Changes in diagnosis and operative treatment of insulinoma over two decades

PURPOSE

Most insulinomas are small solitary, benign neoplasms. Imaging and surgical techniques improved over the last 20 years. Thus, the aim of the present study was to analyze changes in diagnosis and surgery of insulinoma patients in a referral center over two decades.

METHODS

Operated patients with a histologically proven insulinoma were retrieved from a prospective database. Clinico-pathological characteristics and outcomes were retrospectively analyzed with regard to the time periods 2000-2010 (group 1) and 2011-2020 (group 2).

RESULTS

Sixty-one of 202 operated patients with pNEN had an insulinoma, 37 (61%) in group 1 and 24 (39%) in group 2. Of those 61 insulinomas, 49 (80%) were sporadic benign, 8 (13%) benign MEN1-associated insulinomas, and 4 (7%) sporadic malignant insulinomas. In 35 of 37 (95%) patients of group 1 and all patients of group 2, the insulinoma was preoperatively identified by imaging. The most sensitive imaging modality was endoscopic ultrasound (EUS) with correctly diagnosed and localized insulinomas in 89% of patients in group 1 and 100% in group 2. In group 1, significantly less patients were operated via minimally invasive approach compared to group 2 (19% (7/37) vs. 50% (12/24), p = 0.022). Enucleation was the most frequently performed operation (31 of 61, 51%), followed by distal resection (15 of 61, 25%) without significant differences between groups 1 and 2. The rate of relevant postoperative complications was not different between groups 1 and 2 (24% vs. 21%, p = 0.99). Two patients with benign insulinoma (1 out of each group) experienced disease recurrence and underwent a second resection. After a median follow-up of 134 (1-249) months, however, all 57 (100%) patients with benign insulinoma and 3 out of 4 patients with malignant insulinoma had no evidence of disease.

CONCLUSION

Insulinoma can be preoperatively localized in almost all patients, allowing for a minimally invasive, parenchyma-sparing resection in selected patients. The long-term cure rate is excellent.

[Controversy: asymptomatic small pancreatic neuroendocrine neoplasms : Current standards in diagnostics and treatment]

BACKGROUND

For the increasingly diagnosed entity of small asymptomatic, sporadic, nonfunctional, pancreatic neuroendocrine neoplasms (pNEN), a negligible or at least unclear prognostic relevance of the disease for patient survival has often been observed.

OBJECTIVE

Safety and acceptance of a watch-and-wait strategy versus surgical resection for small, asymptomatic nonfunctional (NF) pNEN.

METHODS

Presentation and evaluation of the relevant literature as well as the corresponding national and European guidelines.

RESULTS

Surgery of small NF-pNEN shows complication rates of 15-32% (Clavien-Dindo ≥ 3) and a mortality of 3.6%. Even for pNEN < 2 cm the presence of lymph node metastases has been observed in 11% of cases, while their prognostic relevance in G1-pNEN compared with active surveillance remains unclear. On average 14% of patients under active surveillance for small NF-pNEN, underwent a resection. Relevant tumor growth during surveillance was found in < 20% of cases. In all well-selected surveillance cohorts no metachronous lymphatic or distant metastases occurred during active surveillance and especially no cases of a metachronous no longer curable disease.

CONCLUSION

Even small asymptomatic NF-pNEN have a certain metastatic potential but the clinical relevance has prospectively not yet been clearly determined. Controlled surveillance of these tumors is at least an alternative to immediate tumor resection. Especially patients above 70 years old do not seem to benefit from resection. The pros and cons of a resection should therefore be individually evaluated with the patient.

A retrospective comparison of robotic versus laparoscopic distal resection and enucleation for potentially benign pancreatic neoplasms

PURPOSE

The present study aimed to compare robotic-assisted versus laparoscopic distal pancreatic resection and enucleation for potentially benign pancreatic neoplasms.

METHODS

Patients were retrieved from a prospectively maintained database. Demographic data, tumor types, and the perioperative outcomes were retrospectively analyzed.

RESULTS

In a 10-year period, 75 patients (female, n = 44; male, n = 31; median age, 53 years [range, 9-84 years]) were identified. The majority of patients had pancreatic neuroendocrine neoplasms (n = 39, 52%) and cystic neoplasms (n = 23, 31%) with a median tumor size of 17 (3-60) mm. Nineteen (25.3%) patients underwent enucleation (robotic, n = 11; laparoscopic, n = 8) and 56 (74.7%) patients underwent distal pancreatic resection (robotic, n = 24; laparoscopic, n = 32), of those 48 (85%) underwent spleen-preserving procedures. Eight (10.7%) procedures had to be converted to open surgery. The rate of vessel preservation in distal pancreatectomy was significantly higher in robotic-assisted procedures (62.5% vs. 12.5%, p = 0.01). Twenty-six (34.6%) patients experienced postoperative complications (Clavien-Dindo grade > 3). Twenty (26.7%) patients developed a pancreatic fistula type B. There was no mortality. After a median follow-up period of 58 months (range 2-120 months), one patient (1.3%) developed local recurrence (glucagonoma) after enucleation, which was treated with a Whipple procedure.

CONCLUSION

The robotic approach is comparably safe, but increases the rate of splenic vessel preservation and reduces the risk of conversion to open surgery.

Well-differentiated neuroendocrine neoplasia: relapse-free survival and predictors of recurrence after curative intended resections

BACKGROUND

Resection with curative intention is the cornerstone of treatment in patients with neuroendocrine tumors. A proportion of patients will relapse after R0 resection, but the factors predictive of recurrence are not well understood.

METHODS

A database established 1998 at the University Hospital Marburg was queried for all patients with documented R0 resection. Recurrence-free survival and overall survival were estimated using the Kaplan-Meier method. Uni- and multivariate analyses were performed.

