Lucas Sideris

Consensus Recommendations for the Diagnosis and Management of Pancreatic Neuroendocrine Tumors: Guidelines from a Canadian National Expert Group

Pancreatic neuroendocrine tumors (pNETs) are rare heterogeneous tumors that have been steadily increasing in both incidence and prevalence during the past few decades. Pancreatic NETs are categorized as functional (F) or nonfunctional (NF) based on their ability to secrete hormones that elicit clinically relevant symptoms. Specialized diagnostic tests are required for diagnosis. Treatment options are diverse and include surgical resection, intraarterial hepatic therapy, and peptide receptor radionuclide therapy (PRRT). Systemic therapy options include targeted agents as well as chemotherapy when indicated. Diagnosis and management should occur through a collaborative team of health care practitioners well-experienced in managing pNETs. Recent advances in pNET treatment options have led to the development of the Canadian consensus document described in this report. The discussion includes the epidemiology, classification, pathology, clinical presentation and prognosis, imaging and laboratory testing, medical and surgical management, and recommended treatment algorithms for pancreatic neuroendocrine cancers.

Hyperthermic Intraperitoneal Chemotherapy with Oxaliplatin for Peritoneal Carcinomatosis Arising from Appendix: Preliminary Results of a Survival Analysis

BackgroundPeritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which the long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive approach used in our institution over the last 5xa0years.MethodsData from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted in complete surgical cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460xa0mg/m2) in 2xa0L/m2 of D5W at 43°C during 30xa0min. Ronnett’s histologic classification was used for tumor grading.ResultsFrom February 2003 to March 2007, 38 patients with PC arising from the appendix underwent laparotomy with curative intent. Mean follow-up was 23xa0months. Twenty-three patients received HIPEC but ten patients could not have complete cytoreductive surgery and received no HIPEC. Five patients with a negative second-look surgery also received no HIPEC. Three-year overall survival (OS) was 100% for the negative second-look patients, 86% for the HIPEC patients, and 29% for the unresectable patients (Pxa0=xa00.0098). Three-year disease-free survival (DFS) was 49% for the HIPEC patients. Histologic grade was a prognostic factor with regard to DFS for the HIPEC patients (Pxa0=xa00.011). There was one postoperative mortality. The overall major (grade III–V/V) complication rate for treated patients was 39%, including intra-abdominal abscess (22%), hemorrhage (18%), and anastomotic leak (9%).ConclusionAlthough these results are preliminary, this therapeutic approach seems both feasible and safe in selected patients.

Adjuvant treatment for endometrial cancer: Literature review and recommendations by the Comité de l'évolution des pratiques en oncologie (CEPO)

OBJECTIVEnDespite the very good prognosis of endometrial cancer, a number of patients with localized disease relapse following surgery. Therefore, various adjuvant therapeutic approaches have been studied. The objective of this review is to evaluate the efficacy and safety of neoadjuvant and adjuvant therapies in patients with resectable endometrial cancer and to develop evidence-based recommendations.nnnMETHODSnA review of the scientific literature published between January 1990 and June 2012 was performed. The search was limited to published phase III clinical trials and meta-analyses evaluating the efficacy of neoadjuvant or adjuvant therapies in patients with endometrial carcinoma or carcinosarcoma. A total of 23 studies and five meta-analyses were identified.nnnRESULTSnThe selected literature showed that in patients with a low risk of recurrence, post-surgical observation is safe and recommended in most cases. There are several therapeutic modalities available for treatment of endometrial cancers with higher risk of recurrence, including vaginal brachytherapy, external beam radiotherapy, chemotherapy, or a combination of these.nnnCONCLUSIONSnConsidering the evidence available to date, the CEPO recommends the following: (1)post-surgical observation for most patients with a low recurrence risk; (2)adjuvant vaginal brachytherapy for patients with an intermediate recurrence risk; (3)adjuvant pelvic radiotherapy with or without vaginal brachytherapy for patients with a high recurrence risk; addition of adjuvant chemotherapy may be considered as an option for selected patients (excellent functional status, no significant co-morbidities, poor prognostic factors); (4)adjuvant chemotherapy and pelvic radiotherapy with or without brachytherapy and para-aortic irradiation for patients with advanced disease;

