Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Acute Myelocytic Leukemia and Chronic Myelomonocytic Leukemia Simultaneously with Resectable Breast Cancer: A Report of two Cases

This report describes 2 patients who developed acute myelocytic leukemie (AML) type M2 and chronic myelomonocytic leukemia (CMML) of the FAB classification, respectively 2 months and 2 weeks after diagnosis of operable breast cancer. The patient with AML showed pancytopenia 2 months before the diagnosis of AML, had a normal karyotype, and showed a good response to chemotherapy. The patient with CMML had a normal karyotype, and she was treated with hydroxyurea and supportive therapy. The 2 patients had no previous exposure to irradiation or cytotoxic therapy. These cases show that breast cancer and either leukemia or myelodysplastic syndrome may be associated even without previous irradiation or combination chemotherapy.

[Patterns of care in community mental health services in Lombardy]

OBJECTIVE

The analysis aims to study patterns of care of patients in contact with 5 Psychiatric Services in Lombardy. Four patterns have been identified long term-high users, non long term-high users, long term-non high users, non long term-non high users.

DESIGN

Data were provided by the regional Psychiatric Information System. The cohort of patients have been composed by 5,670 patients included in 1994 one year prevalence.

SETTING

Five Psychiatric Services (Merate, Treviglio, Crema, Desio, Castano Primo) with a total population of 610,184 inhabitants aged over 14. MAIN UTILISED MEASURES: Some sociodemographic and clinical variables have been taken into consideration for a descriptive analysis; a multinomial logistic regression model was used to identify the characteristics of patients associated with different patterns.

RESULTS

Long term-high users were 5.3%, i.e. a mean rate of 4.9/10,000 residents over 14, and absorbed 60% of resources, the absence of a partner was associated in regression analysis with this pattern. Non long term-high users were 1.2%, i.e. a mean rate of 1.1/10,000 residents over 14, and absorbed 7.8% of resources; age below 45, unemployment, absence of a partner, severe mental illness and first contact with Psychiatric Services in the period 1985-1989 were predictive variables. Long term-non high users were 23.4%, i.e. a mean rate of 21.6/10,000 residents over 14, and absorbed 18.1% of resources; age below 45, unemployment, living alone, absence of a partner, severe mental illness and first contact with Psychiatric Services before 1990 were predictive variables. Non long term-non high users were 70.1%, i.e. a mean rate of 64.8/10,000 residents over 14 and, absorbed 18.1% of resources.

CONCLUSIONS

Data show that on the whole the activity of Psychiatric Services is addressed to most serious patients, though considerable differences between Psychiatric Services utilisation may be found. This study highlights the importance of a regional Psychiatric Information System, that allows the monitoring in time and in the regional territory of patterns of care.

[Pure and primary squamous cell carcinoma of the breast]

A case of a pure squamous cell carcinoma (SCC) of the breast is a 75 y.o. white female is reported. The cancer was discovered at the clinical exam requested by the patient for a growing mass in the left breast. Mammogram and an ultrasound exam showed a big cystic mass (4 cm x 4 cm) with a liquid content and a small polypoid mass of 0.5 cm x 0.5 cm arising from the inner surface of the cyst. A fine needle aspiration was done and the cytological report was consistent with squamous cell carcinoma. A left modified radical mastectomy was carried out. The skin was not involved and the lymph nodes were negative, and no other cutaneous tumor elsewhere was found. The stage was II (T 2a N o M o). The patient did well and was discharged 10 days post-op and now she is still doing well with no signs of recurrences or metastasis. This cancer should not be confused with a much more largely manifest metaplastic changes in a usual breast cancers. The criteria to define "pure" a squamous cell Ca of the breast are: 1) that no other neoplastic element such as ductal or mesenchymal ones are present in the tumor; 2) that the tumor is independent of adjacent cutaneous structure; 3) that no other distant epidermoid tumor exists in the patient. The origin of this tumor is controversial; it has been stated as arising from dermatoid cyst of the breast, chronic abscesses, complete metaplasia of glandular breast tissue. Despite the rarity of this neoplasia it should be kept in mind that in a cystic mass of the breast in older patient could arise a squamous cell carcinoma.