World Journal of Surgical Oncology - Latest articles

The use of fulvestrant, a parenteral endocrine agent, in intestinal obstruction due to metastatic lobular breast carcinoma

Jasmine YM Tang, Rampaul Singh and Kwok L Cheung — 2008-12-01

Background: The role of fulvestrant in the management of intestinal obstruction associated with lobular carcinoma has not been specifically described. Case presentationHerein we present two cases where fulvestrant, as the only available parenteral endocrine agent for postmenopausal advanced breast cancer has the opportunity to provide a means to initiate treatment in those patients who present with varying degrees of intestinal obstruction. Conclusions: Fulvestrant may obviate the use of chemotherapy while achieving sustained clinical benefit with less toxicity, in appropriately selected patients.

A study of lymph node ratio in stage IV colorectal cancer

Kristoffer Derwinger and Bengt Gustavsson — 2008-12-01

Background: The finding of metastasis in colorectal cancer, stage IV disease, has a major impact on prognosis and treatment strategy. Known important factors include the extent of the metastasis and the patients' performance status. The lymph node factors are of known importance in earlier cancer stages but less described in metastatic disease. The aim of the study was to evaluate lymph node status and ratio as prognostic markers in stage IV colorectal cancer.MethodThe study was retrospective and assessing all patients operated, with bowel resection, for an initial stage IV colorectal cancer during 1999-2003 (n=136). Basic demographic data as well as given treatment was assessed. The Lymph node ratio (LNR), the quota between the number of lymph node metastasis and assessed lymph nodes, was calculated. LNR groups were created by ratio thirds, 3 equally sized groups. The analysis was made by LNR group and by eligibility for chemotherapy with cancer specific survival as outcome parameter. Results: The median survival (CSS) for the entire group was 431 days with great variability. For the patients eligible for chemotherapy it ranged from 791 days in LNR-group 1 to 433 days for the patients in group 3. For patients ineligible for chemotherapy the corresponding figures were 209 and 91 days. The eligibility for chemotherapy was a major prognostic factor which also takes co-morbidity, age and performance status into consideration. The LNR (p<0.01) and the tumour differentiation grade were also significant (p<0.05) factors regarding survival. The LNR group 3 was also associated with a higher frequency of multiple metastasis locations (p<0.05) and of more side effects with chemotherapy and thus of reductions in dosage or pre-emptive treatment ending (p<0.05). Conclusion: Stage IV colorectal cancer is a heterogeneous group regarding the survival prognosis. The lymph node ratio was found to be a significant marker for the survival prognosis (p<0.0049). High and low risk groups could be identified with a survival difference of up to one year. It could be of importance when planning a treatment strategy or evaluating clinical data materials. A pathology report should include a node assessment even at presence of synchronous metastasis.

Neoangiogenesis in early cervical cancer: Correlation between color Doppler findings and risk factors. A prospective observational study

2008-11-25

Background: The aim of the present article was to evaluate whether angiogenic parameters as assessed by transvaginal color Doppler ultrasound (TVCD) may predict those prognostic factors related to recurrence. Methods: A total of 27 patients (mean age: 51.3 years, range: 29 to 85) with histologically proven early stage invasive cervical cancer were evaluated by TVCD prior to surgery. Subjective assessment of the amount of vessels within the tumor (scanty-moderate or abundant) and pulsatility index (PI) were recorded. All patients underwent radical hysterectomy and pelvic lymph node dissection. Postoperative treatment (RT or chemoradiotherapy) was given according to risk factors (positive lymph nodes, parametrial and vaginal margin involvement, depth stromal invasion, lymph-vascular space involvement) Results: Tumors with "abundant" vascularization were significantly associated with pelvic lymph node metastases, depth stromal invasion >10 mm, lymph-vascular space involvement, tumor diameter > 17.5 mm, and parametrial involvement. Postoperative treatment was significantly more frequent in patients with "abundant" vascularization (OR: 20.8, 95% CIs: 2 to 211). The presence of scanty-moderate vascularization with a PI < 0.82 or abundant vascularization with either PI > 0.82 or PI < 0.82 was associated with high-risk group in 94.4% of the cases (OR: 21.2, 95% CI: 1.9 to 236.0) Conclusion: The results are consistent with a relationship between tumor angiogenesis and prognostic factors for recurrence in early cervical cancer. "Abundant" vascularization and PI < 0.82 may be related to postoperative treatment due to risk factors.

The complicated management of a patient following transarterial chemoembolization for metastatic carcinoid

Andrew C Pearson, Steven Steinberg, Manisha H Shah and Mark Bloomston — 2008-11-25

Background: Transarterial Chemoembolization (TACE) has been recognized as a successful way of managing symptomatic and/or progressive hepatic carcinoid metastases not amenable to surgical resection. Although it is a fairly safe procedure, it is not without its complications. Case presentationThis is a case of a 53 year-old woman with a patent foramen ovale (PFO) and mild pulmonary hypertension who underwent TACE for progressive carcinoid liver metastases. She developed acute heart failure, due to a severe inflammatory response; this resulted in pneumatosis intestinalis due to non-occlusive mesenteric ischemia. We describe the successful non-operative management of her pneumatosis intestinalis and the role of a PFO in this patient's heart failure. Conclusions: TACE remains an effective and safe treatment for metastatic carcinoid not amenable to resection, this case illustrates the complexity of complications that can arise. A multi-disciplinary approach including ready access to advanced critical care facilities is recommended in managing such complex patients.

