Local Control and Survival After Induction Chemotherapy and Ablative Radiation Versus Resection for Pancreatic Ductal Adenocarcinoma With Vascular Involvement

OBJECTIVE

We sought to compare overall survival (OS) and disease control for patients with localized pancreatic ductal adenocarcinoma (PDAC) treated with ablative dose radiotherapy (A-RT) versus resection.

SUMMARY BACKGROUND DATA

Locoregional treatment for PDAC includes resection when possible or palliative RT. A-RT may offer durable tumor control and encouraging survival.

METHODS

This was a single-institution retrospective analysis of patients with PDAC treated with induction chemotherapy followed by A-RT [≥98 Gy biologically effective dose (BED) using 15-25 fractions in 3-4.5 Gy/fraction] or pancreatectomy.

RESULTS

One hundred and four patients received A-RT (49.8%) and 105 (50.2%) underwent resection. Patients receiving A-RT had larger median tumor size after induction chemotherapy [3.2 cm (undetectable-10.9) vs 2.6 cm (undetectable-10.7), P < 0.001], and were more likely to have celiac or hepatic artery encasement (48.1% vs 11.4%, P <0.001), or superior mesenteric artery encasement (43.3% vs 9.5%, P < 0.001); however, there was no difference in the degree of SMV/PV involvement (P = 0.123). There was no difference in locoregional recurrence/progression at 18-months between A-RT and resection; cumulative incidence was 16% [(95% confidence interval (CI) 10%-24%] versus 21% (95% CI 14%-30%), respectively (P= 0.252). However, patients receiving A-RT had a 19% higher 18-month cumulative incidence of distant recurrence/progression [58% (95% CI 48%-67%) vs 30% (95% CI 30%-49%), P= 0.004]. Median OS from completion of chemotherapy was 20.1 months for A-RT patients (95% CI 16.4-23.1 months) versus 32.9 months (95% CI 29.7-42.3 months) for resected patients (P < 0.001).

CONCLUSION

Ablative radiation is a promising new treatment option for PDAC, offering locoregional disease control similar to that associated with resection and encouraging survival.

Tumor Size Affects Efficacy of Adjuvant Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma and Microvascular Invasion

BACKGROUND

Patients with hepatocellular carcinoma (HCC) and microvascular invasion (mVI) have shown dismal postoperative prognosis; however, whether adjuvant transarterial chemoembolization (TACE) can improve their outcomes remains unclear.

MATERIALS AND METHODS

We retrospectively identified 549 eligible patients to form the crude cohort and adopted propensity score matching method to assemble another cohort of 444 patients with similar baseline characteristics. We assessed the effects of adjuvant TACE by stratified analyses and multivariate Cox analyses in two cohorts.

RESULTS

There was significant interaction between tumor size and adjuvant TACE with respect to overall survival (OS; p = .006 for interaction). In the matched cohort, patients who received adjuvant TACE showed higher rates of 5-year OS (72.4% vs. 50.9%, p = .005) and 5-year recurrence-free survival (50.5% vs. 36.4%, p = .003) in the tumor ≤5 cm subgroup, but not in the tumor >5 cm subgroup (32.3% vs. 24.9%, p = .350 and 18.8% vs. 19.7%, p = .180). The independent protective role of adjuvant TACE on OS was observed in patients with tumor ≤5 cm (adjusted odds ratio [OR] = 0.59, 95% confidence interval [CI] 0.36-0.97) but not in patients with tumor >5 cm (adjusted OR = 1.17, 95% CI 0.84-1.62). The effects of adjuvant TACE did not change materially while the analysis was performed in the crude cohort.

CONCLUSION

For patients with HCC and mVI, adjuvant TACE was associated with improved outcomes, but not for those with tumor >5 cm, according to the current protocol.

IMPLICATIONS FOR PRACTICE

The outcomes of patients with hepatocellular carcinoma and microvascular invasion who received adjuvant transarterial chemoembolization were inconsistent in this study. According to the current protocol, adjuvant transarterial chemoembolization was associated with improved prognosis in patients with microvascular invasion, except for those with tumor >5 cm. Multivariate Cox models confirmed adjuvant transarterial chemoembolization was an independent protective factor in the tumor ≤5 cm subgroup but not in the tumor >5 cm subgroup.

Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer

BACKGROUND

Lateral nodal disease in rectal cancer remains a subject of debate and is treated differently in the East and the West. The predictive value of lateral lymph node and MRI-detected extramural vascular invasion (mrEMVI) features on oncological outcomes was assessed in this study.

METHODS

In this retrospective cohort study, data on patients with cT3-4 rectal cancer within 8 cm from the anal verge were considered over a 5-year period (2009-2013). Lateral lymph node size, malignant features and mrEMVI features were evaluated and related to oncological outcomes.

RESULTS

In total, 192 patients were studied, of whom 30 (15·6 per cent) underwent short-course radiotherapy and 145 (75·5 per cent) received chemoradiotherapy. A lateral lymph node short-axis size of 10 mm or more was associated with a significantly higher 5-year lateral/presacral local recurrence rate of 37 per cent, compared with 7·7 per cent in nodes smaller than 10 mm (P = 0·041). Enlarged nodes did not result in a higher 5-year rate of distant metastasis (23 per cent versus 27·7 per cent in nodes smaller than 10 mm; P = 0·563). However, mrEMVI positivity was related to more metastatic disease (5-year rate 43 versus 26·3 per cent in the mrEMVI-negative group; P = 0·014), but not with increased lateral/presacral recurrence. mrEMVI occurred in 46·6 per cent of patients with nodes smaller than 10 mm, compared with 29 per cent in patients with nodes of 10 mm or larger (P = 0·267).

CONCLUSION

Although lateral nodal disease is more a local problem, mrEMVI mainly predicts distant recurrence. The results of this study showed an unacceptably high local recurrence rate in patients with a short axis of 10 mm or more, despite neoadjuvant (chemo)radiotherapy.

[ANALYSIS OF COMPLICATIONS POSTOPERATIVE CAUSES AND MORTALITY AFTER RADICAL TREATMENT FOR TUMORS OF THE LEFT ANATOMICAL SEGMENT OF THE PANCREAS]

Radical surgery for tumors of the left anatomical and surgical segment of the pancreas proved for distal resection in various versions, central resection and enucleation of tumors. The causes of early postoperative complications and mortality in 129 patients aged from 14 to 81 years, operated on for neoplastic lesions of the left anatomical segment of the pancreas in the period from 2009 to 2014 were analysed. The influence of various factors of risk of complications and mortality were studied in particular, extended resection, for tumor invasion of adjacent organs, and adjacent vessels.

Vascular invasion, but not lymphatic invasion, of the primary tumor is a strong prognostic factor in patients with colorectal cancer

BACKGROUND

We previously showed that the presence of vascular invasion, but not lymphatic invasion, was a strong prognostic factor for breast cancer. Lymphatic invasion may represent mainly the selective affinity of cancer cells for lymph nodes. The present study was undertaken to evaluate the presence of vascular invasion that may reflect systemic disease as a predictor of disease recurrence in colorectal cancer, separate from lymphatic invasion of the primary tumor.

PATIENTS AND METHODS

We retrospectively evaluated the cases of 177 consecutive patients with primary colorectal cancer who underwent colorectal resection. We examined the relationship between recurrence and the prognostic significance of clinicopathological factors, particularly lymphatic and vascular invasion.

RESULTS

The presence of vascular invasion (v) was significant, while that of lymphatic invasion (ly) was not significant in univariate analysis. The presence of vascular invasion was an independent prognostic factor in multivariate analysis. Among the 60 patients in the ly-/v- group, one (1.7%) had disease recurrence, and among the 33 patients in the ly+/v- group, one (3.0%) had disease recurrence. On the other hand, among the 71 patients in the ly+/v+ group, 16 patients (22.5%) suffered recurrence, and among the 13 patients in the ly-/v+ group, four (30.8%) suffered recurrence. It is interesting to note that despite the presence of lymphatic invasion, the group without vascular invasion (ly+/v-) had a few patients with distant metastases, a result which is similar to that of the ly-/v- group.

CONCLUSION

The presence of vascular invasion, but not lymphatic invasion, could be an indicator of high biological aggressiveness and may be a strong prognostic factor for colorectal cancer.

