World Journal of Surgical Oncology - Latest Comments

Chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer patients: is a time of additional randomized trials?

stefano cafarotti — 2011-01-17T13:41:09Z

Stefano Cafarotti, Alfredo Cesario, Venanzio Porziella, Stefano Margaritora and Pierluigi Granone

We compliment Meysan Hurmuzlu and colleagues (1) for their report on outcome of high-dose preoperative chemoradiotherapy (CRT) in operable locally advanced esophageal cancer patients compared to surgery alone, which we have read with great interest.
It is well known that the Patients with esophageal cancer continue to have a poor prognosis with a 5 year survival rate less than 20% due to the advanced stage at the time of presentation. However, there is no universally appropriate treatment and management depends
upon the patient's general condition and resectability criteria. The role of neoadjuvant chemoradiotherapy in technically operable IIa-III esophageal carcinoma is still unresolved. In a phase III trial comparing trimodality therapy with cisplatin, Fluorouracil, Radiotherapy, and Surgery with surgery alone Tepper and associates supported trimodality therapy as a standard of care for patients with this disease (2). In a phase II trial of preoperative CRT followed by surgery Knox and associates reported encouraging survival in trimodality group respect to the surgery alone group (3). . Several randomized studies have also failed to show a survival advantage following neoadjuvant CRT (4) as reported by the Authors themselves. We agree with the Authors that the study was retrospective and with limited number of patients but we consider this in light to demonstrated that future additional randomized trials is necessary. Moreover, they showed no significant survival advantage in esophageal cancer stage IIA-III treated with preoperative high-dose CRT compared to surgery alone in the context of a "positive" underpowered results of recent published trials as demonstrated by Pereira (5). Convincing arguments for changing clinical practice will need to be strong.

References
1. Hurmuzlu M, Øvrebø K, Monge OR, Smaaland R, Wentzel-Larsen T, Viste A. High-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort study. World J Surg Oncol. 2010 Jun 1;8:46.

2. Tepper J, Krasna MJ, Niedzwiecki D, Hollis D, Reed CE, Goldberg R, Kiel K, Willett C, Sugarbaker D, Mayer R. Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol. 2008 Mar 1;26(7):1086-92.

3. Knox JJ, Wong R, Visbal AL, Horgan AM, Guindi M, Hornby J, Xu W, Ringash J, Keshavjee S, Chen E, Haider M, Darling G. Phase 2 trial of preoperative irinotecan plus cisplatin and conformal radiotherapy, followed by surgery for esophageal cancer. Cancer. 2010 Sep 1;116(17):4023-32.
4. Burmeister BH, Smithers BM, Gebski V, Fitzgerald L, Simes RJ, Devitt P, Ackland S, Gotley DC, Joseph D, Millar J, North J, Walpole ET, Denham JW, Trans-Tasman Radiation Oncology Group; Australasian Gastro-Intestinal Trials Group: Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol 2005, 6:659-668
5. Pereira B, Gourgou-Bourgade S, Azria D, Ychou M. Neoadjuvant chemoradiotherapy in esophageal cancer: is it still the question? J Clin Oncol. 2008 Nov 1;26(31):5133-4; author reply 5134.

Errors and omissions

Puthen Veettil Jithesh — 2009-08-12T15:21:00Z

A good review, but from just browsing through the article I found some typos, errors etc. For example, the word "its" is wrongly spelt as "it's" in all the places. On page 2, para 1, under the heading "Genomics", epidermal growth factor receptor has a short form of "EGRF" which should be "EGFR". On para 2, there is omission of word "was" in the last sentence. Further, on para 3, there is a description of the work by Del Rio et al (2007) and a statement at the end: "Since it's publication there have been several further studies". Two of the references for "further studies" were actually published before the Del Rio study.

Simple liver cyst: always a benign entity?

Bernardo Frider — 2009-01-08T13:57:30Z

We read with interest the case report of Fukunaga N et al about a Hepatobiliary cystadenoma exhibiting morphologic changes from simple hepatic cyst shown by 11-year follow up imagings, published in World Journal of Surgical Oncology 2008, 6:129 (11 December 2008). Years ago (2005) we also published in Dig Dis Sci a case of a cystadenoma after years of a diagnosis of a simple liver cyst. ( Nonparasitic simple liver cyst: always a benign entity? Unusual presentation of a cystadenoma. Frider B, Rodriguez JA, Porras LC, Amante M., Dig Dis Sci. 2005 Feb;50(2):317-9. ) This case has similar features of the case reported by Fukunaga et al, with the same considerations about this benign disease, and the need of follow up to exclude potential changes in the cyst. I regret that Dr. N Fukunaga has not read our case report, and then was not included in the bibliography. The relative high frequency of liver cysts, the scarce of publications about the potential cystadenoma transformation of simple cysts and the poor follow up assigned for this type of simple liver cyst in clinical practice support the need of increase the knowledge of this type of situations. Sincerely Bernardo Frider MD Head Deptartment of Medicine-Hepatology C. Argerich Hospital Associated to the University of Bs. As. Profesor of Medicine. Maimónides University Argentina bernardo@frider.com.ar

Rarity of cases questionable

Amber Huber — 2008-11-14T05:34:04Z

In October of 2006 in Indianapolis, Indiana, I was treated surgically for Glassy Cell Cervical Carcinoma.

