Saju Joseph

Lymphatic mapping helps to define resection margins for midgut carcinoids

BACKGROUND The extensive mesenteric lymphadenopathy associated with midgut carcinoids often causes lymphatic obstruction and leads to the development of alternative lymphatic drainage pathways. We hypothesized that altered lymphatic drainage makes traditional determination of resection margins inadequate. METHODS One hundred and seventy patients underwent cytoreductive surgery for neuroendocrine tumors from November 2006 to August 2008. Forty-nine patients underwent intra-operative lymphatic mapping with lymphazurin dye as a single agent. Twenty-seven patients had midgut primaries. We reviewed operative findings and pathology to evaluate the safety and efficacy of lymphatic mapping for midgut carcinoids. Lymphatic mapping defined resection margins were compared to traditional surgical margins. RESULTS There were no adverse events associated with the 49 lymphatic mapping procedures. Twenty-five (92%) patients had ileal and 2 had jejunal primaries. Lymphatic mapping changed traditional resection margins in 88% of patients. We preserved the ileocecal valve in 6 of 15 (40%) of patients with terminal ileal primaries. CONCLUSION Lymphatic mapping seems to be a safe, time efficient, and effective way to determine adequate resection margins for midgut carcinoids. We advocate using lymphatic mapping for patients with midgut carcinoids to identify adequate resection margins and assist in preservation of the ileocecal valve in patients with terminal ileal primary carcinoids.

A prospective trial on the effect of body mass index and sex on plasma octreotide levels in patients undergoing long-term octreotide LAR therapy.

Objectives: Octreotide long acting repeatable (LAR) is commonly used to control the symptoms of patients with functional neuroendocrine tumors. Unfortunately, most patients escape control over time and require higher LAR doses or more frequent rescue therapy to remain asymptomatic. Previous work has shown that body weight and monthly LAR dose will significantly affect circulating plasma octreotide levels in patients undergoing therapy. Methods: To determine if other parameters change circulating plasma octreotide levels, we prospectively studied 82 patients undergoing long-term LAR therapy. Results: Multivariate analysis demonstrated that the plasma octreotide levels decrease by approximately 3.4% for each unit of body mass index (BMI) increase (P = 0.03), adjusting for sex and monthly LAR dose. Plasma octreotide levels for females were approximately 47.6% higher than those for males (P = 0.045), adjusting for BMI and monthly LAR dose. Initial and subsequent octreotide LAR doses should take into consideration sex and BMI. Males are estimated to require 14.1-mg (SD, 7.25) higher monthly LAR doses than females with the same BMI. Conclusions: We have shown that plasma octreotide levels are affected by not only monthly LAR dose but also BMI and sex. We hope these observations will make choosing initial and subsequent octreotide LAR doses easier for physicians.

Breakthroughs in thymic malignancies using international collaborative data

Thymic epithelial tumors (TET) are rare with an overall incidence of 0.15 per 100,000, however, the incidence appears to be increasing (1) ( Figure 1 ). Like many rare tumors, there has been a paucity of data from which to derive best practices, leading to the development of numerous muticenter large databases. These efforts allow for pooling of data and better characterization of the biology, clinical characteristics, and patient outcomes of thymic tumors.

A Prospective Trial on the Effect of Body Mass Index and Gender on Plasma Octreotide Levels in Patients Undergoing Long Term Therapy With Octreotide LAR

Undergoing Long Term Therapy With Octreotide LAR Saju Joseph MD1, Erika Lindholm MD1 , Gang Li, PhD2, Ying Zhou, MS2, Vay Liang W. Go, MD3, Aaron I. Vinik, MD, PhD4, Thomas M. O’Dorisio, MD5, and Gregg Mamikunian, MS6, and Eugene A. Woltering MD, FACS1 1Department of Surgery, Sections of Surgical Endocrinology and Hepato-Biliary Surgery, Louisiana State University Health Sciences Center, New Orleans, LA; 2Department of Biostatistics, University of California, Los Angeles, CA; 3Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA; 4Streletz Diabetes Institute, East Virginia Medical School, Norfolk, VA; 5Division of Endocrinology & Metabolism, University of Iowa, Iowa City, IO, 6Inter Science Institute, Inglewood, CA

Initial Evaluation of Patients With NETS: A Prospective Evaluation of the Influence of Intensive Pre-Visit Counseling

Methods: Over an 18 month period (January 2008 until July 2009) patients were prospectively studied to determine if intensive pre-visit counseling would result in the requested reports being available at the time of the patient’s initial visit. Scan and biomarker results had to be from studies done within six months of the visit. Results were expressed as the percent of patients who had these requested reports available at the time of their initial evaluation.

Extensive Retroperitoneal Carcinoid Involving the Mesenteric Vasculature Does Not Preclude Effective Cytoreduction

John M. Lyons, III1, Erica Lindholm1, Yi-Zarn Wang1, Jessica L. Thomson2, Lowell B. Anthony 3,4, Eugene A. Woltering1,4 , Daniel J. Frey1 , Saju Joseph1 , Thiagaran Ramacharan1 and J. Philip Boudreaux1 Louisiana State University Health Sciences Center, the Department of Surgery, Section of Surgical Endocrinology 1, USDA ARS Southern Regional Research Center, Baton Rouge, LA 2, the Department of Medicine, Section of Medical Oncology 3 and the LSUHSC Stanley S. Scott Cancer Center New Orleans, LA 70112 4