RESULTS

180 patients with a median age of 52 years entered the analysis. We observed 77 recurrences after a median time of 2.9 years. 24% of the recurrences occurred later than 5 years after operation. Median recurrence-free survival of the whole cohort was 101 months. In univariate analysis grade by Ki-67, stage, high lymph node ratio and microangioinvasion were significant predictors of recurrence. On multivariate analysis these parameters were confirmed as independent prognostic parameters with stage and microangioinvasion being the most important predictors.

CONCLUSIONS

After R0 resection of neuroendocrine tumors, postoperative surveillance should be extended to at least 10 years. Patients with distant metastases and microangioinvasion are at high risk of recurrence. Clinical trials of adjuvant treatment protocols are indicated in these patients.

P5-01-19: Endothelin-1 Expression in Breast Cancer Tissue, Surrounding Stroma, Correlation with Tumor Microvessel Density and Clinical Outcome

Background: Endothelin-1 (ET-1) is a peptide which regulates normal biological processes such as vascular tone. In addition, endothelin signaling pathway is dysregulated in pathophysiological conditions such as cancer and fibrosis. It has been shown that endothelin-1 is expressed in breast cancer tissue but little is known with regard to ET-1 expression in surrounding tumor stroma. In the present study, we investigated ET-1 expression in breast tumor cells, surrounding stroma, association with tumor microvessel density (MVD) and impact on clinical outcome.

Materials and Methods: We conducted a retrospective, multicenter study. Patients from 3 medical centers with histologically documented stage I-III invasive breast cancer were included in the study. Paraffin embedded formalin fixed breast cancer tissue and surrounding stroma were evaluated for ET-1 and CD34 (marker for MVD) by IHC. ET-1 cytoplasmic expression was scored as positive (3+ by IHC) or negative (0, 1+, 2+). Stained vessels by CD34 were counted in five consecutive fields at 40 x magnification and their mean was recorded. Demographics, clinical data and recurrence free interval (RFI) in months were available for statistical analysis.

Results: The study included 92 patients with average age of 55 years at diagnosis. Median follow up of patients at the time of analysis was 72 months. Total of 29 patients experienced disease progression ( 17 locoregional and 12 distant). Tumor ET-1 expression positively correlated with earlier stage: odds ratio (OR) = 22 for stage I and OR=20 for stage II as compared with stage III. Positive ET-1 staining in tumor was detected in 72.8 % of cases, while ET-1 positive expression in stroma was detected only in 6.5% of cases. Interestingly, all ET-1 stroma positive tumors were estrogen receptor (ER) positive. The means of CD34 were not different according to ET-1 expression either in the tumor or stroma. Triple negative breast cancer tumors exhibited higher MVD (p=0.0177). In the logistic regression model relating ET-1 expression in tumor to clinical variables, ET-1 positive tumors showed a trend for the association with higher relapse rate (p=0.058). Multivariate analysis suggested that there was no significant difference in the recurrence free interval (RFI) between the ET-1 positive and ET-1 negative groups (long-rank test p-value = 0.71). Survival analysis identified stage as a significant predictor of RFI in the Cox proportional hazard model that included ET-1 expression and other clinical variables.

Conclusions: The significant predictor for ET-1 expression in the tumor was early stage. High tumor ET-1 expression was more common in patients who experienced breast cancer recurrence. No association was found between ET-1 expression and MVD, and between ET-1 expression and time to recurrence. Further studies with larger sample size are needed to better delineate a role of ET-1 as prognostic biomarker in early stage breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-19.

Detection of aberrant drainage after sentinel lymph node mapping and its impact on staging and change of operation in colon cancer

500

Background: Sentinel lymph node mapping in colon cancer leads to the detection of micrometastasis in 15- 20% of patients leading to upstaging to stage III disease.

Methods: Between 1996-2010, patients diagnosed with colon cancer were enrolled in our study and underwent SLNM at the tim of surgery plus standard oncological resection including regional LN resection. After initial years of experience, exact locations of the SLNs were mapped in relation to the primary tumor. Aberrant drainage was observed when a SLN was detected outside the standard lymph node basin. The primary objective of this analysis is to identify the frequency of detection of such aberrant drainage and the rates of positive aberrant SLNs leading to change of operation and staging.

Results: Between 1996-2010, 304 patients were included in the study. The overall success rates of SLNM was 99.7%. The average number of resected LNs was 15.4. SLNM had a sensitivity, negative predictive value, accuracy and false negative rates of 85.3%, 91.7%, 94.4% and 14.6% respectively. Micrometastatic disease was detected in 15.1% of patients with node positive disease. Since 2001, 150 patients were evaluated for the presence of aberrant drainage and potential change of planned surgery. In 27 patients (18%), extended surgery was performed due to aberrant drainage. The nodal positivity in these 27 patients was 59.5%, compared to 46% in the whole group. The average number of lymph nodes in this group was 16 and the average number of SLNs was 4.3. The most common location of the primary tumor was the right colon in 55.6% of patients with aberrant drainage. In 13 patients (8.7% of case), change of operation led to the detection of positive SLNs leading to upstaging to stage IIIA/B diseases. All of these 13 patients had T3 or T4 disease. All node positive patients underwent adjuvant chemotherapy.

Conclusions: SLNM in colon cancer is highly successful, sensitive and overall accurate staging procedure. It leads to detection of SLNs outside the regional lymphatic basin and change of surgery in 18% of patients. This results in higher nodal positivity and significant change of planned surgery in 8.7% of cases.

No significant financial relationships to disclose.

Biological impact of skip metastasis in patients with gastrointestinal cancers undergoing sentinel lymph node mapping

499

Background: As in melanoma and breast cancers, sentinel lymph node (SLN) mapping has been successfully used in gastrointestinal (GI) cancers (Ca) for accurate nodal staging. However, due to variable incidence of skip metastasis between different parts of the GI tract, its usefulness has been questioned for the proper staging. Hence, we aimed to evaluate the rates of skip mets, its mechanism and its biological impact in GICa.

