Margo Shoup

Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection

Liver-enhancing modalities, such as portal vein embolization, are increasingly employed prior to major liver resection to prevent postoperative liver dysfunction. Selection criteria for such techniques are not well described. This study uses CT-based volumetric analysis as a tool to identify patients at highest risk for postoperative hepatic dysfunction. Between July 1999 and December 2000, a total of 126 consecutive patients who were undergoing liver resection for colorectal metastasis and had CT scans at our institution were included in the analysis. Volume of resection was determined by semiautomated contouring of the liver on preoperative volumetrically (helical) acquired CT scans. Hepatic dysfunction was defined as prothrombin time greater than 18 seconds or serum bilirubin level greater than 3 mg/dl. Marginal regression was used to compare the predictive ability of volumetric analysis and the extent of resection. The percentage of liver remaining was closely correlated with increasing prothrombin time and bilirubin level (P < 0.001). After trisegmentectomy, 90% of patients with ≤s25% of liver remaining developed hepatic dysfunction, compared with none of the patients with more than 25% of liver remaining after trisegmentectomy (P < 0.0001). The percentage of liver remaining was more specific in predicting hepatic dysfunction than was the anatomic extent of resection (P = 0.003). Male sex nearly doubled the risk of hepatic dysfunction (odds ratio = 1.89, P = 0.027), and having ≤25% of liver remaining more than tripled the risk (odds ratio = 3.09, P < 0.0001). Hepatic dysfunction and ≤25% of liver remaining were associated with increased complications and length of hospital stay (P < 0.0001 and P = 0.0003, respectively). Preoperative assessment of future liver volume remaining distinguishes which patients undergoing liver resection will most likely benefit from preoperative liver enhancement techniques such as portal vein embolization.

Predictors of survival in recurrent rectal cancer after resection and intraoperative radiotherapy

AbstractPURPOSE: This study was designed to determine predictors of survival after surgery and intraoperative radiotherapy for recurrent rectal cancer. METHODS: From a prospective database, 634 patients undergoing resection for recurrent rectal cancer between January 1990 and June 2000 were identified. Of these, 111 received intraoperative radiotherapy with curative intent, and 100 were available for follow-up. Clinicopathologic variables from both the primary and recurrent operations were evaluated as predictors of disease-free and disease-specific survival by multivariate Cox regression and log-rank test. RESULTS: There were 54 males and 46 females, with a median age of 57 (range, 37–83) years. With a median follow-up of 23.2 months, 60 patients (60 percent) recurred: 20 (33 percent) locally, 27 (45 percent) distantly, and 13 (22 percent) at both sites. Of all variables analyzed, only complete resection with microscopically negative margins and the absence of vascular invasion in the recurrent specimen predicted improved disease-free and disease-specific survival (P < 0.01 for all). Median disease-free survival and median disease-specific survival were 31.2 and 66.1 months, respectively, for complete resection compared with 7.9 and 22.8 months for resection with microscopic or grossly positive margins (P < 0.01 for both). Median disease-free survival and median disease-specific survival were 6.4 and 16.1 months, respectively, in the presence of vascular invasion in the recurrent specimen compared with 23.3 and 57.3 months in the absence of vascular invasion (P < 0.01 and P < 0.05, respectively). Complete resection and the absence of vascular invasion were the only predictors of improved local control as well (P < 0.05 and P < 0.01, respectively). CONCLUSION: Resection with negative microscopic margins and absence of vascular invasion are independent predictors of local control and improved survival after resection and intraoperative radiotherapy for recurrent rectal cancer.

Colorectal cancer pelvic recurrences: determinants of resectability.

PURPOSEThis study was designed to identify preoperative and intraoperative features of locally recurrent colorectal cancer that predict R0 resection in patients scheduled for attempted complete resection followed by intraoperative radiation therapy.METHODSReview of a prospective data base identified 119 patients brought to the intraoperative radiation therapy suite for planned complete resection of locally recurrent rectal (n = 101) and colon (n = 18) cancer between January 1994 and November 2000. R0 resection was achieved in 61 patients. This group was compared with patients in which an R1 (n = 38), R2 (n = 7), or palliative procedure (n = 13) was performed. Variables evaluated included: tumor location, features of the primary tumor, and preoperative findings on computed tomography, magnetic resonance imaging, and history/physical. Tumor location was established by review of operative/pathologic reports and classified as axial (anastomotic/perineal), anterior (bladder/genitourinary organs), posterior (presacral), or lateral (pelvic sidewall).RESULTSWhen recurrence was confined to the axial location only, or axial and anterior locations, R0 resection was achieved significantly more often than when other locations were involved (P < 0.001, P = 0.003, respectively). When a lateral component was present, R0 resection was achieved significantly less often than when there was no lateral component (P = 0.002). For patients with available preoperative computed tomography and/or magnetic resonance imaging results (n = 70), the finding of lateral tumor involvement was associated with R0 resection significantly less often than when lateral disease was not identified (P = 0.004).CONCLUSIONSPelvic recurrences confined to the axial location, or axial and anterior locations, are more likely to be completely resectable (R0) than those involving the pelvic sidewall. Efforts to enhance preoperative identification and imaging of these patients are clearly justified.

