Lloyd A. Mack

An Evidence-Based Approach to the Treatment of Thyroid Lymphoma

Primary thyroid lymphoma is a rare tumor that makes up 1–5% of thyroid malignancies and less than 2% of extranodal lymphomas. The treatment and prognosis of thyroid lymphomas can be divided into two distinct clinicopathologic entities: pure mucosa-associated lymphoid tissue (MALT) lymphomas and diffuse large B-cell or mixed subtypes. An evidence-based review was performed to determine the role of fine-needle aspiration (FNA) biopsy and adjuncts as the first diagnostic test for thyroid lymphoma, the role of open surgical biopsy, the role of palliative surgery as well as the best treatment (combined chemoradiation versus single modality surgery or radiation) for thyroid lymphoma. The ideal treatment of thyroid lymphoma was further assessed for both diffuse B-cell and MALT histologic subtypes. Although an evidence-based review was challenging primarily due to a lack of high-level evidence, several recommendations are possible and presented regarding the optimal diagnostic methods and treatment of thyroid lymphoma. FNA and adjuncts are recommended as the first test to diagnose thyroid lymphoma, but open surgical biopsy may still be required in many cases. Combined chemoradiation therapy is recommended for all diffuse B-cell or mixed lymphomas. Single modality therapy with surgery or radiation alone may be considered for early-stage (IE) intrathyroidal MALT lymphomas. No recommendations could be made regarding the role of palliative surgery. Evidence-based recommendations can be applied to the individual patient with thyroid lymphoma with the involvement of an experienced multidisciplinary team consisting of an endocrine/oncology surgeon, radiation oncologist, and medical oncologist.

Gastric Decompression and Enteral Feeding Through a Double-Lumen Gastrojejunostomy Tube Improves Outcomes After Pancreaticoduodenectomy

Objective:The objective of this study was to assess the feasibility and safety of inserting a double-lumen gastrojejunostomy tube (GJT) after pancreaticoduodenectomy (PD) and to evaluate associated outcomes. Background:Gastroparesis is a frequent postoperative event following PD. This often necessitates prolonged gastric decompression and nutritional support. A double-lumen GJT may be particularly useful in this situation: gastric decompression may be achieved through the gastric port without a nasogastric tube; enteral feeding may be administered through the jejunal port. Methods:Thirty-six patients with periampullary tumors were randomized at the time of PD to insertion of GJT or to the routine care of the operating surgeon. Outcomes, including length of stay, complications, and costs, were followed prospectively. Results:The 2 groups had similar characteristics. Prolonged gastroparesis occurred in 4 controls (25%) and in none of the patients who had a GJT (P = 0.03). Complication rates were similar in each group. Mean postoperative length of stay was significantly longer in controls compared with patients who had a GJT (15.8 ± 7.8 days versus 11.5 ± 2.9 days, respectively; P = 0.01). Hospital charges were

HIPEC + EPIC versus HIPEC-alone: differences in major complications following cytoreduction surgery for peritoneal malignancy.

82,151 ± 56,632 in controls and

Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis

52,589 ± 15,964 in the GJT group (P = 0.036). Conclusions:In patients undergoing PD, insertion of a GJT is safe. Moreover, insertion of a GJT improves average length of stay. At the time of resection of periampullary tumors, GJT insertion should be considered, especially given this is a patient population in which weight loss and cachexia are frequent.

Opening the black box of cancer surgery quality: WebSMR and the Alberta experience.

Peritoneal metastases (PM) can be treated with cytoreduction surgery (CRS) with intraoperative heated intraperitoneal chemotherapy (HIPEC) plus or minus early postoperative intraperitoneal chemotherapy (EPIC). HIPEC + EPIC may be associated with more complications than HIPEC alone.

The Quality of Life Trajectory of Resected Gastric Cancer

BACKGROUND Obtaining a complete cytoreduction in patients with peritoneal carcinomatosis (PC) is one of the most significant prognostic variables for long-term survival. This study explored features on preoperative computed tomography (CT) to predict unresectability. METHODS A retrospective case-control study was conducted of 15 patients with unresectable PC and 15 patients with completely resected PC matched by intraoperative peritoneal cancer index (PCI) and pathology type. Two surgical oncologists blindly analyzed all abdominopelvic CT scans. RESULTS PCI estimated on imaging was not higher in unresectable patients (P = .851) and significantly underestimated intraoperative PCI measurement (P = .003). No single concerning feature was associated with unresectability. However, patients with 2 or more concerning features were more likely to be unresectable (87.5% vs 36.4%, P = .035). CONCLUSIONS Two or more concerning CT imaging features appear to be associated with a higher risk of unresectability in patients with PC. However, no specific imaging feature should exclude a patient from an attempted cytoreduction.

Cytoreduction and heated intraperitoneal chemotherapy for colorectal cancer: are we excluding patients who may benefit?

A web‐based synoptic operative report, the WebSMR (Surgical Medical Record), was developed to define and improve the quality of cancer surgery. Surgeons accurately record the essential steps of an operation including important decision‐making in an analyzable format. Outcomes can be reviewed with provincial aggregates for quality improvement and maintenance of certification. Future synoptic pathology and follow‐up templates will open the “black box” of surgical processes to define quality indicators for the improvement of cancer outcomes. J. Surg. Oncol. 2009;99:525–530.

Long-term follow-up in the treatment of peritoneal carcinomatosis

Few studies describe quality of life (QoL) outcomes following gastrectomy for gastric cancer using a validated instrument. The gastric cancer module for the Functional Assessment of Cancer Therapy system of QoL measurement tools (FACT‐Ga) was utilized to determine the changes in QoL following gastrectomy, and during the disease course.

Phase II study of regional treatment for peritoneal carcinomatosis

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly used to treat peritoneal carcinomatosis from colorectal cancer. It is still relatively unknown which poor prognostic factors to avoid in order to optimize patient selection for CRS + HIPEC.

Setting Performance Standards for Technical and Nontechnical Competence in General Surgery.

BACKGROUND The objective of this study was to report a long-term survival analysis of a phase II protocol of cytoreductive surgery (CS) and heated intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal carcinomatosis (PCs). METHODS Between 2000 and 2008, 101 consecutive patients were treated with CS, HIPEC and early postoperative intraperitoneal chemotherapy using a standardized protocol. Disease recurrence and mortality data were collected prospectively. Primary outcomes were median, 3-year, and 5-year disease-free survival (DFS) and overall survival (OS). RESULTS The median age was 49 years (range, 18-77 years), and the majority (82%) had complete CS with no gross residual cancer. Tumor types included appendiceal (n = 58), colorectal (n = 31), and other (n = 12). Median follow-up was 28 months (range, 0-119 months), with minimum of 24 months among survivors. For appendiceal tumors, median DFS was 34 months (range, 0-119 months) and OS has not yet been defined. Three-year and 5-year DFS was 48% and 42%, respectively, and 3-year and 5-year OS was 76% and 62%, respectively. For colorectal carcinomatosis, median disease-free and OS was 9 months (range, 0-87 months) and 27 months (range, 0-87 months), respectively. Three-year and 5-year DFS was 34% and 26%, respectively, and 3-year and 5-year OS was 38% and 34%, respectively. CONCLUSIONS Long-term survival with regional treatment of PC from appendiceal or colorectal primary tumors with CS and HIPEC is achievable.