Methods: A search of English literature was performed incorporating MEDLINE and Cochrane library database using the following terms: skip metastasis, sentinel node, colorectal, gastric, and esophageal cancer. The following were excluded: comments, case reports, reviews, fewer than 40 patients in the study. The remaining were used for data extraction.

Results: Between 2000-2009, 27 studies including 3,589 patients (122 esophageal, 1,185 gastric, 2,113 colon, and 169 rectal cancers) were reviewed. The overall success rate of SLNM was 95% (96.6% in esophageal, 94% in gastric, 94.3% in colon, and 95.6% in rectal cancer). Nodal positivity (positive SLN and/or non-SLN) was 34% in esophageal, 36.6% in gastric, 48.1% in colon, and 41% in rectal cancers. Rates of skip mets were 18%, 14%, 20%, and 15% in esophageal, gastric, colon, and rectal cancers respectively. In patients with skip mets, T3/T4 disease was found in 65%, 44%, and 82.5% of patients with esophageal, gastric and colon cancers respectively. The average tumor size ranged between 3 cm in gastric to 4.4 cm in colon cancer. The most common primary site for skip mets in colon cancer was the right side (50%), and in LN basin 7, 8, 9 in gastric cancer. All node positive (true and false negative) patients were staged as stage III and were treated with adjuvant chemotherapy.

Conclusions: Skip mets are common in T3/T4 disease, and in larger tumors suggesting difficulty injecting the dye circumferentially. All node positive patients (true positive and skip mets) are treated with chemotherapy. Hence, skip mets has no real clinical impact on either the staging, treatment, or the outcome of the disease.

No significant financial relationships to disclose.

The impact of the number of lymph node metastases on the overall recurrence of colon cancer in the era of sentinel lymph node mapping

4049

Background: Sentinel Lymph Node Mapping (SLNM) in colon Cancerc (Cca) has been shown to be successful, sensitive and accurate. We aimed to evaluate the recurrence rates in patients(pts) with Cca after SLNM and correlate it to the number of positive(+ve) LNs. Methods: Between 1996 and 2006, pts diagnosed with Cca were enrolled in a prospective trial and underwent SLNM and oncologic resection including regional LNs. The primary outcome was development of recurrence with minimum follow-up (f/u) of 24 months. For recurrence analysis, exclusion criteria included: stage IV disease, benign pathology, lost to follow-up, refusal of indicated chemotherapy, non cancer related death or second cancer. A retrospective matched control (diagnosed with Cca undergoing standard colon resection without SLNM, gp B) from our own institution were analyzed and compared to the SLNM group for the same period. Results: A total of 486 pts with Cca were included. Of these, 272 consecutive pts underwent SLNM between 1996–2006. SLNM was successful in 99.8% of pts, with a sensitivity, negative (-ve) predictive value, and overall accuracy of 85.3%, 91.7% and 94.4% respectively. The nodal positivity was 46.0%; of these, 15.1% had micrometastasis. The average number of LNs resected / pt was 15.0 and the average number of SLNs / pt was 2.4. For recurrence analysis, 153/272 pts with minimum f/u 2 years were included. Of these, 49 had stage I, 46 had stage II and 58 had stage III disease. The recurrence rates were 4.1%, 8.6% and 15.5% in stage I, II, and III disease respectively. The recurrence rates were significantly lower when our 153 pts were compared to 214 matched controls ( table 1 ). The recurrence rates increased from 6.3% in pts with no +ve LNs to 11.5% when one LN was +ve, 16.7% when 2 LNs were +ve and 20% when 3 or more LNs were +ve. Conclusions: SLNM in Cca is associated with decreased rates of recurrence as compared to conventional therapy. The number of positive LNs is an independent risk factor for recurrence.

[Table: see text]

No significant financial relationships to disclose.

Correlation of bone marrow micrometastasis to TNM stage of colorectal tumors

e15039

Background: Bone marrow (BM) micrometastasis(M) has been shown to be an important prognostic factor in Breast Cancer. However, there is paucity of data for BMM in Colorectal Cancer(CrCa). Hence a study was undertaken to find any correlation between TNM staging with BMM in CrCa patients(pts). Methods: A total of 155 consecutive patients(pts) from March 2004-October 2008 with CrCa were included in the study. Prior to resection of the primary tumor, pts underwent bilateral posterior-superior-iliac spine BM aspiration and samples were examined for presence of micrometastasis by Automated Cellular Imaging System using Chroma Vision Cytokeratin Detection Kit to detect cells expressing CK 8 as defined by CAM 5.2 monoclonal antibody. BMM and TNM staging were recorded and analyzed for correlations. Results: Of 155 CrCa pts, 11.6%(18/155) were found to have BMM. BMM was positive(+ve) in 50%(9/18) bilaterally and 50%(9/18) unilaterally. BMM was +ve in 11.5%(13/113) of colon pts and 12%(5/42) of rectal pts. When analyzed by T stage in colon pts, BMM was present in 10.5%(2/19) of T1 pts, 16.6%(2/12) of T2 pts, 14% (6/42) of T3 pts, 37.5%(3/8) of T4 pts, and 16%(5/31) of M1 pts. Upon analyzing rectal cancer pts data, BMM was found in 8.3%(1/12) of T1 pts, 16.6%(3/18) of T3 pts and 16.6% (3/18) of M1 pts. Of 113 total Colon pts, 27%(31/113) had nodal disease without distant metastasis(stage III); 13%(4/31) of these pts had BMM with 60% (3/5) unilaterally and 40%(2/5) bilaterally. In the Rectal group, 16%(7/42) had stage 3 disease; 14% (1/7) of stage 3 rectal pts had BMM. Conclusions: BMM did not correlate with tumor size, nodal status or distant metastasis. This discrepancy between tumor stage and BMM suggests BMM to operate independently of TNM staging. Further studies correlating prognosis and disease free survival in +ve BMM pts are needed to examine the significance of BMM in CrCa.

[Table: see text]

No significant financial relationships to disclose.