Pulmonary artery intimal sarcoma. Problems in the differential diagnosis

PURPOSE

Pulmonary artery sarcomas (PAS) are rare malignant tumours that originate from the intimal layer of the pulmonary artery, occur in middle age and have a poor prognosis. In planning appropriate treatment, malignant disease should be suspected whenever there are specific clinical and radiological manifestations, in order to establish the differential diagnosis with acute pulmonary embolism or chronic thromboembolic pulmonary hypertension, with which this malignancy is most commonly confused.

MATERIALS AND METHODS

Between 2008 and 2012, we managed four adult patients with a nonspecific clinical presentation who, at the conclusion of the diagnostic process, were found to be affected by PAS. Because of the initial suspicion of pulmonary embolism, all patients underwent chest radiograph, lung perfusion scintigraphy, trans-oesophageal echocardiography, and computed tomography (CT) angiography of the chest. Then, because of the peculiar CT findings and lack of response to anticoagulation therapy, a clinical suspicion of PAS was considered and all patients underwent positron-emission tomography (PET)-CT, and one patient also magnetic resonance imaging (MRI) of the chest. Subsequently, all patients underwent thromboendoarterectomy with histological investigation of the surgical specimen, which confirmed the clinical and radiological suspicion of PAS.

RESULTS

CT is the technique that enabled the first step in the differential diagnosis between PAS and pulmonary embolism. The CT characteristics suggestive of PAS included the particular filling defect occupying the entire lumen of the pulmonary trunk with increase in diameter of the involved vessel and patchy and delayed contrast enhancement at CT angiography, more evident in the venous phase. PET-CT was used to differentiate between PAS and pulmonary embolism on the basis of the intensity of increased radiopharmaceutical uptake. MRI was used in one case of equivocal results on PET-CT, to improve tissue characterisation of the lesions and differentiation between the thrombotic and neoplastic components.

CONCLUSIONS

The radiologist is usually the first to raise a suspicion of PAS in patients with severe dyspnoea and filling defect in the pulmonary artery, unresponsive to anticoagulation therapy. Combining CT and PET-CT proved to be extremely useful in assessing patients with suspected PAS. Early diagnosis with the help of integrated imaging remains today the main direction to pursue in order to obtain improvements in prognosis.

Primitive retroperitoneal tumors. Vascular involvement--a major prognostic factor

Primitive retroperitoneal tumors, although very rare, arouse an increased interest, because of the poor prognosis, unsatisfactory surgical and complementary therapy results. Up to now, the very low number of cases has impeded the acquisition of a unitary view of these tumors, a unanimously accepted algorithm of diagnostic and treatment being absent. Randomized trials regarding the effects of different therapies have not been possible. The main factor that can fundamentally increase the survival of these patients is radical resection, some authors even recommending compartmental surgery. We found no significant statistical difference between the survival rates of the patients with different types of non-radical interventions, that shoud be therefore, as much as possible, avoided. Our study evidences that vascular involvement is the main limiting factor in achieving radicality. The involvement of large retroperitoneal vessels makes often impossible a radical intervention, usually because of the lack of an adequate material and human endowment for ample vascular resections followed by laborious reconstructions. That is why, in our study, vascular involvement was associated with a decreased survival rate for operated patients. Therefore, we underline the necessity both of a solid material base and of establishing multidisciplinary surgical teams for adequate vascular interventions in oncologic general surgery.

Surgical treatment of pulmonary artery leiomyosarcoma: a good survival without adjuvant therapy

Primary pulmonary artery leiomyosarcoma is a rare tumor that can be misdiagnosed as acute or chronic pulmonary thromboembolic disease. In this report, we present a case of a 58-year-old woman initially diagnosed with chronic thromboembolic pulmonary disease, but who was later found to have pulmonary artery leiomyosarcoma. A complete mass resection was performed surgically. The definitive pathologic examination was consistent with pulmonary artery leiomyosarcoma. Although the patient did not receive adjuvant therapy after the surgery, she had a good outcome and was free of disease 8 months after surgery.

[Surgical treatment of leiomyosarcoma of the inferior vena cava]

The presented review of the literature is generalization of the currently existing data of foreign and Russian literature concerning treatment of a rare non-organic retroperitoneal tumour from smooth-muscle tissue, i. e., leiomyosarcoma of the inferior vena cava. The authors also formulate and lay down the basic principles of surgical interventions depending on the scope and level of the lesion, as well statistical analysis of the outcomes of surgical management of the this severely ill patient cohort.

A stepwise algorithm for the surgical resection of a hyper-nephroma involving the inferior vena cava

INTRODUCTION

Techniques for the resection of renal tumours (RT) with extension to the inferior vena cava (IVC) are based on the experience of individual units. We attempt to provide a logical approach to the surgical strategies in a stepwise fashion.

METHODS

Over 6 years, 9 patients with RT invading the IVC underwent surgery. There were 6 males. The extension was at level IV in 3 and III in 6 cases. Cardiopulmonary bypass was used in 7 and hypothermia and circulatory arrest in 2 patients with level IV disease. The results and an algorithm of the plan of action in relation to the level of extension are presented.

RESULTS

Regarding postoperative morbidity, inotropic support was needed in 5 patients, a prolonged ICU stay in 3 (33.3%), tracheostomy in 1 (11.1%). Methicillin-resistant Staphylococcus aureus infection occurred in 1, sepsis in 2, cerebrovascular accident in 1. There were 2 deaths (22.2%). For level I-II disease there was no cardiothoracic involvement. For level III we used cardiopulmonary bypass and control of the cavo-atrial junction. For level IV or suboptimal thrombectomy of level III disease, we used brief periods of circulatory arrest and repair of the cavotomy with a pericardial patch.

CONCLUSIONS

Total clearance of the IVC from an adherent tumour is important for prognosis, therefore extensive level III and IV disease presents a surgical challenge. We recommend cardiopulmonary bypass for level III and brief periods of total circulatory arrest for level IV disease.

Microvessel density and VEGF/VEGF receptor status and their role in sarcomas of the pulmonary artery

Neoangiogenesis, driven by a variety of angiogenic factors, plays an essential role during development and progression of malignant tumors. Vascular endothelial growth factor (VEGF) and its receptors have been designated a central part in the angiogenic process during malignancy. We studied the vascular parameters by means of morphology and morphometry in 7 sarcomas of the pulmonary artery (SPA) and 10 poorly differentiated leiomyosarcomas of soft tissue. Immunohistochemical analysis of VEGF and VEGFR was related to survival and prognosis. The microvessel density (MVD) and intervascular distances (IVD) differed significantly only at sites of necrosis compared to non-necrotic areas in SPA but not for soft tissue leiomyosarcomas. MVD, IVD and vascular surface area (VSA) revealed no difference between SPA and leiomyosarcomas of different origin. We found a more pronounced expression of VEGF in most tumors at sites of necrosis. The receptors were present in a subset of tumor vessels mostly at the tumor border. VEGFR-2 expression was also seen in a subset of tumor cells whereas VEGFR-1 showed only weak expression in some tumors. Local hypoxia seems to induce a higher MVD and a lower IVD at sites of necrosis compared to those areas without necrosis. The presence of necrosis in both sarcoma groups was correlated with the presence of VEGF due to local tumor hypoxia and subsequent up-regulation of VEGFR-2 and VEGFR-1 in tumor vessels as well as tumor cells. Overall and relapse-free survival showed no difference concerning all examined parameters. Thus, microvessel density does not seem to be a prognostic factor in SPA and other sarcomas.

Leiomyosarcoma of the inferior vena cava: survival after aggressive management

BACKGROUND

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is exceedingly rare. The role of adjuvant therapy remains undefined. This study evaluated outcomes after aggressive management.

METHODS

Records on 20 patients undergoing surgery for IVC LMS between January 1990 and April 2006 were retrieved. Histology was confirmed upon re-review. Most patients received perioperative chemotherapy (CT), radiation therapy (RT), or both (CRT). Disease-free and overall survival (DFS, OS) rates were calculated using the Kaplan-Meier method.

