Jejunostomy in the palliative treatment of gastric cancer: A clinical prognostic score

BACKGROUND

Clinical stage IV gastric cancer (GC) may need palliative procedures in the presence of symptoms such as obstruction. When palliative resection is not possible, jejunostomy is one of the options. However, the limited survival of these patients raises doubts about who benefits from this procedure.

AIM

To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.

METHODS

We performed a retrospective analysis of Stage IV GC who underwent jejunostomy. Eleven preoperative clinical variables were selected to define the score categories, with 90-d mortality as the main outcome. After randomization, patients were divided equally into two groups: Development (J1) and validation (J2). The following variables were used: Age, sex, body mass index (BMI), American Society of Anesthesiologists classification (ASA), Charlson Comorbidity index (CCI), hemoglobin levels, albumin levels, neutrophil-lymphocyte ratio (NLR), tumor size, presence of ascites by computed tomography (CT), and the number of disease sites. The score performance metric was determined by the area under the receiver operating characteristic (ROC) curve (AUC) to define low and high-risk groups.

RESULTS

Of the 363 patients with clinical stage IVCG, 80 (22%) patients underwent jejunostomy. Patients were predominantly male (62.5%) with a mean age of 62.4 years old. After randomization, the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score. The high NLR had the highest value. The ROC curve derived from these pooled parameters had an AUC of 0.712 (95%CI: 0.537-0.887, P = 0.022) to define risk groups. In the validation cohort, the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756, (95%CI: 0.598-0.915, P = 0.006). According to the cutoff, in the validation cohort BMI less than 18.5 kg/m2 (P < 0.001), CCI ≥ 1 (P = 0.001), ASA III/IV (P = 0.002), high NLR (P = 0.012), and the presence of ascites on CT exam (P = 0.004) were significantly associated with the high-risk group. The risk groups showed a significant association with first-line (P = 0.012), second-line chemotherapy (P = 0.009), 30-d (P = 0.013), and 90-d mortality (P < 0.001).

CONCLUSION

The scoring system developed with 11 variables related to patient's performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Diagnostic biopsy of cutaneous melanoma, sentinel lymph node biopsy and indications for lymphadenectomy

The incidence of cutaneous melanoma appears to be increasing worldwide and this is attributed to solar radiation exposure. Early diagnosis is a challenging task. Any clinically suspected lesion must be assessed by complete diagnostic excision biopsy (margins 1-2 mm); however, there are other biopsy techniques that are less commonly used. Melanomas are characterized by Breslow thickness as thin (< 1 mm), intermediate (1-4 mm) and thick (> 4 mm). This thickness determines their biological behavior, therapy, prognosis and survival. If the biopsy is positive, a wide local excision (margins 1-2 cm) is finally performed. However, metastasis to regional lymph nodes is the most accurate prognostic determinant. Therefore, sentinel lymph node biopsy (SLNB) for diagnosed melanoma plays a pivotal role in the management strategy. Complete lymph node clearance has undoubted advantages and is recommended in all cases of positive SLN biopsy. A PET-CT (positron emission tomography-computed tomography) scan is necessary for staging and follow-up after treatment. Novel targeted therapies and immunotherapies have shown improved outcomes in advanced cases.

Pseudomyxoma peritonei originating from small intestine: A case report and review of literature

BACKGROUND

Pseudomyxoma peritonei (PMP) is a distinct form of peritoneal malignancy characterized by diffuse intra-abdominal gelatinous ascites, with an estimated incidence of 1-3 per 1000000. PMP is predominantly secondary to appendiceal mucinous neoplasms, with rarer origins including the ovaries, colon, and urachus. However, PMP originating from small intestine is extremely rare.

CASE SUMMARY

A 60-year-old male patient presented with anorexia and abdominal distension. Computed tomography revealed the presence of abdominopelvic effusions and multiple intra-abdominal space-occupying lesions. Ultrasound-guided aspiration indicated that the aspirated tissue was mucinous. Exploratory laparoscopy and tissue biopsy identified diffuse tumor nodules in peritoneum, omentum, pelvic region, intestinal walls, and mesentery. Histopathological analysis of the resected tumors confirmed the presence of mucinous adenocarcinoma, but the primary lesion was difficult to determine. The patient was referred to our center for further treatment and underwent cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) under general anesthesia. The intraoperative peritoneal cancer index was 30. The surgery lasted 8 hours, with a blood loss of about 600 mL. A complete cytoreduction (CCR0) was achieved. No serious complications occurred after surgery, and the patient's condition was good during the telephone follow-up. Postoperative pathology confirmed the diagnosis of small intestinal mucinous adenocarcinoma at proximal jejunum, which was complicated by high-grade PMP.

CONCLUSION

PMP originating from small intestine is an exceptionally rare entity that exhibits non-specific clinical features. The preferred treatment is CRS + HIPEC.