The number of lymph node metastases as a prognostic indicator of disease-specific survival in the era of sentinel lymph node mapping in colon cancer

e15000

Introduction: Sentinel Lymph Node Mapping (SLNM) in colon cancer (CCa) is shown to be successful, sensitive and accurate. We aimed to evaluate the survival of patients (pts) undergoing SLNM in addition to the standard colon resection, compare it to pts without SLNM and correlate it to the number of LN metastasis. Methods: Staging and survival analysis from our prospective database (gpA, 195 pts) were compared to the Surveillance, Epidemiology, and End Results (SEER) database (gpB, 126,484 pts) between 1996–2003. All pts had invasive CCa. GpA pts underwent SLNM plus complete resection. The minimum follow up (F/U) was 5 years. The primary outcome was cancer-specific survival. Exclusion criteria were stage IV disease, 2nd malignancy, or lost to F/U. Cancer specific survival of gpA was then analyzed according to the number of positive LNs. Results: In gpA (195 pts), SLNM was successful in 99.7%, of pts with a sensitivity, negative (-ve) predictive value, and false -ve rates of 86.3%, 91.7% and 14.6% respectively. In 15.1% of node +ve pts, the disease was upstaged because of micrometastasis (0.2–2mm). In gpA, 128 pts were included, of which 17(13.3%) lost to F/U as compared to 89,483 pts included in gpB, of which 47,168 (52.7%) lost to F/U. The average number of LNs examined per pt was 15 in gpA as compared to 12.4 in gpB (p=<0.0001). The 5 year-cancer specific survival of pts in gpA vs gpB was 100% vs 94.9% in stage I, 91.2% vs 83.5% in stage II and 81.8% vs 63% in stage III disease. For gpA pts, the 5 year cancer-specific survival decreased from 95.0% in node -ve disease to 92.8% when 1 LN was +ve, 83.3% when 2 LNs were +ve and 71.4% when 3 or more LNs were +ve (Table). Conclusions: A significant number of pts with CCa are being upstaged and the true node -ve disease is being identified when SLNM is performed at the time of surgery leading to improved survival as compared to conventional surgery. Our study showed that the number of LN metastasis is a predictor of cancer specific survival even after SLNM in CCa. [Table: see text]

No significant financial relationships to disclose.

Nodal positivity between <12 and >12 lymph nodes harvested in colorectal cancer undergoing SLNM compared with conventional surgery

4048

Background: Sentinel Lymph Node Mapping (SLNM) upstages significantly more patients (pts) than conventional surgery (Conv Sx) in Colon Cancer (CCa). According to current guidelines, the examination of 12 or more LNs are required to ensure accurate staging. Our study compares the rates of nodal positivity between differing numbers of total Lymph Nodes (LNs) harvested to see if the nodal positivity of <12 LN harvested by SLNM is equivalent to >12 LN obtained by Conv Sx. Methods: Of 951 pts with CCa, 545 pts underwent SLNM and standard oncological resection; 406 pts received Conv Sx without SLNM. The total number of LNs harvested for each pt as well as number of pts with metastatic LNs were recorded. Pts were grouped according to 2–11 LNs, 12–25 LNs and >25 LNs. Results: Of 951 pts, 81 pts in SLNM group and 6 in Conv Sx group were excluded due to benign disease. Average (avg) total nodes harvested in 2–11 node group for SLNM and Conv Sx was 7.9 vs 6.8 nodes respectively. Overall nodal positivity for SLNM pts and Conv Sx pts in the 2–11 node groups was 48% vs. 33% (p=.02). In the 12–25 node group, avg total number of LNs harvested was 17.23 and 16.32 respectively. In the 12–25 node group, 53% of pts in the SLNM arm had +ve nodes vs 44% (p=0.17) in the Conv Sx group. In pts with >25 nodes harvested avg nodal positivity was 33.78% vs 32.38% for SLNM and Conv Sx. Overall nodal positivity was 55% for SLNM vs 37% for Conv Sx group. When SLNM pts with 2–11 LN harvested were compared to Conv Sx pts with 12–25 LN harvested, nodal positivity was 48% vs 44% (p=0.55). Conclusions: Increased survival has been shown when >12 nodes are harvested in CCa. On avg SLNM identified a higher number of total nodes than conventional surgery. In addition, SLNM pts had higher nodal positivity with <12 LNs harvested compared to the nodal positivity of >12 nodes harvested in the Conv Sx group. A higher number of LN harvested coupled with a greater nodal positivity with less LNs make SLNM a more accurate way to stage CCa.

[Table: see text]

No significant financial relationships to disclose.

Ultrastaging of sentinel lymph nodes (SLNs) compared to non-SLNs in colorectal (CRca) cancer: Do we need both?

4055

Background: SLN mapping (M) accurately stages many solid tumors including CRca. SLNs are 3–5 times more likely to have metastases (mets) when ultrastaged by microsections and IHC as compared to non-SLNs examined by standard pathological methods. It is unknown whether ultrastaging of initially -ve non-SLNs would lead to higher incidence of +ve nodes. Hence, we retrospectively analyzed all initially -ve non-SLNs by microsections and IHC similar to SLNs in CRca patients (pts) undergoing SLNM to determine its impact on final nodal staging. Methods: All CRca pts underwent SLNM by circumferential subserosal injection of 1% lymphazurin. First 1–4 blue nodes were marked as SLNs and ultrastaged by 4 section with H&E and 1 with IHC. All non-SLNs were initially examined by single H& E section and initial staging was made as per AJCC criteria. We re-examined all initially -ve non-SLNs similar to the SLNs by a senior pathologist blinded to prior results. Results: There were 156 pts with Cca and 44 pts with Rca. SLNM was successful in 100% pts with 94% accuracy rate. A total of 2,755 nodes (13.78/pt) were identified, of which 494 were SLNs and 2,261 were non-SLNs. Nodal positivity was 46% and 16% for Cca and Rca pts respectively. Mets were detected in 20.9% of SLNs vs. 8.6% of non-SLNs (p< 0.0001). The exclusive site of nodal mets was detected in 6.5% of SLNs vs.0.8% of non-SLNs (p< 0.0001). Skip mets were found in 6% of pts. After ultrastaging all initially -ve non-SLNs (n=2,065), only 0.58% (12/2065) nonSLNs became +ve in 12 pts. Of these, 10 pts already had +ve SLNs, hence no change of staging occurred. Only 2/200 pts (1%) with initially -ve non-SLNs were found to have a cluster of tumor cells. Thus, ultrastaging of 2065 initially -ve non-SLNs in 200 pts changed the staging from II to III only in 1% of pts. Conclusions: SLNM is highly accurate in staging CRca. The chance of finding additional mets by ultrastaging of all non-SLNs is extremely low (< 1%), hence of little benefit. Therefore, ultrastaging restricted to SLNs alone will assure accurate staging of CRca.