RESULTS

Twenty patients (60% women, median age 57 years) with primary IVC LMS were treated with curative intent. Median follow-up was 41 months. All patients underwent resection of the primary tumor; one was found to have unresectable liver metastases. The IVC was managed with ligation (3), primary repair (12), or prosthetic graft (5). Additional organs were resected in 14 (70%) patients. Chemotherapy and/or RT were administered to 9 (45%) patients preoperatively (CT 2, RT 6, CRT 1) and 8 (40%) postoperatively (CT 4, RT 1, CRT 3). Median DFS was 21 months. Of 13 (68%) patients who developed recurrence, 4 underwent surgery, and 11 received CT. Median OS for 19 patients who underwent complete resection was 71 months. Tumor size was associated with disease recurrence (P = .004). No variables were prognostic for OS.

CONCLUSIONS

Patients with IVC LMS treated with curative intent develop early recurrent disease. Nevertheless, long-term OS can be achieved even in the setting of metastatic disease. The independent impact of perioperative CT, RT, or CRT treatments cannot be adequately determined.

Significance of the depth of portal vein wall invasion after curative resection for pancreatic adenocarcinoma

HYPOTHESIS

The depth of portal vein (PV) wall invasion is a prognostic factor for survival after curative pancreatic resection for pancreatic ductal adenocarcinoma.

DESIGN

Retrospective clinical study.

SETTING

Department of digestive surgery and transplantation.

PATIENTS

From January 1, 1990, through December 31, 2002, 121 patients underwent a curative pancreatic resection for ductal adenocarcinoma of the pancreas. Among these, 37 pancreatic resections combined with PV resection were performed.

MAIN OUTCOME MEASURES

Prognostic factors for survival and predictive factors for the depth of PV wall invasion.

RESULTS

The morbidity and mortality rates did not differ between patients undergoing or not undergoing PV resection (32.4% and 2.7% [1/37], respectively, vs 38.1% and 2.4% [2/84], respectively). The 3-year survival rate after curative pancreatic resection was significantly associated with the depth of PV wall invasion. Indeed, the 3-year overall survival rate was similar for patients with no PV invasion and those with superficial invasion into the tunica adventitia (40.0% vs 32.9%, respectively; P = .85). Deeper PV wall invasion into the tunica media or the tunica intima was associated with a poorer 1-year survival rate similar to that of patients undergoing noncurative resection (21.5% vs 34.4%, respectively; P = .53). Multivariate analysis showed that the depth of PV wall invasion, number of involved lymph nodes, and volume of blood transfusion were independent factors of overall and disease-free survival. Tumor size of 45 mm or more (evaluated by computed tomography) and angiographic type C or D on a portogram were significantly correlated with the depth of PV wall invasion. Patients presenting with both factors simultaneously had poor survival.

CONCLUSIONS

The depth of PV wall invasion significantly alters survival after curative pancreatic resection combined with PV resection. However, occasional long-term survival could be observed after curative resection in patients with deep PV wall invasion.

[Hepatic and the portal vein resection in the surgical treatment of hepatocellular carcinoma]

Modern problems of the portal vein resection while hepatectomy performance are enlighted. Indications for resection of the portal vein bifurcation zone are adduced, various methods of portoplasty are depicted. New methods of the portal vein passability restoration in disparity of its sutured parts diameters are proposed. The results of hepatectomy combined with portal vein resection are studied.

Surgical Experience for the Pulmonary Artery Sarcoma

BACKGROUND

Pulmonary sarcoma arising from the pulmonary artery is a rare disease and its prognosis is disastrous.

METHODS

Five patients who underwent surgery for pulmonary artery sarcoma were reviewed.

RESULTS

All patients except one were initially diagnosed with pulmonary embolism. One patient with preoperative profound shock could not wean from cardiopulmonary bypass. Two patients are still surviving for 36 and 30 months, respectively.

CONCLUSIONS

Early diagnosis and complete surgical resection is perhaps the best way to improve patients with pulmonary artery sarcoma.

Intravascular lymphoma: a neoplasm of 'homeless' lymphocytes?

Intravascular lymphoma (IVL) is an extremely rare form of non-Hodgkin lymphoma characterized by almost exclusive growth of neoplastic lymphocytes within blood vessel lumen. IVL is morphologically characterized in most instances by large cells with B-cell lineage. IVL is an aggressive and usually disseminated disease that predominantly affects elderly patients, resulting in poor PS, B-symptoms, anemia, and high lactate dehydrogenase serum level. The brain and skin are the most commonly involved sites; nodal disease is rare. Survival after conventional chemotherapy is disappointing, with a relevant impact of diagnostic delay and lethal complications. Notwithstanding these results, IVL limited to the skin (cutaneous variant) is a favorable presentation with distinctive clinical characteristics. Moreover, differences in clinical presentation with Eastern Countries IVL cases, mostly associated with hemophagocytic syndrome, do exist. Intensive combinations containing drugs with higher central nervous system bioavailability are needed in cases with brain involvement; the role of high-dose chemotherapy with autologous stem cell transplantation should be investigated in younger patients with unfavorable features. The present review will discuss the most recent acquisitions related either to diagnosis and immunophenotypic/biologic characteristics as well as clinical/therapeutic issues of IVL.

Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement

PURPOSE

The study was conducted to evaluate the clinical results of resection for retroperitoneal soft tissue sarcoma (STS) with vascular involvement.

METHODS

The study group consisted of consecutive patients (mean age, 52 years) who underwent surgery for retroperitoneal STS with vascular involvement. The procedures were performed between 1988 and 2004. Vessel involvement by STS was classified as type I, artery and vein; type II, only artery; type III, only vein; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database and retrospectively analyzed.

RESULTS

Of 141 patients with retroperitoneal STS, 25 (17.7%) underwent surgery for tumors with vascular involvement. The most common vascular involvement pattern was vein only (type III) at 64%. Arterial and vein (type I) and arterial only (type II) involvement were observed in 16% and 20% of the cases, respectively. STS originating from the vessel wall (primary vessel involvement) was seen in eight patients, and 17 patients had secondary vascular involvement. Resection and vascular repair were done in 22 patients (no vascular repair in three patients due to ligation of the external iliac vein in one patient, and debulking procedures in two). All patients with arterial involvement (type I and II) had arterial reconstruction consisting of aortic replacement (Dacron, n = 3; and expanded polytetrafluoroethylene [ePTFE], n = 2), iliac repair (Dacron, n = 3), and truncal reimplantation (n = 1). The inferior vena cava (6 ePTFE tube grafts, 3 ePTFE patches, 2 venoplasties), iliac vein (1 ePTFE bypass, 1 Dacron bypass, 1 venous patch), and superior mesenteric vein (1 anastomosis, 1 Dacron bypass) were restored in 80% of the patients (n = 16) with either arterial and venous or only venous involvement (type I and type III setting). Morbidity was 36% (hemorrhage, others), and mortality was 4%. At a median follow-up of 19.3 months (interquartile range, 12.8 to 49.9 months) the arterial patency rate was 88.9%, and the venous patency rate was 93.8% (primary and secondary). Thrombosis developed in one arterial and venous (type I) iliac reconstruction due to a perforated sigmoid diverticulitis 12 months after surgery. The local control rate was 82.4%. The 2-year and 5-year survival rates were 90% and 66.7% after complete resection with tumor-free resection margins (n = 10 patients, median survival not reached at latest follow-up). The median survival was 21 months in patients with complete resection but positive resection margins (n = 7) and 8 months in patients with incomplete tumor clearance (n = 8, persistent local disease or metastasis).

CONCLUSIONS

Patency rates and an acceptable surgical risk underline the value of en bloc resection of retroperitoneal STS together with involvement of blood vessels. The oncologic outcome is positive, especially after complete resection with tumor-free resection margins. A classification of vascular involvement can be used to plan resection and vascular replacement as well as to compare results among reports in a standardized fashion.

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

BACKGROUND

Tumour clearance during pancreatectomy may be facilitated by resection of the portal-superior mesenteric vein, but this is associated with increased perioperative risk. There is no consensus about which patients benefit from portal-superior mesenteric vein resection.

METHODS

A systematic appraisal was carried out of the literature on portal-superior mesenteric vein resection during pancreatectomy to identify recurrent themes to guide management. A computerized search of the Medline and Embase databases found 52 non-duplicated studies providing relevant data in 1646 patients. Pooled data were examined for information on outcome categories relating to operation, complications, histopathology and overall outcome.