These sentences are perfect

Keita Tanaka — 2008-03-21T12:21:57Z

These sentences are perfect

The Insidiousness of Mammary Paget's

Angelina Lenahan — 2007-10-28T12:53:57Z

I thoroughly enjoyed reading this article on the day after I was scheduled for a biopsy for assumed mammary Paget's. A week prior, I had my six month follow up mammogram (alternating with six month MRI), which was perfectly normal. For the past nine years, all of the imaging studies have been normal, even though I am in the high-risk category with a strong family history of breast/ovarian and colon cancer on the maternal side. My sister was diagnosed with DCIS within months of my DCIS diagnosis nine years ago, and last year her cancer recurred as full blown metastases to bone, calvaria, spine and lung. She had never taken tamoxifen or an aromatase inhibitor, whereas I had taken tamoxifen for five years, and had diligently followed up every six months with imaging studies and breast exams with my medical oncologist.

I say this disease is insidious because of my own experience. I had taken for granted that everything was fine, as usual. I just happened to mention to the mammography technician that I had a little redness around the areola, nothing bothersome, for about a few months. I asked her to pass that along to the radiologist, who then called me into his office after reading the mammogram. He announced that the images were perfectly normal, but he was concerned that the redness around the areolar complex was Paget's, and that I should see my oncologist soon. I quickly went to my breast surgeon, who agreed.

What about the women who do not have the kind of education I have? I am a health information editor with a speciality in oncology, and thus I am up to date with signs and symptoms of most cancers. If it weren't for my career, I would have assumed the redness was caused by a new detergent, or a fungal rash, or eczema.

With all the medical education about self breast exams, looking for lumps or unusual textures beneath the skin, I would like to also include in that education information about Paget's disease of the nipple / areolar complex, and that women (and men) should seek medical attention if they note a redness, flaky, scaling rash, something resembling eczema, that does not respond to topical creams or steroids. They should get a skin biopsy, preferably by a cancer dermatologist or specialist. Until my personal experience, and reading this article, I had not heard of Paget's disease of the mammary in my 30 years of medical editing.

Inherited lythiasis biophysical-semeiotic constitution and lythiasis real risk.

Sergio Stagnaro — 2007-08-21T15:55:48Z

Bed-side diagnosis of the cholelithiasis is mainly difficult, due to the fact that the clinical phenomenology either is completely absent (“silent gall-bladder stones”) or, if present, it is aspecific and, therefore, not easy to be correctly interpreted. Obviously, more difficult is recognizing at the bed-side both silent stones, i.e. gall-bladder stones without any clinical symptomatology, cholecyst diseases with light, not severe, symptomatology, and particularly lythiasis biophysical-semeiotic constitution and lythiasis real risk.

Unfortunately, until now doctors were not able to identify individuals apparently healthy but at “real” risk of gall-bladder stones, as well as the “variant” Reavens syndrome, which represents the conditio sine qua non of lithiasis in whatever biological system, including arterial wall, obviously in presence of inherited lythiasis biophysical-semeiotic constitution (1-5).

As following, simple biophysical semeiotic signs, reliable in prompt recognizing both this sometime dangerous cholecyst disease and the “real” risk of cholelithiasis, in a “quatitative” manner, easily recognizable with the aid of Biophysical Semeiotics, are briefly described. Surely, by means of the old, traditional semeiotics, bed-side diagnosing such as disorder disorder is rather difficult until now.

In fact, with the aid Biophysical Semeiotics (1-3), based on auscultatory percussion, doctor is able to recognize promptly not only gall-bladder stones, even clinicallly silent, but also, for the first time to my knowledge, the individuals at “real” risk of them, with favorable influence on primary prevention.

In order to perform this biophysical semeiotic procedure, doctor has to know, at least, the auscultatory percussion of the stomach (Fig.1). (For further information, See www.semeioticabiofisica.it Practical Applications).

The knowledge of liver and gall-bladder auscultatory percussion , of course, enlightens and enriches this method of examination (1).