Contemporary outcomes of total pelvic exenteration in the treatment of colorectal cancer

PurposeTotal pelvic exenteration is performed infrequently in selected patients with locally advanced or recurrent colorectal cancer. We reviewed our contemporary experience with pelvic exenteration for colorectal cancer to identify selection criteria and prognostic factors for longterm survival. METHODS: Between 1991 and 2000, 55 patients (males, 29; median age, 62 years) undergoing total pelvic exenteration for colorectal cancer were identified from a prospective database. Clinicopathologic variables were evaluated as prognostic indicators of long-term survival by log-rank test and multivariate Cox regression. RESULTS: Indications for surgery were recurrent colorectal cancer in 71 percent and primary colorectal cancer in 29 percent. Of 39 patients with recurrent colorectal cancer, 85 percent had previous radiotherapy, and 64 percent had previous abdominoperineal resection. At the time of pelvic exenteration, 49 percent of patients received intraoperative radiation, and 20 percent required sacrectomy. Complete resection with negative margins was achieved in 73 percent. Perioperative mortality after pelvic exenteration was 5.5 percent, and complications included perineal wound infection (40 percent), pelvic abscess (20 percent), abdominal wound infection (18 percent), and cardiopulmonary events (18 percent). Median disease-specific survival for all patients was 48.9 (range, 3.2-105.6) months. Univariate analysis identified five factors associated with decreased survival: male gender, recurrent colorectal cancer, previous abdominoperineal resection, positive surgical margin, and administration of intraoperative radiation. On multivariate analysis, only previous abdominoperineal resection was an independent predictor of unfavorable outcome (P < 0.04). CONCLUSIONS: Total pelvic exenteration can be performed safely in highly selected patients with colorectal cancer and can result in significantly prolonged survival. Less satisfactory outcomes are observed in patients whose indication for pelvic exenteration is recurrent colorectal cancer after abdominoperineal resection.

Unfavourable prognosis associated with K-ras gene mutation in pancreatic cancer surgical margins

Background: Despite intent to cure surgery with negative resection margins, locoregional recurrence is common in pancreatic cancer. Aims: To determine whether detection of K-ras gene mutation in the histologically negative surgical margins of pancreatic cancer reflects unrecognised disease. Patients: Seventy patients who underwent curative resection for pancreatic ductal adenocarcinoma were evaluated. Methods: All patients had surgical resection margins (pancreatic transection and retroperitoneal) that were histologically free of invasive cancer. DNA was extracted from these paraffin embedded surgical margins and assessed by quantitative real time polymerase chain reaction to detect the K-ras gene mutation at codon 12. Detection of K-ras mutation was correlated with standard clinicopathological factors. Results: K-ras mutation was detected in histologically negative surgical margins of 37 of 70 (53%) patients. A significant difference in overall survival was demonstrated between patients with margins that were K-ras mutation positive compared with negative (median 15 v 55 months, respectively; p = 0.0008). By univariate and multivariate analyses, detection of K-ras mutation in the margins was a significant prognostic factor for poor survival (hazard ratio (HR) 2.8 (95% confidence interval (CI) 1.5–5.3), p = 0.0009; and HR 2.8 (95% CI 1.4–5.5), p = 0.004, respectively). Conclusions: Detection of cells harbouring K-ras mutation in histologically negative surgical margins of pancreatic cancer may represent unrecognised disease and correlates with poor disease outcome. The study demonstrates that molecular-genetic evaluation of surgical resection margins can improve pathological staging and prognostic evaluation of patients with pancreatic ductal adenocarcinoma.

Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract malignancies: an uncommon entity.