RESULTS

The median (range) number of patients with portal-superior mesenteric vein resection per cohort was 23 (4-172). Median operating time was 513 (168-1740) min and blood loss 1750 (300-26000) ml. Postoperative morbidity ranged from 9 to 78 per cent with a median per cohort of 42 per cent. There were 73 perioperative deaths (5.9 per cent of 1235 for whom mortality data were provided). Median survival was 13 months, and 1-, 3- and 5-year survival rates were 50, 16 and 7 per cent respectively. Specimen histopathology confirmed positive nodes in 67.4 per cent.

CONCLUSIONS

This is the largest collective report to date on portal-superior mesenteric vein resection in pancreatectomy. The high rate of nodal metastases and low 5-year survival rates suggest that by the time of tumour involvement of the portal vein cure is unlikely, even with radical resection.

[Resection for lung cancer invading the superior vena cava]

OBJECTIVE

To analyze the feasibility and the value of resection for lung cancer invading the superior vena cava (SVC).

METHODS

Between 1988 and 2005 the data of 31 patients who underwent resection were analyzed retrospectively. The reconstruction was done using simple suture, pericardial patch or prosthetic replacement. Postoperative morbidity, long-term survival were examined using the Kaplan-Meier method (Log rank test) and the COX model for survival.

RESULTS

Seventeen squamous cell carcinomas, 8 adenocarcinomas, and 6 undifferentiated small cell carcinomas were resected. There were 13 partial SVC resection, the reconstruction was done using a simple running in 5 patients, and a pericardial patch in 8 patients. Eighteen patients underwent complete resection of SVC with prosthetic replacement. The time of clamping the SVC system was from 8 to 35 minutes for complete resection patients, while the time was from 3 to 15 minutes for partial resection patients. One patient didn't clamp the SVC. Postoperative morbidity and mortality were 48% and 0%, respectively. One, 3 and 5-year survival rates were 61%, 33% and 21%, respectively, with median survival at 31 months. Survival rate of patients with N2 disease was obviously lower than those with localized (N0/N1) nodal disease (chi2 = 14.3, P = 0.000), the median survival was 42 and 13 months respectively. There were no significant effects on overall survival with pathologic features and surgery methods. Survival rate of patients with induction chemotherapy before operation or intraoperative chemotherapy was higher than those received direct surgery (chi2 = 5.0, P = 0.025), the median survival was 39 and 14 months respectively.

CONCLUSIONS

The resection of the SVC for involvement by lung cancer can be performed in selected patients, especially for those with localized (N0/N1) nodal disease. Induction chemotherapy should be performed.

Adolescent melanoma: Risk factors and long term survival

AIMS

To report the adolescent melanomas with focus on differences in clinical characteristics, prognostic factors, disease free (DFS) and overall survival (OS) in comparison with adults.

METHODS

A single institution retrospective study in which 49 adolescent patients were compared to an adult group of 972 patients. The 10-year DFS, 10-year OS and prognostic factors were calculated for both groups.

RESULTS

The median age for the adolescent patients was 17 (range 12-19) years and 49 (range 20-93) years for the adult patients. Median follow-up time was 92 (range 4-366) months. Adolescent patients presented more often with locally advanced melanoma (p<0.01). The median Breslow thickness was 1.6 vs 2.0mm for the adults (p=0.075). Increasing age, ulceration, Breslow thickness, tumour location, male gender and stage at diagnosis were calculated to be negative prognostic factors for the adult group. In the adolescent group, only the stage at diagnosis was a significant negative predictor. The 10-year DFS and OS for the adolescent patients and adult group were not significantly different regarding AJCC stages I-III.

CONCLUSION

Although adolescent patients presented more often with locally advanced disease, there are no significant differences in the 10-year DFS and OS between adolescent and adult patients. In our series, we could not confirm the prognostic factors found in the adult group for the adolescent patients, except for the stage at diagnosis.

Intravascular Lymphomatosis: A Study of 20 Cases in Thailand and a Review of the Literature

BACKGROUND

According to the World Health Organization classification (2001), intravascular large B-cell lymphoma (IVLBCL) is characterized by the presence of lymphoma cells only in the lumina of small vessels. It has not been proven whether IVLBCL is a specific clinicopathologic entity. Intravascular large B-cell lymphoma and other intravascular lymphomatoses (IVLs), including IVL with B-cell phenotype and extravascular growth (B-IVL) and IVL with T-cell phenotype (T-IVL), were compared in a series of cases diagnosed at a single institution and in cases reported in the literature.

PATIENTS AND METHODS

Twenty cases of IVL diagnosed among 1826 consecutive cases of non-Hodgkin's lymphoma (NHL,1.1%) at Siriraj Hospital included 3 cases of IVLBCL, 14 cases of B-IVL, and 3 cases of T-IVL. In the literature, 102 cases of IVLBCL, 88 cases of B-IVL, and 18 cases of T-IVL were described in sufficient detail to be analyzed.

RESULTS

All 3 groups were quite similar in clinical manifestations and outcome. Contrary to the previous review of 79 cases of IVL in 1989, blood, marrow, and nodal involvement could be detected in approximately 30% of cases. Patients who received chemotherapy had better survival than patients without treatment (statistically significant in IVLBCL and B-IVL; P < 0.05). Cases with skin involvement had better survival than cases without skin involvement (statistically significantly in T-IVL; P < 0.05).

CONCLUSION

These results indicate that IVLBCL is not different from B-IVL or T-IVL in a biologic sense, and IVL seems to be better terminology than IVLBCL because it includes the T-cell phenotype that constitutes approximately 9% of cases. Early diagnosis is very important because chemotherapy significantly prolongs survival.

Malignant vascular tumors: clinical presentation, surgical therapy, and long-term prognosis

BACKGROUND

The aim of this study was to analyze the presentation of, surgery for, and prognosis of malignant vascular tumors (MVTs).

METHODS

This was an observational single-center study. Patients who underwent operation for MVTs between 1988 and 2004 were included. Data were gathered prospectively in a computerized registry.

RESULTS

Of 568 adult patients with soft tissue malignancies, 43 (7.6%) were treated for MVTs. Twenty-four men and 19 women (median age, 55.3 years) were referred for 30 primary tumors and 13 recurrences. Symptoms were observed in 90.7% of the cases (swelling [37.2%], pain [34.9%], extrusion [11.6%], hemorrhage [7%], weight loss [4.7%], loss of energy [4.7%], impaired function [4.7%], and others [30.2%]). Tumors were located in the extremities (n = 16), trunk (n = 3), abdomen (n = 15), retroperitoneum (n = 7), and thyroid gland (n = 2). Twenty-two (51.2%) angiosarcomas, nine (20.9%) malignant hemangiopericytomas, eight (18.6%) malignant epithelioid hemangioendotheliomas, and four (9.3%) lymphangiosarcomas were seen. The median overall survival after surgery was 21.4 months, with 2-, 5-, and 10-year overall survival rates of 41.5%, 38.3%, and 18.8%, respectively. MVTs of the extremities and trunk and localized disease indicated a better prognosis than abdominal or retroperitoneal MVTs (univariate and multivariate analyses: P = .0122 and P = .0287) and metastasized stages (univariate and multivariate analyses: P = .0187 and P = .0287).

CONCLUSIONS

A considerable number of patients with soft tissue malignancies undergo surgery for MVT. Various symptoms and a multilocular occurrence are typical. The course of MVTs is aggressive. Tumor site and stage are important prognostic factors. Surgery is potentially curative, especially for localized disease of the extremities and trunk.

Results of limb-sparing surgery with vascular replacement for soft tissue sarcoma in the lower extremity

OBJECTIVE

To evaluate limb-salvage surgery with vascular resection for lower extremity soft tissue sarcomas (STS) in adult patients and to classify blood vessel involvement.

METHODS

Subjects were consecutive patients (median age, 56 years) who underwent vascular replacement during surgery of STS in the lower limb between January 1988 and December 2003. Blood vessel involvement by STS was classified as follows: type I, artery and vein; type II, artery only; type III, vein only; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database.