[Table: see text]

No significant financial relationships to disclose.

Correlation of bone marrow micrometastases with nodal status in gastrointestinal tumors

14577

Background: Presence of bone marrow micrometastases (BMM) is an important prognostic factor for patients (pts) with solid tumors. Sentinel lymph node (SLN) mapping (M) has been found to upstage pts with gastrointestinal (GI) malignancies. However, a direct correlation between the presence BMM and nodal metastases (mets) is lacking. Hence, a retrospective study was undertaken to determine the relationship between BMM and nodal status in various GI malignancies. Methods: A total of 159 consecutive pts with GI malignancies were analyzed. Of these, 6 pts with non-epithelial tumors were excluded. All pts underwent bilateral posterior-superior-iliac spine bone marrow (BM) aspiration. BM samples were examined for micrometastases by Automated Cellular Imaging System using ChromaVision Cytokeratin Detection Kit to detect cells expressing CK8 as defined by CAM 5.2 monoclonal antibody. When feasible, SLNM was performed followed by standard oncologic resection (n=105). The SLN were examined by H&E and immunohistochemical (IHC) staining. Results: A total of 153 pts were analyzed in the study. Of these 13.72% (21/153) were found to have BMM (CI 8.70–20.21, p=0.05). When analyzed by sites, the incidence of BMM was 33.3% (4/12) for stomach cancer, 9.1% (1/11) for pancreatic cancer, 12.36% (11/89) for colon cancer and 16.13% (5/31) for rectal cancer. No BMM were detected in pts with cancer of esophagus (n=7), small bowel (n=2) and liver (n=1). The BMM was positive bilaterally in 61.9% (13/21), and unilaterally in 38.1% (8/21). In pts who underwent SLNM (n=105), BMM were detected in 11.11% of SLN positive pts vs. 10.14% for SLN negative pts (p=0.87). For a subgroup of pts with colorectal cancer who underwent SLNM (n=97), BMM were detected in 9.67% of SLN positive pts vs. 9.09% for SLN negative pts (p=0.92) Conclusions: BMM did not correlate with nodal status for GI malignancies suggesting a possible different mechanism for metastases. Detection of BMM may have a significant clinical value in SLN negative pts who may benefit from adjuvant therapy.

[Table: see text]

No significant financial relationships to disclose.

Angiogenesis index (AI) as a predictor of tumor burden in lymph nodes in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

14509

Background: Lymph Node (LN) status is the most important prognostic factor in colon cancer (Cca). Angiogenesis Index (AI) has been studied as a prognostic marker in various solid tumors with conflicting results. Hence, a retrospective analysis was done to evaluate the role of AI as a prognostic marker in Cca. Methods: Pts with Cca who underwent SLNM to determine LN status were included. A portion of tumor was sent for tumor marker analysis including p53, Thrombospondin-1 and CD31 by IHC. AI was derived for each specimen by summing the biomarker specific score for the three tumor markers. AI of -ve 6 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and non-SLNs were measured in greatest diameter by ocular micrometer; and were added for each pt to estimate overall tumor burden in SLNs and non-SLNs. Results: A total of 111 consecutive pts with Cca were included in the study. SLNM was successful in 100% pts. Pts with distant metastasis (mets) (n=18), Tis (n=1) and skip mets (n=9) were excluded from final analysis. Out of the remaining 83 pts, an AI of -6 or less was found in 22 pts (26.5%) while 61 pts (73.5%) had AI of more than (>) -6. Of the 61 pts with AI > -6, 37.7% pts were SLN +ve while 62.3% pts were SLN -ve (p=0.05)( Table 1A ). Of the 22 pts with AI less than or -6, 45.5% pts were SLN +ve and 54.5% pts were SLN -ve (p=0.65). Size of the metastatic tumor burden in lymph nodes was available in 69.7% of SLN +ve pts. Total average tumor burden for pts with AI > -6 (n=15) was 2.04cm as compared to 1.48cm in pts with AI of -6 or less (n=8)(p=0.66). Average SLN met size was 0.73cm in pts with AI > -6 and 0.63cm in pts with AI of -6 or less (p=0.66)( Table 1B ). Conclusions: AI did not correlate with nodal positivity or tumor burden in LNs in pts with Cca. LN status remains the most important prognostic marker in Cca. Further larger trials are required to determine the role of AI as a prognostic marker in Cca.

[Table: see text] [Table: see text]

No significant financial relationships to disclose.