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal carcinomatosis arising from colorectal cancer

Peritoneal carcinomatosis (PC) from colorectal cancer is associated with a poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival compared to systemic chemotherapy. We evaluate the results of this treatment in our institution.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with oxaliplatin for peritoneal mesothelioma: Preliminary results and survival analysis

BACKGROUNDnPeritoneal mesothelioma is a rare disease with poor prognosis. The present study reports single center experience with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy with oxaliplatin (HIPEC-OX) over an eight-year period.nnnMETHODSnProspectively collected data of all consecutive patients with epithelial or multicystic peritoneal mesothelioma from August 2004 to October 2012 was analyzed. Patients with sarcomatoid or biphasic peritoneal mesothelioma were not included due to general poor prognosis. Treatment consisted in CRS and HIPEC-OX (460 mg/m(2)) at 43 °C during 30 min. For statistical analysis, Kaplan-Meier survival curves were plotted and compared using log-rank tests. Cox proportional-hazards regression model was used to analyze the influence of different variables on survival.nnnRESULTSnNineteen patients with peritoneal mesothelioma underwent laparotomy with CRS and HIPEC-OX with curative intent (15 epithelial, and 4 multicystic). Mean follow-up was 36.7 months. The estimated one-year and three-year overall survival rates were respectively 100% and 91%. The estimated one-year and three-year disease-free survival rates were respectively 77% and 50%. Complications were graded according to the Clavien-Dindo classification [1] and major complications occurred in 57% of cases. There was no postoperative mortality. Histological grade was not a prognostic factor of disease-free survival (p = 0.37).nnnCONCLUSIONnWhen comparing survival results as well as morbidity-mortality rates, the present study shows that CRS and HIPEC-OX is a valid treatment for peritoneal mesothelioma.

Hyperthermic intraperitoneal chemotherapy with oxaliplatin as treatment for peritoneal carcinomatosis arising from the appendix and pseudomyxoma peritonei: a survival analysis

BackgroundAppendiceal peritoneal carcinomatosis (PC) is rare and its long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive treatment approach used in our institution for the last eight years.MethodsData from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted of complete surgical cytoreduction (CRS), followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460xa0mg/m2) at 43°C over 30xa0minutes. Ronnett’s histologic classification was used for tumor grading.ResultsBetween February 2003 and April 2011, 78 patients underwent laparotomy with curative intent. The mean follow-up period was 33.7xa0months. A total of 58 patients received HIPEC, but 11 patients could not have CRS and received no HIPEC. Nine patients with a negative second-look surgery also received no HIPEC. The five-year overall survival for the entire cohort was 66.2%; 100% for the negative second-look patients, 77% for the HIPEC patients and 9% for the unresectable patients (P <0.0001). A total of 15 patients (25.9%) had isolated peritoneal recurrence, no patient had visceral recurrence only, and five patients (8.6%) had both. In regards to the five-year disease-free survival for the HIPEC patients, histologic grade (disseminated peritoneal adenomucinosis 100%, peritoneal mucinous carcinomatosis with intermediate features 40%, peritoneal mucinous carcinomatosis 20%; p =0.0016) and completeness of cytoreduction (CCR-0 56%, CCR-1 24%; P =0.0172) were prognostic factors. There was one postoperative mortality. The major complication rate for patients treated with HIPEC was 40%, including intra-abdominal abcess (17%), hemorrhage (12%) and anastomotic leak (10%). One patient in the HIPEC group experienced temporary grade II neuropathy and grade III thrombocytopenia.ConclusionsThis therapeutic approach seems both feasible and safe in selected patients. Recurrence is, however, frequent and represents a challenge.