Delayed malignant melanoma recurrence simulating primary ovarian cancer

2008-11-20

Background: Metastatic involvement of the ovary from malignant melanoma is uncommon and presents a diagnostic challenge. Most cases are associated with disseminated disease and carry a dismal prognosis. Delayed ovarian recurrences from melanoma may mimic primary ovarian cancer and lead to aggressive cytoreductive procedures. Case presentationA case of malignant melanoma in a premenopausal patient is presented with late abdominal and ovarian metastatic spread, where ascitic fluid cytology led to an accurate preoperative diagnosis and the avoidance of unnecessary surgical procedures. Conclusions: Secondary ovarian involvement is associated with a poor prognosis and efforts should be made for adequate palliation. Pathologic diagnosis with non-invasive procedures is crucial in order to avoid unnecessary surgery. Surgical interventions may be undertaken only in selected cases of limited metastatic disease, where complete resection is expected

Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery?

2008-11-12

Tumor related pancreatic surgery has progressed significantly during recent years. Pancreatoduodenectomy (PD) with lymphadenectomy, including vascular resection, still presents the optimal surgical procedure for carcinomas in the head of pancreas. For patients with small or low-grade malignant neoplasms, as well as small pancreatic metastases located in the mid-portion of pancreas, central pancreatectomy (CP) is emerging as a safe and effective option with a low risk of developing de-novo exocrine and/or endocrine insufficiency. Total pancreatectomy (TP) is not as risky as it was years ago and can nowadays safely be performed, but its indication is limited to locally extended tumors that cannot be removed by PD or distal pancreatectomy (DP) with tumor free surgical margins. Consequently, TP has not been adopted as a routine procedure by most surgeons. On the other hand, an aggressive attitude is required in case of advanced distal pancreatic tumors, provided that safe and experienced surgery is available. Due to the development of modern instruments, laparoscopic operations became more and more successful, even in malignant pancreatic diseases. This review summarizes the recent literature on the abovementioned topics.

Metastatic colorectal cancer to a primary thyroid cancer

Martin H Cherk, Maggie Moore, Jonathan Serpell, Sarah Swain and Duncan J Topliss — 2008-11-11

Background: Metastatic malignancy to the thyroid gland is generally uncommon due to an unfavourable local thyroid micro-environment which impairs the ability of metastatic cells to settle and thrive. Metastases to the thyroid gland have however been reported to occur occasionally particularly if there has been disruption to normal thyroid tissue architecture.Case presentationWe report a patient with a history of surgically resected rectal adenocarcinoma who presents with a rising serum CEA level and an 18F-FDG PET scan positive thyroid nodule which was subsequently confirmed at surgery to be a focus of metastatic rectal adenocarcinoma within a primary poorly differentiated papillary thyroid carcinoma.Subsequent treatment involved right hemi-thyroidectomy, pulmonary wedge resection of oligometastatic metastatic colorectal cancer and chemotherapy. Conclusion: Metastatic rectal carcinoma to the thyroid gland and in particular to a primary thyroid malignancy is rare and unusual. Prognosis is likely to be more dependent on underlying metastatic disease rather than the primary thyroid malignancy hence primary treatments should be tailored towards treating and controlling metastatic disease and less emphasis placed on the primary thyroid malignancy.

Transsacral colon fistula: late complication after resection, irradiation and free flap transfer of sacral chondrosarcoma

2008-11-11

Background: Primary sacral tumors are rare and experience related to accompanying effects of these tumors is therefore limited to observations on a small number of patients.Case presentationIn this case report we present a patient with a history of primary sacral chondrosarcoma, an infection of an implanted spinal stabilization device and discuss the challenges that resulted from a colonic fistula associated with large, life threatening abscesses as late complications of radiotherapy. Conclusion: In patients with sacral tumors enterocutaneous fistulas after free musculotaneous free flaps transfer are rare and can occur in the setting of surgical damage followed by radiotherapy or advanced disease. They are associated with prolonged morbidity and high mortality. Identification of high-risk patients and management of fistulas at an early stage may delay the need for subsequent therapy and decrease morbidity.

Lung adenocarcinoma presenting as obstructive jaundice: a case report and review of literature

Stephanos Pericleous, Samrat Mukherjee and Robert R Hutchins — 2008-11-11

Background: Lung cancer is known to metastasize to the pancreas with several case reports found in the literature, however, most patients are at an advanced stage and receive palliative treatment. Case presentationWe describe the case of a 56 year old male patient who presented with a picture of obstructive jaundice. Investigations revealed an obstructing lesion in the pancreas and a further lesion in the lung with benign appearances. The patient underwent a pancreatectomy and, unexpectedly, the histology of the resected specimen demonstrated metastatic adenocarcinoma of bronchogenic origin. He was referred to a cardiothoracic team who proceeded to resect the patient's thoracic lesion before administration of adjuvant chemotherapy. The patient was reviewed 18 months post operatively and remains symptom free with no clinical or radiological evidence of recurrence. We were unable to identify any previous case reports (of lung adenocarcinoma) with such a presentation which were ultimately treated with resection of both lesions. Conclusions: Similar situations are bound to arise again in the future and we believe that this report could demonstrate that there is a case for aggressive surgical management in a highly selected group of patients: those with NSCLC and a synchronous solitary pancreatic deposit.