Comparative analysis of bone marrow (BM) micrometastasis (M) with sentinel lymph node (SLN) status in early breast cancer (BRCa)

508

Background: While sentinel lymph node (SLN) metastasis (mets) and bone marrow (BM) micrometastases (M) provide prognostic information in breast cancer (BRCa) patients (pts), a definitive relationship between the two has not yet been proven. We hypothesize that the presence of BMM may not infer an increased risk of SLN mets due to differences in their mechanisms of spread. Methods: We conducted a 6-year retrospective study of 251 T1/T2 BRCa pts who underwent bilateral iliac crest bone marrow aspiration, SLN mapping, and either lumpectomy, partial mastectomy, modified radical mastectomy, or total mastectomy by a single surgeon. BM samples were examined for micrometastases by Automated Cellular Imaging System using Chroma Vision Cytokeratin Detection Kit to detect cells expressing CK 8 as defined by CAM 5.2 monoclonal antibody. Pts with BMM underwent repeat BM analysis after completion of adjuvant chemotherapy. Data was collected for SLN, BM, ER/PR and HER2/neu status. Results: There were 251 consecutive pts entered into the study. Of these, 27.5% (69/251) had SLN mets and 9.6% (24/251) had BMM. Of the pts with SLN mets, 11.6% (8/69) had BMM vs. 88.4% (61/69) with no BMM ( Table ). In pts with ER/PR negative (-ve) BRCa, 7.1% (2/28) had BMM vs. 92.9% (26/28) with no BMM and 25% (7/28) had SLN positive (+ve) vs. 75% (21/28) SLN -ve pts ( Table ). Of the pts with HER2/neu +ve BRCa, 13.1% (8/61) had BMM vs. 86.9% (53/61) with no BMM and 26.2% (16/61) were SLN +ve vs. 73.8% (45/61) SLN -ve pts. After completion of adjuvant chemotherapy all pts with BMM (n=24) converted to BM -ve status. Conclusions: No correlation was identified between BMM and SLN status in T1 and T2 BRCa pts. This study suggests that BMM can occur independently of SLN status. Furthermore, (-ve) ER/PR and (+ve) HER2/neu status did not have a direct correlation with either BMM or SLN mets. Pts with BMM status may benefit from adjuvant therapy. Long-term implications of BM (+ve) have to be evaluated by larger multi- center trials.

[Table: see text]

No significant financial relationships to disclose.

Benefits, limitations and pitfalls of sentinel lymph node (SLN) mapping (M) for colorectal carcinoma (CRCa): A multicenter trial

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Background: Clinical application of SLNM in CRCa patients (pts) is controversial due to the variable results in the literature for its success, skip metastases (mets) and accuracy. Hence prospective data from 5 institutions were analyzed to identify the factors associated with failure and skip mets in CRCa pts undergoing SLNM. Methods: SLNM was performed by peri-tumoral injections of 1–3 ml of 1% lymphazurin subserosally. First 1–4 blue nodes marked as SLNs were examined by 4 sections with H & E and 1 for cytokeratin. Rate of failure and skip mets rate along with age, sex, tumor site, size, grade, T & N stages were analyzed. Results: 549 consecutive CRCa pts underwent SLNM; 453 colon (C) and 96 rectal (R) pts. M: F ratio was 48%: 52% and median age of 72 years. The average no. of LNs was 14.5. SLNM failed in 1% of C and 8% of R pts ( Table ). Of the 8 R failures, 7 had neoadjuvant therapy. No correlation was found between failure, size or T-stage. Overall nodal positivity (+ve) rate was 48%. Of the 466 invasive CRCa pts with successful SLNM, rate of skip mets was 7% in C and 4% in R. Age, sex, grade and neoadjuvant therapy had no correlation with skip mets. Of 28 skip mets pts, 79% had tumors >3cm and 93% had advanced (T3, T4) tumors. Higher skip mets also was found in the transverse colon tumor. The success, accuracy, and sensitivity rates were 98%, 95%, and 88% respectively. Of node +ve pts, 47% had mets found only in the SLNs. SLNM upstaged 35% of C and 36% of R pts with micromets. Conclusions: In CRCa, SLNM is highly successful and accurate in predicting the presence or absence of nodal mets. Submucosal fibrosis of the lymphatics due to neoadjuvant therapy may result in higher failure rates for R pts. Skip mets are higher in transverse C tumors and increase in frequency as the T-stage increases. Pts upstaged by SLNM may benefit from adjuvant chemotherapy.

[Table: see text]

No significant financial relationships to disclose.

P53 as a predictor of tumor burden in lymph nodes (LN) in colon cancer (Cca) patients (pts) undergoing sentinel lymph node (SLN) mapping (M)

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Background: p53 and LN status(S) are important prognostic markers in Cca. Our study was done to evaluate whether p53 S could predict tumor burden in LNs in Cca undergoing SLNM. Methods: Pts with Cca underwent SLNM to determine the LN S. A portion of tumor was used for detection of p53 S by IHC.p53 Histo Score (HS) was defined as (Intensity of stain in cells from 0–4 +1) × (% cells staining). HS of 180 was taken as cut off for significance based on previous studies on solid tumors. Metastatic foci in SLNs and nonSLNs were measured in greatest diameter by ocular micrometer. For overall tumor burden in SLNs and nonSLNs,all metastatic foci were added for each pt. Results: SLNM was successful in 100% of the 117 consecutive pts with Cca. Pts with distant metastasis (mets) (18) and skip mets (9) were excluded. Of the remaining 90 pts,39% were SLN positive (+ve) and 61% were SLN negative (-ve). HS of ≤ 180 was found in 66% and HS >180 was found in 34% of the pts. In 55 SLN -ve pts 76% had HS ≤ 180 while 24% had HS >180. In 35 SLN +ve pts, 49% had HS of ≤ 180 and 51% had HS >180. ( Table ) Of SLN +ve pts, size of metastatic tumor in LNs was available in 86% of pts. Average (av.) non SLN met size was 0.95 cms in pts with HS ≤ 180 and 3.4 cms in pts with HS > 180. Av. SLN met size was 0.63 cms in pts with HS ≤ 180 and 0.9 cms in pts with HS>180 ( Table ). No statistical significance was found among T stage of pts with HS >180 vs ≤ 180. Conclusion: Pts with p53 HS >180 showed significantly greater tumor burden in both SLNs and non SLNs as compared to pts with HS ≤ 180. Also probability of having SLN -ve disease is higher in pts with HS ≤ 180 as compared to pts with HS >180 in Cca. Thus,even in SLN -ve pts, high HS may indicate a worse prognosis. Hence,a high p53 HS might predict pts with Cca having higher tumor burden in LNs and thus identify an aggressive subgroup of pts.

