.0006). Operative mortality fell significantly in CR patients in the interval 1970–1981 compared to 1941–1969 and was significantly lower than in the PR group in the interval 1970–1981 (P ⩽ 0.01). Five‐year survival increased significantly (P ⩽ 0.03) in the CR group when results in the two time intervals were compared but not in other groups.