Neutropenic enterocolitis and docetaxel neoadjuvant chemotherapy

Neutropenic enterocolitis (NE, typhlitis) is a rare complication of intensive chemotherapy, and though it is more often observed in leukemia and lymphoma, there are a few reported cases of patients with lung cancer [1], hormone-refractory prostate cancer [2] and metastatic breast cancer [3]. Docetaxel, a taxane-based compound, has been proven to be a very effective treatment with acceptable toxicity in breast cancer [4]; it also increases the efficiency of neoadjuvant therapy when combined with doxorubicin and cyclophosphamide (AC) [5]. We report here a unique case of NE in a young, healthy patient with locally advanced breast cancer who received such a regimen.

Video Coaching as an Efficient Teaching Method for Surgical Residents—A Randomized Controlled Trial

BACKGROUNDnAs surgical training is evolving and operative exposure is decreasing, new, effective, and experiential learning methods are needed to ensure surgical competency and patient safety. Video coaching is an emerging concept in surgery that needs further investigation.nnnDESIGNnIn this randomized controlled trial conducted at a single teaching hospital, participating residents were filmed performing a side-to-side intestinal anastomosis on cadaveric dog bowel for baseline assessment. The Surgical Video Coaching (SVC) group then participated in a one-on-one video playback coaching and debriefing session with a surgeon, during which constructive feedback was given. The control group went on with their normal clinical duties without coaching or debriefing. All participants were filmed making a second intestinal anastomosis. This was compared to their first anastomosis using a 7-category-validated technical skill global rating scale, the Objective Structured Assessment of Technical Skills. A single independent surgeon who did not participate in coaching or debriefing to the SVC group reviewed all videos. A satisfaction survey was then sent to the residents in the coaching group.nnnSETTINGnDepartment of Surgery, HôpitalMaisonneuve-Rosemont, tertiary teaching hospital affiliated to the University of Montreal, Canada.nnnPARTICIPANTSnGeneral surgery residents from University of Montreal were recruited to take part in this trial. A total of 28 residents were randomized and completed the study.nnnRESULTSnAfter intervention, the SVC group (n = 14) significantly increased their Objective Structured Assessment of Technical Skills score (mean of differences 3.36, [1.09-5.63], p = 0.007) when compared to the control group (n = 14) (mean of differences 0.29, p = 0.759). All residents agreed or strongly agreed that video coaching was a time-efficient teaching method.nnnCONCLUSIONSnVideo coaching is an effective and efficient teaching intervention to improve surgical residents technical skills.

Adrenal metastasis of a phyllodes tumor of the breast: Case report and review of the literature

INTRODUCTIONnA phyllodes tumor is a neoplasm of mixed mesenchymal and epithelial origin affecting the breast. It may pursue a benign or malignant evolution with distant metastases in the latter case. Sites most commonly affected by metastases are the lungs and bones. Simple mastectomy is the mainstay of treatment. This article presents the first described case of metastasis to the adrenal gland after sarcomatous transformation of a phyllodes tumor. A review of the literature is presented afterwards.nnnPRESENTATION OF CASEnA 57-year old female patient presented with a voluminous breast mass which was completely resected. Unfortunately she presented with malignant recurrence in the breast which was also resected. A later recurrence within the lung presented and was completely resected but showed aspects of sarcomatous changes. Finally a recurrence was pathologically documented within the adrenal gland. Unfortunately, disease later progressed and the patient refused further treatment at that point.nnnDISCUSSIONnWhile malignant transformation of breast phyllodes tumors and metastasis is relatively common, the prognosis for initially benign lesion that are completely excised is usually good. This case represents the first documented metastasis to the adrenal gland of a breast phyllodes tumor.nnnCONCLUSIONnWe presented the first case of adrenal metastasis of a phyllodes tumor after sarcomatous degeneration. This is an unusual presentation of a relatively uncommon but well-recognized disease of variable malignant potential.

Postoperative complications affect long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis

Morbidity after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRSu2009+u2009HIPEC) for colorectal peritoneal carcinomatosis (PC) may negatively affect survival. The objective was to determine the impact of postoperative complications (CX) on survival in patients undergoing CRSu2009+u2009HIPEC for colorectal PC.