[Table: see text]

No significant financial relationships to disclose.

Comparative analysis of CT-scan and PET-scan with intraoperative ultrasound (IOUS) in detecting liver metastases

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Background: Open, laparoscopic or percutaneous radiofrequency ablation (RFA) has been used for the surgical treatment of liver metastases (mets). However, it requires accurate preoperative (preop) localization of liver mets. CT scan and PET scan have been widely used for such preop evaluation. However, intraoperative ultrasound (IOUS) remains the gold standard. Very little data is available comparing IOUS with preop CT and/or PET scan. Thus, a retrospective study was done to compare the efficacy of IOUS with preop CT and/or PET scan in detecting the number of liver mets. Methods: A retrospective chart review was done that included all patients (pts) who underwent surgical treatment for liver mets. Data was obtained from medical records, radiology, intraop reports. Results: 53 pts including 57% men and 43% women with a median age of 62years (age range 35–80 years) were included in the study. Imaging data was available for CT, PET and IOUS in 53, 24 and 39 pts respectively. CT, PET, and IOUS detected 2.4, 1.7 and 2.6 lesions/ pt respectively. In 24 patients, both CT and PET scan report was available. Of these, the imaging study detecting the maximum number of lesions was selected for comparison of preop evaluation with IOUS. A comparison between preop imaging (CT/PET scan) vs. IOUS in these 24 pts revealed an average of 2.3 vs. 2.8 lesions/pt respectively ( Table ). When compared with preop imaging (CT/PET scan), IOUS detected additional lesions in 33% pts; fewer lesions in 17% pts and similar number of lesions in 50% pts. Comparison between CT and IOUS in 39 patients revealed 1.9 vs. 2.6 lesions/pt respectively and that between PET and IOUS in 24 patients revealed 1.7 vs. 2.8 lesions/pt respectively. Conclusions: Although CT scan and PET scan remains effective modalities for preop evaluation of liver mets, IOUS is found to be superior for planning accurate surgical treatment. Thus, the efficacy of percutaneous RFA may be limited due to inability to perform IOUS.

[Table: see text]

No significant financial relationships to disclose.

Ultrastaging of colorectal cancer by sentinel lymph node mapping technique--a multicenter trial

Sentinel lymph node (SLN) mapping accurately diagnoses the status of nodal basin with >95% accuracy in melanoma and breast cancer. A multicenter trial for SLN mapping was performed on 203 patients with colorectal cancer to determine accuracy, upstaging, skip metastasis, and aberrant drainage. Lymphazurin 1% was injected subserosally around the tumor and 1-4 blue staining nodes were marked as SLNs for detailed histological analysis. SLN mapping was successful in 98% of patients with an average of 1.7 SLNs per patient. SLNs were negative in 63% of the patients and positive in 37% of the patients. Skip metastasis was seen in 8 of the patients. Occult micrometastasis was found in 14% of patients. In 5% of the patients, unusual lymphatic drainage lead to an alteration of the extent of lymphadenectomy. This multicenter trial proved that SLN mapping in patients with colorectal cancer is simple, cost effective, and upstages at least 14% of patients from AJCC stage I/II to stage III. These patients may then benefit from adjuvant chemotherapy.

Molecular staging of early colon cancer on the basis of sentinel node analysis: a multicenter phase II trial

PURPOSE

Approximately 30% of patients with American Joint Committee on Cancer stage I or II colorectal cancer (CRC) develop systemic disease. We hypothesized that multimarker reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of sentinel lymph nodes (SNs) draining a primary CRC could detect micrometastases not detected by conventional histopathologic analysis.

PATIENTS AND METHODS

In a multi-institutional study, 40 patients with primary CRC underwent dye-directed lymphatic mapping at the time of colon resection. Each dye-stained SN was tagged, and the tumor and regional nodes were resected en bloc. All lymph nodes were examined by conventional hematoxylin and eosin (HE) staining. In addition, each SN was cut into multiple sections for cytokeratin immunohistochemical (CK-IHC) staining and for RT-PCR and electrochemiluminescent detection of three markers: beta-chain human chorionic gonadotropin, hepatocyte growth factor receptor, and universal melanoma-associated antigen. Whenever possible, RT-PCR assay was also performed on primary tumor tissue. The detection sensitivity of individual markers was 10(-3) to 10(-4) microg of RNA and one to five tumor cells in 10(7) lymphocytes of healthy donors.

RESULTS

One to three SNs were identified in each patient. An average of 15 nodes were removed from each CRC specimen. No nonsentinel (untagged) node contained evidence of tumor if all tagged (sentinel) nodes in the same specimen were histopathology tumor-negative. HE staining of SNs identified tumor in 10 patients (25%), and CK-IHC of SNs identified occult micrometastases in four patients (10%) whose SNs were negative by HE. Of the remaining 26 patients with no evidence of SN involvement by HE or CK-IHC, 12 (46%) had positive RT-PCR results. The number of markers expressed in each SN correlated (P <.04) with the T stage of the primary tumor. There was 79% concordance in marker expression for the respective pairs (n = 38) of primary tumor and histopathologically positive SNs, and 86% (12 of 14) concordance between RT-PCR positive and histopathologically positive SNs.

CONCLUSION

Identification and focused examination of the SN is a novel method of staging CRC. CK-IHC and RT-PCR identified occult micrometastases in 53% of patients whose SNs were negative by conventional staging techniques. These ultrasensitive assays of the SN can identify patients who may be at high risk for recurrence of CRC and therefore are more likely to benefit from systemic adjuvant therapy.