RESULTS

Twenty-one (9.9%) of 213 patients underwent vascular resections for lower limb STS. Besides 17 type I tumors (81.0%), 3 (14.3%) type II and 1 (4.7%) type III STS were diagnosed. Arterial reconstruction was performed for all type I and II tumors. Venous replacement in type I and III tumors was performed in 66.7% of patients. Autologous vein (n = 8) and synthetic (Dacron and expanded polytetrafluoroethylene; n = 12) bypasses were used with comparable frequency for arterial repair, whereas expanded polytetrafluoroethylene prostheses were implanted in veins. Morbidity was 57.2% (hematoma, thrombosis, and infection), and mortality was 5% (embolism). At a median follow-up of 34 months, the primary and secondary patency rates of arterial (venous) reconstructions were 58.3% (54.9%) and 78.3% (54.9%). Limb salvage was achieved in 94.1% of all cases. The 5-year local control rate and survival rate were 80.4% and 52%, respectively. We observed a 5-year metastasis-free survival rate of 37.7% and found vessel infiltration and higher tumor grade (low-grade vs intermediate grade and high grade tumors) to be negative prognostic factors at univariate and multivariate analysis.

CONCLUSIONS

Long-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of STS involving major vessels in the lower limb. Disease-specific morbidity must be anticipated. The classification of vascular involvement (type I to IV) is useful for surgical management.

[Resection and reconstruction of the retrohepatic vena cava in combination with liver resections]

Liver resection combined with the resection and reconstruction of the vena cava represents the only potential curative therapy for malignant hepatic tumors with invasion of the vena cava. We performed a liver resection with segmental replacement of the retrohepatic vena cava by synthetic grafts in 29 patients. In three cases, the additional presence of central involvement of all three hepatic veins required ex situ tumor resection. Four patients underwent a simultaneous exstirpation of the primary tumor (kidney or suprarenals). The remaining hepatic veins were reimplanted into the graft in three cases, and in two cases the renal veins were reimplanted. There was no perioperative mortality. A distal arteriovenous fistula was not applied. Five patients revealed postoperative transient liver insufficiency, requiring temporary dialysis in three cases. Two of these patients developed a transient multiorgan failure with the need of mechanical ventilation. 18 patients died during the course of follow-up, 17 of these cases due to recurrent metastases of the primary disease. Infection or thrombosis of the prosthetic vascular graft have not been observed. Beside tumor exstirpation, extended liver resection and concomitant vena cava replacement may prevent embolism as well as the obstruction of the vena cava with lower extremity swelling and the possibility of developing a Budd Chiari syndrome. We were able to achieve a long-term survival for surgically treated patients even in cases with advanced tumor stages.

Leiomyosarcoma of the Inferior Vena Cava: Surgical Management and Clinical Results

Leiomyosarcoma of the inferior vena cava (IVC) is a rare lesion with less than 300 cases reported. Optimal management and long-term outcomes are not well described. From August 1984 to June 2004, eight patients with leiomyosarcoma of the IVC were treated at our institution. Clinical and pathologic data, surgical management, and outcomes were assessed. Eight cases were identified (4 males) with a median age of 52 (range 29–66). Presenting symptoms included abdominal pain (n = 5, 63%), lower extremity edema (n = 2, 25%), and palpable mass (n = 2, 25%). Tumor location was between the renal and iliac veins (low) (n = 4, 50%), between the hepatic and renal veins (middle) (n = 3, 38%), and above the hepatic veins with right atrial extension (high) (n = 1, 12%). Two patients with preoperative IVC occlusion were managed with tumor excision and IVC ligation. Three patients had primary repair of the IVC after tumor excision. A polytetrafluorothylene (PTFE) tube graft was used for IVC reconstruction in three cases. There was no postoperative mortality. Postoperative morbidity included deep venous thrombosis (DVT) (n = 1), lower extremity edema (mild n = 1; moderate n = 1), GI bleed (n = 1), and chronic renal insufficiency (n = 1). One patient is currently receiving adjuvant chemotherapy. Four patients received chemotherapy after recurrence, and one received palliative radiation therapy as well. Median survival to this point was 60 months with a median follow-up of 39 months. The 5-year overall survival and disease-free survival was 31 per cent for both (CI 0.1–1.0). The type of IVC reconstruction had no effect on survival ( P = 0.22). Recurrence was discovered in four patients (50%) at a median time of 14 months. Resection of leiomyosarcoma of the IVC should be attempted whenever feasible. The management of the IVC can be managed with primary repair, ligation, or prosthetic graft. Long-term survival is possible if complete resection can be achieved.

Should the inferior vena cava be reconstructed after resection for malignant tumors?

BACKGROUND

Caval replacement after circumferential resection of the inferior vena cava remains controversial. The aim of the current study is to determine whether or not inferior vena cava replacement should be performed.

METHODS

We reviewed 36 cases undergoing resection of the inferior vena cava concomitant with resection of malignant neoplasms. Our criteria for circumferential resection of the inferior vena cava were half or more of the circumference of the vessel wall invaded by tumor, a primary tumor of the caval wall, or massive intraluminal tumor thrombus suspected of adhering to the caval wall. We detailed 10 patients undergoing circumferential resection of the inferior vena cava.

RESULTS

Most of patients who did not undergo replacement of the inferior vena cava showed no sign of swelling of the lower limbs, but one showed persistent leg edema with oliguria. This patient had poor development of collateral circulation and mild obstruction of the inferior vena cava before surgery. Two patients who underwent replacement of inferior vena cava had no venous sequelae, although they had poor development of collateral circulation before surgery.

CONCLUSION

Caval replacement after circumferential resection of the inferior vena cava may be necessary in patients who have preoperative poor development of collateral circulation or who have oliguria or unstable hemodynamics intraoperatively.

Prognostic value of lymphovascular invasion in transitional cell carcinoma of upper urinary tract

OBJECTIVES

To elucidate the prognostic significance of lymphovascular invasion (LVI) in patients with upper tract transitional cell carcinoma.

METHODS

Of 86 patients with upper tract transitional cell carcinoma who underwent nephroureterectomy with bladder cuff (95%) or parenchymal-sparing (5%) surgery from 1991 to 2002, and who met our inclusion criteria, the data of 73 were available for pathologic review of LVI. The mean patient age was 59.1 years, and the median follow-up was 42.3 months. Using univariate and multivariate analyses, we determined the influence of multiple prognostic factors, including age, sex, tumor stage (T or N), tumor grade, and LVI, on the 5-year disease-specific and recurrence (local recurrence or distant metastasis)-free survival rates. We generated 5-year disease-specific and recurrence-free survival curves in terms of LVI in patients without lymph node involvement.

RESULTS

The overall 5-year disease-specific and recurrence-free survival rate was 88% and 75%, respectively (n = 73). In univariate analysis, T stage, grade, and LVI significantly affected both survival rates. N stage was significant for 5-year recurrence-free survival. In multivariate analysis, LVI was the only significant predictor of recurrence-free survival, and no factor was significant for disease-specific survival. Of 10 patients with positive lymph nodes, 7 had LVI. In patients without lymph node involvement or Stage T4 disease (Ta-T3N0M0, n = 62), the 5-year disease-specific and recurrence-free survival rate was 98% and 94%, respectively, in the absence of LVI and 70% and 60%, respectively, in the presence of LVI (P = 0.0005 and P = 0.0007, respectively).

CONCLUSIONS

LVI is an independent prognostic factor for recurrence-free survival in transitional cell carcinoma of the upper urinary tract. Because LVI is strongly associated with a poorer prognosis, systemic adjuvant therapy should be considered in the presence of LVI, even if the lymph nodes are not involved.

Prognostic value of microscopic venous invasion in renal cell carcinoma: long-term follow-up

OBJECTIVE

To assess the prognostic value of microscopic venous invasion (MVI) in a long-term follow-up series.

PATIENTS AND METHOD

255 patients had a radical nephrectomy between 1980 and 1990 for pT1 to pT3b N0 M0 renal cell carcinoma. We reviewed the disease free, specific and overall survival after 183 months of median follow-up. Survival analyses using Kaplan-Meier and Log-rank models for univariate comparisons and Cox proportional hazards model for multivariate analyses were performed. The studied variables were: age, size, side, extracapsular invasion, renal vein invasion, local stage, Fuhrman's grade and MVI.

RESULTS

MVI was found in 74 cases (29%). The MVI was strongly correlated to metastases appearance and survival (p < 0.0001). Multivariate analysis of disease free survival showed the following independent variables: size (p < 0.0001) and Fuhrman's grade (p < 0.0001). For cancer specific survival, the analysis found size (p < 0.0001), age (p = 0.0005), Fuhrman's grade (p = 0.0035) and MVI (p = 0.016) with a relative risk of cancer related death of 2.16. Independent prognostic factors of overall survival were age (p < 0.0001), size (p < 0.0001), MVI (p = 0.015) and Fuhrman's grade (p = 0.045). The relative risk of cancer related death for MVI is 1.82.