Inflammatory myofibroblastic tumor of epididymis: a case report and review of literature

Pankaj P Dangle, Wenle P Wang and Kamal S Pohar — 2008-11-11

Background: Epididymal inflammatory myofibroblastic tumor, also known by various other synonyms is a rare benign disease. Only eight cases have been reported to date. The most common presentation is a scrotal mass of variable duration. For a scrotal mass it is difficult to distinguish a benign or malignant etiology, in addition to the origin whether from testis or epididymis. As a result the definitive diagnosis can only be established by surgical exploration. Case presentationWe report the ninth case of epididymal IMT who based on clinical and radiological findings underwent radical orchidectomy, with the histology suggestive of inflammatory myofibroblastic tumor. At 4 years follow up the patient is free of disease recurrence. Conclusions: IMT though rare should be considered in the differential diagnosis of epididymal mass. Clinically it is often difficult to distinguish the origin of mass and even though the disease has benign nature and course it is crucial to counsel patients for orchidectomy as definitive diagnosis is established on surgical exploration.

Experience with adjuvant chemotherapy for pseudomyxoma peritonei secondary to mucinous adenocarcinoma of the appendix with oxaliplatin / fluorouracil /leucovorin (FOLFOX4)

Chin-Fan Chen, Che-Jen Huang, Wan-Yi Kang and Jan-Sing Hsieh — 2008-11-11

Background: Pseudomyxoma peritonei (PMP) is a rare condition characterized by mucinous tumors, disseminated intra-peritoneal implants, and mucinous ascites. So far its diagnosis remains challenging to most clinicians.Case presentationA 55-year-old male patient had suffered from acute onset of abdominal pain and abdominal distension for one day prior to his admission. Physical examination revealed tenderness over the right lower quadrant of the abdomen without diffuse muscle guarding. A large amount of ascites was identified by abdominal computed tomography (CT) scan. Paracentesis showed the appearance of sticky mucinous ascites. He underwent laparotomy under the impression of pseudomyxoma peritonei. There was a lot of mucinous ascites, one appendiceal tumor and multiple peritoneal implants disseminated from the subphrenic space to the recto-vesicle pouch. Pseudomyxoma Peritonei caused by mucinous adenocarcinoma of appendiceal origin, was confirmed by histopathology. We performed an excision of the appendiceal tumor combined with copious irrigation and debridement. After the operation, he received 10 cycles of systemic chemotherapy with FOLFOX4 regimen, without specific morbidity. Follow-up of abdominal CT and colonoscopy at post-operative 17 months showed excellent response without evidence of local recurrence or distal metastasis. He made an uneventful recovery (up to the present) for 21 months after the operation. Conclusion: This case report emphasizes the possible new role of systemic chemotherapy in the treatment of patients with this rare clinical syndrome.

Giant breast tumors: Surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature

2008-11-11

Background: Phyllodes tumors are biphasic fibroepithelial neoplasms of the breast. While the surgical management of these relatively uncommon tumors has been addressed in the literature, few reports have commented on the surgical approach to tumors greater than ten centimeters in diameter--the giant phyllodes tumor.Case presentationWe report two cases of giant breast tumors and discuss the techniques utilized for pre-operative diagnosis, tumor removal, and breast reconstruction. A review of the literature on the surgical management of phyllodes tumors was performed. Conclusions: Management of the giant phyllodes tumor presents the surgeon with unique challenges. The majority of these tumors can be managed by simple mastectomy. Axillary lymph node metastasis is rare, and dissection should be limited to patients with pathologic evidence of tumor in the lymph nodes.

The synchronous occurrence of squamous cell carcinoma and gastrointestinal stromal tumor (GIST) at esophageal site

2008-11-05

Background: Esophageal squamous cell carcinoma is a relative common malignancy with a very poor prognosis, even adopting an integrated and multidisciplinary approach. According to the literature, gastrointestinal stromal tumors (GISTs) rarely originate from the esophagus. Moreover there are not reports of synchronous occurrence of squamous cell carcinoma and GIST at esophageal site. Case presentationWe describe a case of a 74 year old patient who underwent surgery for squamous cell carcinoma of the lower third of the esophagus with an incidental pathologic diagnosis of a concomitant GIST in the thoracic tract. Conclusion: In literature there is no evidence of concomitant squamous carcinoma and GIST of the thoracic esophagus, even if esophageal GISTs are sometimes described. The occasional finding of this neoplastic lesion underlines the importance of a carefully pathological diagnosis for its identification. Surgery, followed by a multidisciplinary approach remains the first-line treatment in both squamous and stromal neoplasm