General traits of personality and affectivity as predictors of satisfaction in intimate relationships: evidence from self- and partner-ratings

Self- and partner-ratings on trait affect and the Big Five were obtained from 74 married and 136 dating couples. The relationship satisfaction of each person (the "target") was correlated with four sets of ratings: (a) target's self-rated personality, (b) target's partner-rated personality, (c) partner's self-rated personality, and (d) partner's target-rated personality. Self- and partner-ratings of the target's personality yielded very similar results. Negative and positive affectivity were consistent predictors of satisfaction in both samples. Conscientiousness and agreeableness were reliably related to satisfaction in the dating couples, whereas extraversion consistently correlated with satisfaction in the married couples. These traits jointly predicted as much as 34% (self-ratings) and 26% (partner-ratings) of the variance in satisfaction. In contrast, the partner's personality played a lesser role in satisfaction.

Self-other agreement in personality and affectivity: the role of acquaintanceship, trait visibility, and assumed similarity

Self- and other-ratings on the Big Five and a comprehensive inventory of trait affect were obtained from 74 married couples, 136 dating couples, and 279 friendship dyads. With the exception of Surprise, all scales showed significant self-other agreement in all 3 samples, thereby establishing their convergent validity. Consistent with the trait visibility effect, however, the Big Five consistently yielded higher agreement correlations than did the affectivity scales. Conversely, the affective traits consistently showed stronger evidence of assumed similarity (i.e., the tendency for judges to rate others as similar to themselves) than did the Big Five. Cross-sample comparisons indicated that agreement was significantly higher in the married sample than in the other 2 groups; however, analyses of 3 potential moderators in the dating and friendship samples failed to identify the source of this acquaintanceship effect.

Self-other agreement in personality and affectivity: the role of acquaintanceship, trait visibility, and assumed similarity

Self- and other-ratings on the Big Five and a comprehensive inventory of trait affect were obtained from 74 married couples, 136 dating couples, and 279 friendship dyads. With the exception of Surprise, all scales showed significant self-other agreement in all 3 samples, thereby establishing their convergent validity. Consistent with the trait visibility effect, however, the Big Five consistently yielded higher agreement correlations than did the affectivity scales. Conversely, the affective traits consistently showed stronger evidence of assumed similarity (i.e., the tendency for judges to rate others as similar to themselves) than did the Big Five. Cross-sample comparisons indicated that agreement was significantly higher in the married sample than in the other 2 groups; however, analyses of 3 potential moderators in the dating and friendship samples failed to identify the source of this acquaintanceship effect.

Technical details of sentinel lymph node mapping in colorectal cancer and its impact on staging

BACKGROUND

Sentinel lymph node (SLN) mapping for melanoma and breast cancer has greatly enhanced the identification of micrometastases in many patients, thereby upstaging a subset of these patients. The purpose of this study was to see if SLN mapping technique could be used to identify SLNs in colorectal cancer and to assess its impact on pathological staging and treatment.

METHODS

At the time of surgery, 1 ml of Lymphazurin 1% was injected subserosally around the tumor without injecting into the lumen. The first to fourth blue nodes identified were considered the SLNs, which have the highest probability to contain metastases. A standard oncological resection of the bowel was then performed. Multilevel microsections of the SLNs, including a detailed pathological examination of the entire specimen, was performed.

RESULTS

SLN was successfully identified in 85 (98.8%) of 86 patients. In 85 patients, there were 1,367 (16 per patient) lymph nodes examined, of which 140 (1.6 per patient) were identified as SLNs. In 53 (95%) of 56, of whom the SLNs were without metastases (negative), all other non-SLNs also were negative. In 29 (34% of 85) patients, SLNs were positive for metastases; in 14 of the 29 patients, other non-SLNs also were positive in addition to the SLNs. In the other 15 of the 29 patients (18% of 85 patients), SLNs were the only site of metastases, and all other non-SLNs were negative. In 7 patients (8.2% of 85 patients), micrometastases were identified only in 1 or 2 of the 10 sections of a single SLN. In five of seven patients, such micrometastases were detected by hematoxylin and eosin staining and immunohistochemistry; in the other two patients, it was detected only by immunohistochemistry. In patients with negative SLNs, the rate of occurrence of micrometastases in non-SLNs was 5 (0.4%) of 1,184 lymph nodes.

CONCLUSIONS

SLN mapping can be performed easily in colorectal cancer patients, with an accuracy of more than 95%. The identification of submicroscopic lymph node metastases by this technique may have upstaged these patients (18%) from stage I/II to stage III disease, who may then benefit from further adjuvant chemotherapy.

Low-dose methotrexate treatment for interstitial pregnancy. A case report

BACKGROUND

Only a small number of case reports have described medical treatment of interstitial ectopic pregnancies. Almost all of the reported patients were treated with repeated high doses (1 mg/kg) of methotrexate.

CASE

At 6 weeks of gestation, a 31-year-old woman, gravida 5, para 4, was diagnosed with a 0.96 x 1.36-cm right cornual pregnancy. As the patient desired future fertility, she received 100 mg of intramuscular methotrexate (50 mg/m2). She was then followed on an outpatient basis, with serum human chorionic gonadotropin values appropriately declining. Serial ultrasound also showed decreasing size of the gestational sac. Twenty-one days after the methotrexate dose, the patient experienced rupture of the right posterior cornu, necessitating exploratory laparotomy.

CONCLUSION

Extreme caution should be used when treating interstitial gestations with single-dose methotrexate. All patients should be extensively counseled regarding the significantly increased risk of failure, possibility of rupture and need for emergency surgery.

Appendiceal endometriosis presenting as massive lower intestinal hemorrhage

Appendiceal endometriosis is a very uncommon clinical entity. We describe a 33-yr-old white female who presented with painless profuse rectal bleeding. Emergency colonoscopy revealed bleeding from the appendiceal opening. An emergency appendectomy was performed which controlled her bleeding. The histopathological examination demonstrated appendiceal endometriosis. Painless bleeding from appendiceal endometriosis is extremely rare; however, it should be considered when evaluating young women of reproductive age who present with rectal bleeding.

Orientation of small, flat, frozen-section specimens

A method for orienting small, flat, frozen-section specimens perpendicular to the plane of sectioning can be performed by double-embedding and freezing. The technique is fast, simple, and reliable; it requires no special equipment.