CONCLUSION

It seems that MVI is an independent prognostic factor of survival for patients with pT1 to pT3b N0 M0 renal cell carcinoma.

Intravascular lymphoma: clinical presentation, natural history, management and prognostic factors in a series of 38 cases, with special emphasis on the ‘cutaneous variant’1

Despite its recognition as a distinct, extremely rare entity, no large studies of intravascular lymphoma (IVL) have been reported. The clinico-pathological characteristics of 38 human immunodeficiency virus-negative patients with IVL diagnosed in Western countries were reviewed to better delineate clinical presentation, clinical variants, natural history and optimal therapy. The IVL is an aggressive and usually disseminated disease (Ann Arbor stage IV in 68% of cases) that predominantly affects elderly patients (median age 70 years, range: 34-90; male:female ratio 0.9), resulting in poor Eastern Cooperative Oncology Group Performance Status (ECOG-PS >1 in 61%), B symptoms (55%), anaemia (63%) and high serum lactate dehydrogenase level (86%). The brain and skin are the most common sites of disease. In contrast to previous reports, hepatosplenic involvement (26%) and bone marrow infiltration (32%) were found to be common features in IVL, while nodal disease was confirmed as rare (11% of cases). Patients with disease limited to the skin ('cutaneous variant'; 26% of cases) were invariably females with a normal platelet count, and exhibited a significantly better outcome than the remaining patients, which deserves further investigation. Overall survival was usually poor; however, the early use of intensive therapies could improve outcome in young patients with unfavourable features. ECOG-PS >1, 'cutaneous variant', stage I and chemotherapy use were independently associated with improved survival.

[Comparative assessment of the results of different surgical treatments in patients with pituitary adenomas infiltrating the cavernous sinus]

Benign pituitary tumors or adenomas are highly common, occasionally inclined to infiltrate the adjacent structures, the cavernous sinus in particular. Despite the fact that drug and radiation therapy are at present widely used treatments, surgical procedures remain highly topical. Different modifications of two basic surgical methods (transcranial intradural and transsphenoidal) that fail to completely remove a tumor from the cavernous sinus in most cases are mostly frequently used as before. Attempts to improve surgical procedures and introduction of current technologies have led to the emergence of an extradural method for tumor removal from the cavernous sinus and to the introduction of endoscopic monitoring during transsphenoidal operations. A strategy of two-stage removal of pituitary tumors has simultaneously been developed. The paper presents the results of surgical treatment of 297 patients with pituitary adenomas growing into the cavernous sinus, by using currently available procedures: transsphenoidal, transcranial intradural, and intra-extradural, and two-stage ones. The findings have confirmed that transsphenoidal removal of pituitary adenomas is the safest method. However, this method has a number of limitations in cases with tumor being grown into the cavernous sinus especially when there is a medial displacement of the intracavernous segment of the internal carotid artery. Moreover, secondary tumor nodes that may be removed by transcranial intradural access are a contraindication to its use. With this, attempts to remove a tumor from the cavernous sinus fail to ensure the desired completeness of removal from the cavernous sinus. The application of an intra-extradural access is the most adequate procedure for tumor removal from the cavernous sinus. The two-stage removal is the most adequate procedure in cases of simultaneously significant spread of a tumor intracranially and into the structures of the base of the skull.

Results of superior vena cava resection for lung cancer

AIMS

The benefits of superior vena cava (SVC) resection for lung cancer remain controversial. Data obtained in four international centers were analyzed in order to identify prognostic factors and thus guide in future patient selection.

MATERIALS AND METHODS

Retrospective study. Prognostic factors were examined by logistic regression for postoperative morbidity/mortality using the Kaplan-Meier method (log rank test) and the Cox proportional-hazard model for survival.

RESULTS

From 1963 to 2000, 109 patients underwent SVC resection. Induction treatment was given to 23 (21%) patients. The SVC was resected for T involvement in 78 (72%) cases and for N involvement in 31 (28%) cases. Fifty-five (50.5%) patients underwent pneumonectomy (20 with carinal resection), while the remaining underwent lobar resections. Prosthetic SVC replacement was performed in 28 (26%) patients; partial resection with running suture (53%), vascular stapler (13%), or patch (7%) was performed in 80 patients; 1 patient did not undergo reconstruction. Pathological examination identified direct involvement (T4) in 66 (60%) patients and N2 disease in 55 (50%) patients. Major postoperative morbidity and mortality were 30 and 12%, respectively. Median intensive care unit stay was 3 days, while median hospital stay was 16 days. Five-year survival was at 21%, with median survival at 11 months. In multiple regression analysis, induction treatment was associated with an increased risk of major complications (P = 0.016). None of the factors assessed demonstrated an association with postoperative death. In multivariate survival analysis, both pneumonectomy and complete resection of the SVC with prosthetic replacement were associated with a significant increased risk of death (P = 0.0013 and 0.014, respectively).

CONCLUSIONS

The radical resection of lung cancer involving the SVC may result in a permanent cure in carefully selected patients. The type of pulmonary resection (i.e., pneumonectomy) and the type of SVC resection (i.e., complete resection with prosthetic replacement) are the prognostic factors with the greatest adverse effect on survival.

Invasion of blood vessels as significant prognostic factor in radically resected T1-3N0M0 non-small-cell lung cancer

OBJECTIVES

Radical resection is the therapy of choice in non-small-cell lung cancer (NSCLC). However, even in early stages (T1N0, T2N0) up to 35% of patients will experience recurrence. The aim of this retrospective study was to evaluate the prognostic influence of lymph vessel or blood vessel invasion in N0 patients.

METHODS

A total of 72 patients (male, 49; female, 23; median age 59; range 40-72) with NSCLC entered the study. The stages were T1-3N0 (T1, 25; T2, 41; T3, 6). Thirteen pneumonectomies and 59 lobectomies or bilobectomies with systematic lymphadenectomy and R0 resection were performed. Histologically, 24 adenocarcinomas, 31 squamous cell carcinomas and 14 subtypes of large cell carcinoma were found. In 22 cases microscopic invasion of the lymphatic vessels and in 11 invasions of blood vessels were found. Six patients showed invasion of either structure.

RESULTS

The patients were followed up for at least 5 years or until death. During the follow-up period 27 patients died (21 because of recurrence and 6 because of diagnosis not related to NSCLC). The 5 years overall survival amounted to 62.5%. In cases with invasion of the blood vessels the survival rate was 23.5%, in cases without invasion 74.5% (P< or = 0.01), whereas lymph vessel invasion had no significant impact on survival. Multivariate analysis covering T stages, histological subtypes, location of the tumor, grading, age, sex, and invasion of the lymphatic or the blood vessels showed invasion of the blood vessels as the only factor with significant prognostic impact in the study population.

CONCLUSIONS

In resectable N0 patients with NSCLC the microscopic invasion of blood vessels should be considered as an additional prognostic parameter.

[Prognostic significance of intrapulmonary metastases in cases of surgically treated lung cancer]

OBJECTIVE

The aim of this retrospective study was to establish the prognosis in lung tumour cases in which resection was followed by synchronous or metachronous intrapulmonary metastasis.

METHODS

Between 1990 and 1999, 857 patients were operated on for primary lung cancer. Intrapulmonary metastases were observed in 21 patients. 11 cases were in stage III/B (on the basis of T4), and 10 were in stage IV (on the basis of M1). The histologic distribution of the primary tumours was 7 squamous cell carcinomas, 11 adenocarcinomas, 2 large cell carcinomas and 1 carcinoid. In 8 patients, histology demonstrated N1 or N2 lymph node metastasis. In 4 cases, there were more than one metastases.