In healthy, without “risk” for stones, i.e., in absence of “variant” Reaven’s syndrome digital pressure, applied upon the skin projection area of gall-bladder, i.e. right superior abdominal quadrant, preferebly delimitated as indicates Fig. 1, provokes the so-called "gastric aspecific reflex" (= in the stomach, fundus and body dilate; on the contrary, antral-pyloric region contracts), as clearly indicated in Fig 1, after latency time of 8 sec. exactly: intensity < 2 cm. Physiologically, the reflex persists identical for less than 4 sec. and finally disappears for > 3 sec. < 4 sec.: this value parallels the fractal dimension of local microvessel fluctuations, calculated in a sophysticated manner.

Interestingly, in case of gall-bladder stone(s), even clinically silent, the latency time is shorter (< 8 sec.), intensity is 2 cm. or more (in relation to disorder entity) and, soon thereafter, characteristically its intensity decreases rapidly of 1/3 of greatest intensity: "lythiasic reflex", observed also during stimulation of specific trigger-points, in case of other stones and calcium deposition, localized in whatever biological system, including kidneys and arterial wall.

It seems really interesting the fact that, if patient performs the Valsalva's manouvre, due to abdominal pressure increase, the reflex appears spontaneously in the same manner, described above. This evaluation is, however,less specific than the first one.

Moreover, the reliable "gall-bladder preconditioning" (2) provides usefull information: after an interruption of exact 5 sec., doctor carries out a second (and third) evaluation. In healthy, the latency time turns out lenghtened (latency time = 10-12 sec. versus 8 sec.).

On the contrary, in both “real” risk for gall-bladder-stones and cholelythiasis, the latency time of gastric aspecific reflex is either identical in initiasl stage to basal value (which can be apparently normal, i.e., 8 sec.), or shorter (latency less than 8 sec.), in relation to disease seriousness. In any case, reflex duration is 4 sec. or more: parameter value of central importance from the diagnostic viewpoint. The physio-pathology of the biophysical-semeiotic signs is based upon microvascular conditions of the gall-bladder wall, according to

Further interesting signs of gall-bladder stones are fully described elsewehre in previous papers as the cholelithyasic constitution (1-6).

Due to reader’s knowledge of Biophysical Semeiotics, unfortunately, clinical microangiological signs are at the moment not referred in this paper. (For further information See: http:// www.semeioticabiofisica.it/microangiologia). In conclusion, in my opinion,Helicobacter species may play only the role of a risk factor of the disorder!

Bibliography.

1. Stagnaro S., Stagnaro-Neri M., Diagnosi percusso-ascoltatoria dei calcoli biliari silenti. 6 ° Incontro Segusino di Medicina e Chirurgia. Susa 19 Maggio, 1990. Atti, pg. 79. Ed. Minerva Medica, Torino.1990

2. Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ed. Travel Factory, Roma, 2004. http://www.travelfactory.it

3. Stagnaro-Neri M., Stagnaro S., La "Costituzione Colelitiasica": ICAEM-a, Sindrome di Reaven variante e Ipotonia-Ipocinesia delle vie biliari. Atti. XII Settim. It. Dietol. 20, 239, 1993

4. Stagnaro-Neri M., Stagnaro S., La sindrome dispeptica funzionale da discinesia delle vie biliari. Diagnosi percusso-ascoltatoria. Cin. Ter. 127, 363, 1988 (Medline)

5. Stagnaro-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzione diabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617, 1993.

6) Stagnaro S., Stagnaro-Neri M. Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Ed. Travel Factory, Roma, 2005.

Some Advice

Ian Leeds — 2007-06-28T05:01:39Z

I am a Man of 48 with a suspected thyroglosal duct syst how common is this in older adults, this article is very informative as any lump or bump in the neck is very worring to say the least.

If any one has any advice please reply to this coment.

Colo Vagianl Fistula re: hysterectomy

Cindee Rice — 2007-06-10T03:57:15Z

Excessive bleeding during Jun 2006 Supra Cervical Hysterectomy...1 MO PO CT DX of hematoma with small opening present and 6 MO CT DX of same opening extending several cm into the colon. Daily pain in lower left abdomen and groin extending down inner side of left leg. Cervix extremely tender causing aggravation of symptoms. What causes the extreme tenderness and constant daily pain/fever after nearly one year post op?

Dad

Glenn Yokel — 2007-04-25T12:22:50Z

Regarding, "Primary Malignant Melanoma of the Lung: A Case Report".

After reading this case report about the 41 year old female with primary malignant melanoma of the lung, I submit this comment hoping it reaches someone with insight on the subject.

About a year ago, my Dad presented with MM in his lymph nodes. While a surgical procedure was performed, the MM spread to his lungs.

He then participated in a clinical trial that used a new monoclonal antibody to target the MM. It was unfortunately ineffective. Any vaccines, clinical trials or non invasive procedures - other than chemotherapy - currently available to treat MM in the lungs?

Sincerely,

Glenn Yokel

732-901-6890

glennyokel@aol.com