John D. Cunningham

Intussusception in adults : Institutional review

BACKGROUND Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults. STUDY DESIGN A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed. RESULTS There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively. CONCLUSIONS Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.

Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival.

INTRODUCTION Small bowel neoplasms account for only a small percentage of gastrointestinal tumors, but their prognosis is one of the worst. PURPOSE This study examines the histopathology, treatment, recurrence, and overall survival of a group of patients with primary small bowel tumors. METHODS From 1970 to 1991, a retrospective review identified 73 patients with primary small bowel tumors. Four histologic groups were identified: 1) group 1, adenocarcinoma, 29 patients; group 2, lymphoma, 18 patients; group 3, sarcoma, 8 patients; and group 4, carcinoid, 18 patients. There were 44 men and 29 women. The median age was 57 years (range, 26 to 90). Median follow-up was 15 months. Survival analysis was by the Mantel-Cox and Breslow methods. RESULTS The most common, by type, was group 1, duodenum; group 2, jejunum; group 3, jejunum; and group 4, ileum. The preoperative diagnosis was made in only 14 patients. The median survival for adenocarcinomas and lymphomas was 13 months, 18 months for sarcomas, and 36 months for carcinoids. Curative resection could be achieved in 48 (65%) of 73 patients, and the median survival was significantly longer for this group (26 months vs. 11 months, p < 0.05). Of the 48 curative resections, 20 patients (42%) recurred: group 1, 8/19 (42%); group 2, 4/12 (33%); group 3, 4/13 (31%); group 4, 4/4 (100%). The median time to recurrence was 17 months, and the median survival after recurrence was 20 months. Adjuvant chemotherapy-radiation therapy did not alter survival in any group. CONCLUSIONS The preoperative diagnosis of small bowel tumors rarely is made because symptoms are vague and nonspecific. Surgical resection for cure results in improved survival. Recurrence is common and survival after recurrence is poor. Other treatment methods have no role in the management of these patients.

Awareness and attitudes concerning BRCA gene testing

AbstractBackground: The availability of a commercial test for the breast cancer susceptibility genes, BRCA1 and BRCA2, has generated interest in both the medical community and the general public. Methods: Patients and family members were approached in the waiting room and asked to fill out an anonymous questionnaire about their awareness of breast cancer genes and breast cancer gene testing, and their desire to be tested. χ2 analysis was used to analyze frequencies between groups. Results: A total of 354 women completed a questionnaire concerning the breast cancer genes BRCA1 and BRCA2. The very young, the very old, and African-Americans were the least informed in terms of awareness of the genes and the availability of testing for the breast cancer susceptibility genes. Jewish people, people with a college education or beyond, people earning more than

Breast carcinoma associated with pregnancy and lactation.

30,000 a year, and Caucasians were more aware of the genes and of testing for these genes. Interest in being tested was similar in all groups, except for participants over 60 and those who had only an elementary-school education. Conclusions: Information concerning the breast cancer susceptibility genes has not reached the general public uniformly. A concerted effort is needed if this information is to be passed on to those people at risk.

The Efficacy of Neoadjuvant Chemotherapy Compared to Postoperative Therapy in the Treatment of Locally Advanced Breast Cancer

The most common malignancy concurrent with pregnancy is breast cancer. Since an increasing number of women are electing to postpone pregnancy to their late thirties and forties, the incidence of breast cancer concurrent with pregnancy is increasing. This article critically reviews the incidence, unique diagnostic and therapeutic considerations, the natural history and ultimate prognosis of breast carcinoma associated with pregnancy and lactation.

Salvage therapy for pelvic recurrence following curative rectal cancer resection

The current approach to the treatment of locally advanced breast cancer is sequential chemotherapy, surgery and/or radiation, and consolidation chemotherapy. Although significant tumor response is seen with this regimen, there are few studies that compare this approach to postoperative chemotherapy. The purpose of this study was to compare the disease-free and overall survival of patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and surgery to patients treated with surgery followed by adjuvant chemotherapy. Ninety-four patients with stage IIB, IIIA, and IIIB breast cancer were treated with a standardized chemotherapy regimen. The first group, 60 patients who were followed prospectively, was treated with neoadjuvant chemotherapy (NCT) consisting of vincristine, prednisone, cytoxan, methotrexate, and 5-FU (CVFMP) followed by surgery and consolidation chemotherapy with adriamycin. The second group, 34 patients evaluated retrospectively, had surgery followed by postoperative chemotherapy (PCT) with CVFMP followed by adriamycin. Overall median follow-up was 38 months. In the NCT group, 45/60 (75%) patients had a clinical response to induction therapy and the median reduction in tumor size was 50%. The rates of local recurrence, distant recurrence, and death from disease were similar in the two groups. The time to local recurrence was similar for the two groups. However, the median time to distant recurrence was shorter in the NCT group (19 month vs. 31 months, p = NS). Overall median survival among the NCT patients was shorter than for the PCT group (30 vs. 47 months, p = NS). The current study suggests that postoperative therapy is comparable to a neoadjuvant regimen in patients with locally advanced breast cancer with regard to local recurrence, distant recurrence, and overall survival.