RESULTS

The 5-year survival was 21%, and the mean survival time (MST) was 29.5 months. For both the 5-year survival rate and MST, there was significant difference between the lymph node negative (N0) and lymph node positive (N1/N2) patients (N-: 30.7%, N+: 0%, p=0.017, MST: N-: 38.3 months, N+: 10.5 months, p=0.014), according to the stage (III/B: 30%, IV: 11.1%, p=0.025, III/B: 40.1 months, IV: 17.8 months, p=0.04) and the number of metastases (1 metastasis: 26.6%, more than 1 metastasis: 0%, p=0.036, 1 metastasis: 35.2 months, more than 1 metastasis: 8.5 months, p=0.045). No significant difference was detected on the basis of histological type, pleural, vascular and lymphatic invasion. In patients where 1 metastasis was found within one lobe and there were no lymph node metastases, the 5-year survival rate was 42.8% and MST was 49 months. The complication rate was 28.5% and the 30-day mortality was 4.7% (1 patient). Reoperation was performed in 1 case, for thoracic wall haematoma.

CONCLUSION

Primary lung tumours giving intrapulmonary metastases, under certain conditions (lymph node negativity, 1 metastasis in the same lobe), can be operated on with good survival possibilities.

Estrogen and progesterone expression of vessel walls with intravascular leiomyomatosis; discussion of histogenesis

We report seven cases of intravenous leiomyomatosis. Growth beyond the uterus occurred in two of the seven cases in the broad ligament. One 21-year-old patient is one of the youngest reported cases in the literature. Five patients had total abdominal hysterectomy with removal of the adnexa and two patients underwent myomectomy. One of the myomectomy cases had abdominal hysterectomy and bilateral salpingo-oophorectomy one year later due to recurrence. The other one was disease free six months after the operation. Vessel walls harboring intravascular tumor were investigated immunohistochemically for Factor VIII, CD 34, estrogen and progesterone receptors with the hope of making the histogenesis of intravenous leiomyomatosis clear. Immunohistochemical analyses of estrogen receptors, progesterone receptors, vimentin, desmin, smooth muscle actin, CD 10 and h-caldesmon were performed on intravascular tumor cells. Endothelial and subendothelial cells expressed none to scant, very weak progesterone and estrogen receptor positivity. Intravascular tumor cells showed weak (10%) to strong (70%) progesterone receptor positivity and weak (10%) to strong (60%) estrogen receptor positivity. These results do not support the hypothesis of a vessel wall origin for intravenous leiomyomatosis.

Primary malignant tumors of the aorta: clinical presentation, treatment, and course of different entities

OBJECTIVE

The objective of this study was to analyze possible correlations between the clinical presentation and the course of patients with different types of primary malignant aortic tumors.

METHODS

A single academic center's experience was reviewed retrospectively.

RESULTS

Four patients with primary malignant tumors of the aorta were treated in an 11-year period. Three different histologic entities were found: malignant fibrous histiocytoma, epitheloid angiosarcoma, and unclassified sarcoma. Two female patients presenting with clinical symptoms of vasculitis proved to have epitheloid aortic sarcoma. Both developed diffuse metastasis to bone and skin with initial lymphatic disease in the groin. The other patients developed local recurrence and pulmonary metastasis. Survival of the 4 patients was 11, 20, and 51 months, 1 patient with metastatic disease is still alive 6 months after surgery.

CONCLUSION

Different types of malignant aortic tumors seem to have different clinical presentation and course.

Surgical treatment and outcomes of patients with primary inferior vena cava leiomyosarcoma

BACKGROUND

The inferior vena cava (IVC) is a rare site for primary soft tissue sarcoma. There are limited data in the literature regarding surgical management of the IVC and longterm survival of these patients.

STUDY DESIGN

From 1982 to 2002, a total of 25 patients with primary IVC leiomyosarcoma was treated as inpatients and followed in a prospective database at Memorial Sloan-Kettering. Presenting symptoms, tumor characteristics, operative management, postoperative morbidity, and disease-specific survival were assessed for each patient.

RESULTS

The 25 patients with primary IVC leiomyosarcoma accounted for 0.5% of all adult patients with soft tissue sarcoma treated during this time. The median patient age was 56 years (range 41 to 79 years). The three most common presenting symptoms were abdominal pain (52%), distention (20%), and deep venous thrombosis (12%). Of the patients, 21 (84%) underwent complete resection of the tumor. The IVC was managed in one of three ways: ligation (n = 11), primary/patch repair (n = 8), and expanded polytetrafluoroethylene tube grafting (n = 2). Among patients undergoing IVC ligation and primary/patch repair (n = 19), 11% had severe postoperative edema and none had worsening renal function. Local recurrence occurred in 33% of patients and distant recurrence occurred in 48% of patients. Patients undergoing complete resection had 3-year and 5-year disease-specific survival rates of 76% and 33%, respectively. There were no 3-year survivors among patients with incomplete resections.

CONCLUSIONS

Complete resection of primary IVC leiomyosarcomas is feasible and associated with improved survival. The IVC can be managed by primary repair or ligation with a low risk of severe postoperative edema.

[Indication and surgical outcome in hepatocellular carcinoma with infiltration of blood vessels, bile ducts and lymph nodes]

From 1995 to 2001, 243 patients with hepatocellular carcinoma were recorded at Jena University Hospital, 59 (24%) underwent curative hepatic resection or orthotopic liver transplantation. 28 tumors (12%) showed microvascular invasion, and 29 (12%) presented with gross vascular invasion. 32 patients (13%) had regional lymph node metastases. In one patient (0.4%) CT scan showed involvement of the extrahepatic bile duct. Curative removal of the tumor was possible in 61%, 21%, 3% and 0%, respectively. Vascular invasion did not influence survival statistically significant. 3 year survival rates in patients with and without regional lymph node involvement were 0% and 38% (p < 0.01).

Charlson co-morbidity index as a predictor of outcome after surgery for renal cell carcinoma with renal vein, vena cava or right atrium extension

PURPOSE

Surgery is the most effective treatment for renal cell carcinoma with tumor thrombus but predictors of outcome and patient survival are variable. Co-morbidity may affect therapeutic decision making and survival, although to our knowledge this factor has not been studied in patients with tumor thrombus. We analyzed the Charlson co-morbidity index as a predictor of outcome after surgery.

MATERIAL AND METHODS

From 1970 to 1998, 303 patients underwent surgical resection. The Charlson index, surgical era, completeness of resection, patient age, sex, tumor level, TNM stage, grade and perinephric fat invasion were studied retrospectively as univariate and multivariate predictors of outcome.

RESULTS

The level of tumor thrombus was 0 (renal vein only) in 127 patients, and I to IV in 66, 58, 36 and 16, respectively. At 5 years overall, cause specific and metastasis-free survival were 32%, 42% and 41%, while at 10 years they were 21%, 32% and 30%, respectively. For the whole cohort significant multivariate predictors of cause specific survival were metastasis (p = 0.0001), grade (p = 0.0001), perinephric fat involvement (p = 0.02) and tumor levels 0 versus I to IV (p = 0.048). The Charlson index did not predict outcome (univariate model p = 0.65).

CONCLUSIONS

Characteristics of the primary tumor remained the most important predictors of cause specific survival in this cohort. The Charlson index did not predict cause specific survival in this cohort of surgically treated patients. Prospective assessment of co-morbidity in patients treated with surgery versus conservative therapy is warranted.

[Renal carcinoma with invasion of the suprahepatic vena cava (Staehler stage III and IV): surgical treatment and results]

The operative treatment of patients with renal cell carcinoma (RCC) and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV) is still an interdisciplinary challenge. The potential high complication rate and the enormous operative-technical efforts have to be brought into line with the individual benefit for the patient. In this study, we have retrospectively analyzed the operative results of 24 patients. We have further compared the patients during follow-up and immunotherapy due to metastasis with a control group of 75 patients without vena cava invasion. Perioperative mortality in the 24 patients was 4%. Four patients had metastasis at presentation and 14 further patients developed metastatic disease during median follow-up of 23.5 months. Median survival was 45 months with a 1-, 3-, and 5-year survival rate of 92, 57, and 33%, respectively. In a multivariate analysis, only the presence of metastasis (p=0.002) and marginal immunotherapy (p=0.1), but not vena cava invasion (p=0.259) or a positive lymph node status (p=0.624) were significant predictors of a poor survival. For patients with RCC and suprahepatic infradiaphragmatic or supradiaphragmatic vena cava invasion (Staehler stage III and IV), the combination of an aggressive surgical treatment combined with subsequent immunotherapy in the presence of metastatic disease offers a realistic therapeutic option with reasonable survival rates.