BackgroundThe role of laparoscopy for diagnosing, staging, and treating intra-abdominal malignancies is increasing. This study was designed to examine the incidence of port site metastasis and open incision site metastasis for upper gastrointestinal tract (GI) malignancies.MethodsFrom a prospective database maintained by the Department of Surgery, patients undergoing laparoscopy for upper GI malignancies were identified. Clinical outcomes and recurrences were noted.ResultsBetween January 1993 and January 2001, 1965 laparoscopic procedures were identified. After those patients lost to follow-up were excluded, 1650 procedures were performed in 1548 patients. Port site implantation for all laparoscopies occurred in 13 (.79%) of 1650, with a median time to recurrence of 8.2 months. After laparotomy, open incision site recurrence occurred in 9 (.86%) of 1040 (not significant). Among the patients resected, there were 5 (.60%) of 830 port site recurrences and 7 (.84%) of 830 open incision site recurrences. At the time of diagnosis of recurrence, all of the patients with port site and five of seven with open site implantation had distant or local disease, or both, as well.ConclusionsPort site implantation after diagnostic laparoscopy for upper GI malignancy is uncommon, does not seem to be different from open incision site recurrence, and occurs in the setting of advanced disease. Therefore, the risk of port site recurrence cannot be used as an argument against laparoscopy in upper GI malignancy.

Is there a role for staging laparoscopy in patients with locally advanced, unresectable pancreatic adenocarcinoma?

The study objective was to determine the incidence of laparoscopically detected metastasis in patients with radiographically staged locally advanced adenocarcinoma of the pancreas. Patients with locally advanced pancreatic cancer are considered candidates for novel treatment protocols. Stratification of patients into locally advanced disease versus metastatic disease is imperative to accurately evaluate treatment outcome. Between 1994 and 2000, 100 consecutive patients undergoing staging laparoscopy with radiologic evidence of unresectable locally advanced pancreatic cancer were identified from a prospective database. All patients had preoperative contrast-enhanced, thin-cut computed tomography scanning or magnetic resonance imaging and had no evidence of detectable metastatic disease. There were 53 men and 47 women, with a median age of 64 years. The disease site was the pancreatic head in 69 cases and the body or tail in 31. Radiographic assessment of nonresectability was due to encasement of the celiac or hepatic artery in 37 patients, of the portal vein and superior mesenteric vessels in 56, and extrapancreatic extension in 7. Laparoscopy identified metastatic disease in 37% of patients, not seen on preoperative imaging. Peritoneal disease was noted in 12 cases and liver metastasis in 18 cases, and 7 patients had both. Neither the primary tumor size nor location influenced the incidence of metastatic disease. Standard imaging modalities failed to detect metastatic disease in 37% of patients who were considered to have locally advanced pancreatic cancer. Patients considered for treatment protocols for locally unresectable pancreatic cancer should be staged laparoscopically before initiation of therapy.

Defining a role for endoscopic ultrasound in staging periampullary tumors

BACKGROUND The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. METHODS Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. RESULTS Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CONCLUSIONS CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

The Surgical and Systemic Management of Neuroendocrine Tumors of the Pancreas

Neuroendocrine tumors of the pancreas comprise a class of rare tumors that can be associated with symptoms of hormone overproduction. Five distinct clinical endocrinopathies are associated with neuroendocrine tumors; however, most of these tumors remain asymptomatic and follow an indolent course. Complete surgical resection offers the only hope for cure, but understanding the basic biology of the tumors has advanced the medical management in metastatic disease. Surgical resection of hepatic metastases offers survival advantage and should be performed when feasible. Although hepatic artery embolization is currently the preferred mode of nonsurgical palliation for pain and hormonal symptoms, other modalities may play a role in metastatic disease.

Prediction of postoperative seroma after latissimus dorsi breast reconstruction

Background: The latissimus dorsi flap has become a first-line option in reconstruction of the breast cancer patient. Donor-site seroma is a commonly described postoperative complication of the latissimus dorsi flap. Methods: A retrospective chart review from 1998 to 2003 of all patients undergoing latissimus dorsi breast reconstruction was performed (n = 50). Age of the patients, timing of breast reconstruction, type of nodal dissection (axillary versus sentinel versus none), and chemotherapy status of the patients were examined. Results: The overall incidence of seroma formation was 47 percent. Those patients who had undergone prior or concurrent nodal dissection at the time of breast reconstruction were found to have a higher incidence of seroma formation than patients who had no nodal dissection (52 percent versus 25 percent ) (p = 0.15). Age also was a risk factor for seroma formation, as 63 percent of patients older than 50 had formed seroma as compared with 39 percent of those younger than age 50 (p = 0.08). Conclusion: The authors conclude that advanced age and the presence of nodal disruption before or concurrent with latissimus dorsi breast reconstruction are predictors of donor-site seroma formation.