Complications requiring reoperation following pancreatectomy

INTRODUCTION: Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients. PURPOSE: In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection.METHODS: A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy. RESULTS: For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P= 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI groupvs.the MSKCC group (34/51vs.9/25;P <0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients. CONCLUSIONS: Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.

Indications for surgical resection of metastatic ocular melanoma : A case report and review of the literature

SummaryConclusionsIn this series, the overall reoperative rate following pancreatic surgery is 9%. Complications following pancreatectomy that require reoperation fall into four categories: hemorrhage, infectous, delayed gastric emptying, and anastomotic leak. A delay in the management of these types of complications can be fatal.BackgroundDespite the improvement in the morbidity and mortality rates associated with pancreatic resection, complications still arise that require surgical intervention. This study reviews the pancreatic surgical experience at a major medical center to determine the overall reoperative complication rate.Study DesignFrom 1985 to 1995, 107 patients underwent pancreatic resection. There were 50 pancreaticoduodenectomies, 20 total pancreatectomies, and 37 distal pancreatectomies for 102 periampullary or pancreatic cancers and five for chronic pancreatitis. The operative mortality rate was 6.5% and the morbidity rate was 43%. Ten patients (9%) developed complications that required reoperation.ResultsRe-exploration was performed in five patients for hemorrhage. Four patients had bleeding intra-abdominally and one had a suture line bleed. One patient developed a wound infection and fascial necrosis which necessitated reoperation. Three patients were explored for sepsis and one was found to have a pancreatic leak. One patient had persistent gastric outlet obstruction and he required conversion of the gastrojejunostomy to a Roux-en-y anastomosis. The mortality rate for re-exploration was 3/10 (30%).

The Use of Spiral Computed Tomography in the Evaluation of Vessel Encasement for Pancreatic Cancer

SummaryConclusionsOcular melanoma can metastasize to the gallbladder and porta hepatic nodes and mimic pancreatic carcinoma. If one suspects metastatic disease, a complete metatstatic work-up must be done prior to surgery to prevent unnecessary surgery. If no distant disease is present or the patient is symptomatic, metastatic disease should be resected.PurposeTo review the literature pertaining to the spread of ocular melanoma and to determine if distant disease should be resected.Patients and MethodsA 44-yr-old Egyptian male presented to an outside institution with mid-epigastric and right upper quadrant abdominal pain. His past medical history was significant for a left orbital enucleation for uveal melanoma in 1982. On physical examination, there was no supraclavicular adenopathy and no skin lesions were noted. There was a mass in the right upper quadrant. The total bilirubin was 4.8 mg/dL. A computed tomography showed a mass in the head of the pancreas and portal vein involvement could not be determined.ResultsThe patient was taken to the operating room and a pancreatico-duodenectomy was performed for a cystic mass in the head of the pancreas. Final pathology revealed metastatic melanoma in the gallbladder and an enlarged, cystic lymph node growing into the head of the pancreas replaced with metastatic melanoma. The patient did well psot-operatively and was discharged home on the eighth post-operative day.

Loss of heterozygosity and homozygous deletion of the tpr locus in human gastric cancer

SummaryConclusionsSpiral CT allows for a noninvasive evaluation of the mesenteric arterial and venous vessels. This test can be performed quicker, with less expense, and with a reduced radiation and contrast load than angiography. Comparison studies of angiography and spiral CT are needed in patients with pancreatic cancer to determine the best method of evaluating possible vessel involvement.BackgroundPreoperative imaging of patients with pancreatic cancer is crucial in determining resectability and planning management. Computed tomography (CT) remains the diagnostic procedure of choice for the evaluation of the primary tumor and angiography is the gold standard to evaluate vessel encasement. This case evaluates the usefulness of spiral computed tomography in determining vessel encasement.MethodsA 53-yr-old female presented with vague abdominal complaints and evaluation revealed a mass in the pancreas. CT suggested portal vein involvement and collateralization was noted in the upper abdomen. Spiral CT revealed normal arterial anatomy and near complete obstruction of the portal vein at the superior mesenteric vein (SMV) splenic vein (SV) confluence.ResultsOperative findings confirmed the involvement of the portal vein at the confluence of the SMV and SV. Pancreatico-duodenectomy with portal vein resection and primary anastomosis was performed. The patients postoperative course was uneventful and she was discharged home on the 13th postoperative day.