Combined heart and lung transplantation for unresectable primary cardiac sarcoma

OBJECTIVE

The prognosis for patients with primary cardiac sarcoma is poor. Median survival is less than 10 months, especially when complete surgical excision is not feasible. Removal of all cardiopulmonary structures involved by tumor followed by orthotopic allotransplantation has been proposed to improve long-term survival.

METHODS

From 1996 through 1999, we performed combined heart and lung resection followed by en bloc heart and bilateral lung transplantation in 4 patients (2 men and 2 women): 2 with inoperable pulmonary arterial sarcoma and 2 with left atrial sarcoma extending into the pulmonary vein.

RESULTS

Median age at diagnosis was 39 years (range 37-45 years). All 4 patients were given chemotherapy before transplantation: doxorubicin and ifosfamide in 2 cases, and doxorubicin, ifosfamide, mesna, and dacarbazine in 2 cases. There were no operative deaths. Median survival after transplantation was 31 months (range 5-49 months). All patients had tumor recurrence: local recurrence in the chest (n = 1) and distant metastases in the brain (n = 2) and abdomen (n = 1). One patient remains alive 49 months after disease progression with cerebral metastasis as the only site of recurrence treated with whole-brain irradiation, resection, and stereotactic radiosurgery.

CONCLUSIONS

Combined heart and lung transplantation is a technically feasible treatment for highly selected patients with localized advanced primary cardiac sarcomas. The high incidence of metastatic disease, however, limits its utility.

Progress in surgical treatment of hepatocellular carcinoma

Surgery for hepatocellular carcinoma has improved dramatically during the last two decades, and the improvement is mainly attributable to the development of intraoperative ultrasound-guided operative procedures such as Makuuchi's segmentectomy, introduction of the intermittent vascular occlusion technique, and establishment of the precise criteria for indications of various hepatectomy procedures. The use of preoperative portal vein embolization for inducing compensatory hypertrophy of remnant liver in the future has increased the safety and extended indications of hepatectomy for hepatocellular carcinoma. Operative mortality has fallen below 2% in the 1990s, with the 5-year survival rate reaching nearly 50% in a recent nationwide survey in Japan. More than 90% of hepatectomies at our institution are performed without red blood cell transfusions, and the mean hospital stay is shortened to approximately 23 days. Moreover, not a single case of operative death has been recorded since 1993.

Analysis of factors affecting survival in dogs with aortic body tumors

OBJECTIVE

To evaluate the effect of perioperative and operative variables on survival time in dogs with aortic body tumors.

STUDY DESIGN

Retrospective study.

SAMPLE POPULATION

Twenty-four client-owned dogs with histologically confirmed aortic body tumor.

METHODS

Seventy-eight patient records of dogs seen at the University of Illinois Veterinary Teaching Hospital between 1989 and 1999 with a diagnosis of a heart-base mass were reviewed. Dogs without histologic conformation of an aortic body tumor were excluded. Age; sex; breed; the presence of pleural effusion, pericardial effusion, or abdominal effusion; evidence of cardiac arrhythmias; evidence of distant metastasis; treatment with pericardectomy; treatment with chemotherapy; and time from diagnosis until euthanasia or death were recorded on a spreadsheet. Cox proportional-hazard ratios were used to calculate the relationship of risk variables to survival time. Median survival time was determined using life-table analysis.

RESULTS

Twenty-four dogs met the criteria for inclusion in the study. The median age of dogs with aortic body tumors was 9 years. All dogs had a surgical biopsy performed. Fourteen dogs had a pericardectomy at the time of the biopsy procedure. Of all factors analyzed, only treatment with pericardectomy had a significant influence on survival (P =.0029). Dogs that had pericardectomy survived longer (median survival, 730 days; range, 1-1,621 days) compared with dogs that did not have pericardectomy (median survival, 42 days; range, 1-180 days). This finding was independent of the presence or absence of pericardial effusion at the time of surgery.

CLINICAL RELEVANCE

Dogs that are diagnosed with aortic body tumors may benefit from a pericardectomy at the time of surgical biopsy.

The analysis of resectability and survival in pancreatic cancer patients with vascular invasion

One of the major limitations of curative resection in patients with pancreatic cancer is local tumor extension to the mesenteric vessels. Thus, the purposes of our study were to assess the clinical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival of patients with pancreatic cancer with suspicious vascular invasion and to assess the influence of curative resection on the survival of these patients. We enrolled 40 patients with pancreatic cancer who were suspected of having an involvement of the adjacent large vessels and who subsequently underwent operation with curative intent in the study. Resectability and survival were correlated with CT findings such as segment length, degree of encasement, and type and number of vessels involved. The survival rate was compared between the curative and palliative resection groups, and survival rate was compared between the resected and unresected groups. Of the 40 patients with adenocarcinoma of the pancreas, 14 had curative resections and 26 had palliative resections. The probability of curative resection was higher in patients with segment lengths less than 2 cm, as compared with segment lengths more than 2 cm. However, there was no difference in survival between the two groups. There were no differences in resectability and survival according to the degree of encasement and type and number of vessels involved. There was no difference in survival between the curative and palliative resection groups. There was no difference in survival between the resected and unresected groups. A survival benefit was not achieved by curative resection in patients with pancreatic cancer with vascular invasion. Therefore, it would be better to avoid aggressive surgery in patients with pancreatic cancer with vascular invasion.

Surgical exposure of superior sulcus lung tumors with vascular involvement

Choice of exposure route for surgical excision of superior sulcus lung tumors depends on involvement at the thoracic inlet. From December 1985 to September 1999, we performed surgical treatment of superior sulcus tumors in 42 patients, including 22 with vascular involvement. Various exposure techniques were used, including a novel technique combining transverse supraclavicular cervicotomy and posterolateral thoracotomy in 11 cases, anterior transclavicular cervicothoracotomy in 7 cases, isolated posterolateral thoracotomy in 3 cases, and cervicosternotomy in 1 case. Vascular procedures consisted of subadventitial dissection of the subclavian artery in 5 patients, arterial resection-anastomosis in 7, and prosthetic bypass in 10. Postoperative mortality was 11.9% in the overall series of 42 patients (n = 5) and 9% (n = 2) in the subgroup of patients with vascular involvement. During follow-up, 13 patients died of tumor recurrence and 1 patient died of respiratory insufficiency. Actuarial 5-year survival was 22.7 +/- 17.5% overall and 18 +/- 17.9% in the subgroup of patients with vascular involvement. This study indicates that the combined exposure route with transverse supraclavicular cervicotomy and posterolateral thoracotomy was useful for treatment of superior sulcus lung tumors requiring lobectomy and pneumonectomy.

Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series

OBJECTIVE

To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement.

SUMMARY BACKGROUND DATA

Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial.

METHODS

The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients.

RESULTS

In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year.

CONCLUSION

Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.

[Portal vein resection in the framework of surgical therapy of pancreatic head carcinoma: clarification of indication by improved preoperative diagnostic procedures?]

Tumor invasion of the portal vein by ductal adenocarcinoma of the pancreatic head is classically known as a criterion for inoperability. Despite improvement in operation techniques for portal vein resection during Whipple's procedure and acceptable mortality and morbidity, in the case of uncertain tumor infiltration vascular resection cannot be recommended in general. The problem is the preoperative detection of tumor infiltration of the portal vein. Often the surgeon is confronted with unsuspected macroscopic portal vein infiltration or tumor adhesion during the operation. Between 1986 and 1995 105 patients underwent Whipple's procedure for ductal adenocarcinoma of the pancreatic head in our department. In eight of these cases partial portal vein resection was performed because of macroscopic tumor infiltration or tumor adhesion. In all eight cases the preoperative diagnostic procedures with CT and portography did not show any suspicion of tumor infiltration. In four of the eight cases histological tumor infiltration of all vascular layers was found. In the others we found no or only adventitial tumor invasion. The patients without tumor infiltration of the portal vein showed a survival time after surgery of 27.78 months in contrast to 6.67 months in the group with histologically proven tumor infiltration. Endovascular, intraportal ultrasound (IPEUS), a new diagnostic procedure, can give helpful information regarding portal vein involvement. Although the IPEUS is not a standard diagnostic procedure it was shown to detect portal vein infiltration with high sensitivity and specificity. Our results indicate that in such cases where portal vein infiltration has been excluded by IPEUS, patients with macroscopic tumor adhesion do benefit from partial portal vein resection.