Jonathan C. Salo

Surgical Salvage of Recurrent Rectal Carcinoma After Curative Resection: a 10-Year Experience

Background: Local recurrence after resection of rectal carcinoma is a difficult clinical problem that adversely affects both survival and quality of life. Surgical resection is possible for a subset of patients with localized recurrences. We reviewed our experience with surgical salvage of recurrent rectal carcinoma, to determine predictors of resectability and postsalvage survival rates.Methods: A 10-year, retrospective analysis of 131 patients who underwent exploration with curative intent for local recurrence after radical resection of rectal carcinomas, in a single referral institution, was performed. Preoperative and pathological factors were examined for their ability to predict postresection survival rates and resectability.Results: The overall 5-year survival rate for patients who underwent exploration with curative intent was 24%. Resection of recurrent disease was possible for 103 of 131 (79%) patients, with a resulting 5-year survival rate of 31%. Patients who were treated initially with abdomino-perineal resection (n = 35) presented later and were less likely to have resectable tumors than were those treated initially with some form of sphincter-preserving resection (n = 96). Among patients who could undergo resection, normal carcinoembryonic antigen levels and recurrent disease limited to the bowel wall were both favorable features.Conclusions: Surgical salvage of local recurrence after radical resection of rectal carcinoma can be performed safely and can result in substantial long-term survival benefits for selected patients.

Factors predictive of the status of sentinel lymph nodes in melanoma patients from a large multicenter database.

BackgroundNumerous predictive factors for cutaneous melanoma metastases to sentinel lymph nodes have been identified; however, few have been found to be reproducibly significant. This study investigated the significance of factors for predicting regional nodal disease in cutaneous melanoma using a large multicenter database.MethodsSeventeen institutions submitted retrospective and prospective data on 3463 patients undergoing sentinel lymph node (SLN) biopsy for primary melanoma. Multiple demographic and tumor factors were analyzed for correlation with a positive SLN. Univariate and multivariate statistical analyses were performed.ResultsOf 3445 analyzable patients, 561 (16.3%) had a positive SLN biopsy. In multivariate analysis of 1526 patients with complete records for 10 variables, increasing Breslow thickness, lymphovascular invasion, ulceration, younger age, the absence of regression, and tumor location on the trunk were statistically significant predictors of a positive SLN.ConclusionsThese results confirm the predictive significance of the well-established variables of Breslow thickness, ulceration, age, and location, as well as consistently reported but less well-established variables such as lymphovascular invasion. In addition, the presence of regression was associated with a lower likelihood of a positive SLN. Consideration of multiple tumor parameters should influence the decision for SLN biopsy and the estimation of nodal metastatic disease risk.

Drain amylase aids detection of anastomotic leak after esophagectomy

BACKGROUND Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak. METHODS The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated. RESULTS Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak. CONCLUSIONS Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.

Surgery for Esophageal Cancer: Quality of Life Matters

Esophageal cancer and its treatment have a profound impact not only on a patient’s length of life, but quality of life as well. Dysphagia, weight loss, and eating restrictions are frequent sequelae of both the disease and its treatment. In this issue, investigators from the Academic Medical Center in Amsterdam examined quality of life before and after resection for distal esophageal cancers. 1 They found that among preoperative patients, the quality-of-life physical symptom scale predicted postoperative overall survival independent of the tumor length and endoscopic ultrasound T-stage. After surgical resection, the quality-of-life pain scale, social function, and activity level predicted overall survival independent of pathological T-stage and N-stage. Clearly, self-reported health-related quality of life (HRQoL) adds predictive value to our best available preoperative and postoperative prognosticators. The challenge is how to use this information. One important benefit of quality-of-life research is to help evaluate the outcomes of different therapies, such as the analysis by the same investigators who examined quality of life after transhiatal compared with transthoracic esophagectomy. 2 It is intriguing to speculate about what mechanisms may underlie the effects of HRQoL on overall and diseasespecific survival. These speculations may help to generate hypotheses for further investigation that may help further understand tumor biology. One mechanism of these interactions may be that quality of life is a marker for occult metastatic disease. Recent advances in serum proteonomics in gastrointestinal cancer patients suggest that even among patients thought to have localized disease, cancer-associated proteins can be detected within the serum. 3 It would be reasonable to assume that even localized tumors, in patients with imaging negative for distant disease, might elaborate serum factors that would adversely affect quality of life. As this field grows and specific proteins are identified, it will be interesting to see whether the age-old problem of cancerassociated cachexia can be more fully understood. Health-related quality of life may also be a window into the patient’s host response to their neoplasm. Social function, activity level, and pain may be surrogates for their ability to recover from surgery and the presence of major or subclinical surgical complications. Postoperative decrements in quality of life may also be a marker for postoperative complications, which are known to affect quality of life and alter prognosis, even subsequent to the perioperative period. 4,5 On the other hand, social function and activity level may be related to cancer-related alterations in circadian rhythms. Circadian rhythm alterations and social function are related in complex ways: social cues help to reset the biological clock, while disruptions in circadian and sleep cycle patterns tend to affect social interactions. It been shown, for instance, that cancer patients exhibit abnor

Minimally Invasive Esophagectomy in the Community Hospital Setting

We report our initial experience with minimally-invasive esophagectomy in 32 patients at Carolinas Medical Center, a community academic medical center. Indications for surgery were adenocarcinoma in 27, squamous cell carcinoma in 3, and benign stricture in 2. Transthoracic Ivor-Lewis esophagectomy with laparoscopy and thoracoscopy was performed in 28, a 3-stage esophagectomy in 3, and transhaital esophagectomy in 1. There was no operative mortality and median hospital stay was 10.5 days for patients treated with minimally invasive esophagectomy. This compares with an operative mortality of 8.9% and median hospital stay of 17 days for open esophagectomy in our institution.

Frequency of unplanned surgical intervention in patients with stage IV colorectal cancer receiving palliative chemotherapy: An analysis of SEER-Medicare.

640 Background: Patients (pts) with synchronous stage IV colorectal cancer commonly begin palliative chemotherapy while the primary tumor remains. Single institution series report low rates of surgical intervention, but this has not been examined nationally. The present study utilizes a large national dataset to examine the natural history of unplanned surgical intervention in stage IV colorectal cancer pts on palliative chemotherapy. Methods: SEER-Medicare was queried for pts with metastatic colorectal cancer (1998-2009) who underwent resection or diversion (ICD9 procedure/CPT). The cohort was separated into 3 groups: elective (surgery on admission without urgent/emergent flag), urgent (surgery not on day of admission but within hospitalization or with urgent flag) and emergent (emergent flag). Pts who underwent any procedure for curative intent (elective colorectal surgery, liver directed therapy or surgery for pulmonary metastases) at any time were excluded. Demographics, tumor grade and comorbidities ...

Cancer Biology Relating to Minimal Access Management

The introduction of laparoscopic colon resection for colon carcinoma in the 1990s was accompanied by a series of case reports of port site recurrences which appeared to occur with alarming frequency [1–8]. These reports tempered the initial enthusiasm for laparoscopic colectomy for colon cancer. They also prompted several lines of laboratory and clinical investigation, including animal experiments which attempted to replicate the cancer biology of laparoscopic cancer surgery, prospective accumulation of data regarding laparoscopic colon resection, and finally the organization and execution of several large-scale randomized clinical trials comparing laparoscopic and open resection for colorectal cancer.