Role of laparoscopy in the staging of gastrointestinal cancer

Accurate staging plays a primary role in determining the appropriate treatment of gastrointestinal malignancies. Recently, laparoscopy has emerged as a staging modality that is more sensitive and specific in staging most gastrointestinal cancers than preoperative imaging modalities. The addition of laparoscopic ultrasonographic techniques has achieved even greater staging accuracy. Consequently, patients with disease that is amenable to resection are better identified, and others with locally advanced disease are spared unnecessary laparotomies. Since laparoscopic techniques may be associated with low morbidity and a rapid recovery, palliative procedures are being developed for patients with advanced gastrointestinal malignancies. This reviews summarizes the current status of laparoscopic staging of gastrointestinal malignancies and compares this technique to preoperative imaging modalities. Also discussed are promising staging technologies and therapeutic procedures that may soon play an important role in the management of gastrointestinal cancer patients.     

Benign glandular elements and decidual reaction in retroperitoneal lymph nodes

Among 70 patients with gynecologic malignancies who underwent surgical staging and pelvic and periaortic lymphadenectomy, five were found to have benign glandular and/or stromal elements in the retroperitoneal lymph nodes. In three instances, these were originally diagnosed as metastatic cancer. The literature on this subject is reviewed and its significance is discussed.     

The postpubertal change in the playful defense of male rats depends upon neonatal exposure to gonadal hormones

Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.     

Children with chronic arthritis: the management of transition to adulthood

Primary fallopian tube carcinoma represents less than 1% of all gynecologic malignancies and is therefore one of the less common malignancies of the female genital tract. Fallopian tube carcinoma is rarely diagnosed preoperatively and is often mistaken for benign pelvic disease or ovarian cancer. Compared with ovarian carcinoma, fallopian tube cancer more often presents in early stage but seems to have a worse prognosis, stage for stage. Treatment consists of surgical debulking followed by chemotherapy, adjuvant or otherwise. New studies are needed to better delineate the clinical course, prognostic factors, and appropriate chemotherapy recommendations.     

Enterovaginal and enterocutaneous fistulae in women with gynecologic malignancies

From 1957 to 1975, 43 women with gynecologic malignancies had associated enterocutaneous or enterovaginal fistula. Thirty-four of these women underwent surgical correction of the fistula. The etiology, diagnostic evaluation, preoperative complications, and surgical correction of such fistulae are discussed. In addition, a staged planned management of these fistulae is outlined.     

Preoperative sonographic evaluation and laparoscopic management of persistent adnexal masses: a 1994 review

Carcinoma of the ovary is a frightening disease because it is a major cause of death due to cancer in women and is the leading cause of deaths from gynecologic malignancies. The disease is associated with a common clinical problem: persistent adnexal masses, most of which are benign. Operative laparoscopy has become an increasingly attractive way of diagnosing and removing adnexal masses. The practicing general gynecologist thus faces two new dilemmas: not to miss an early ovarian cancer or manage an unsuspected one to the patient's detriment, and not to perform extensive major surgery for adnexal masses, most of which can be handled laparoscopically. Fortunately, pertinent data exist on which the resolution of these dilemmas may be based.     

Treatment of gynecologic cancer in elderly patients

Due to the increasingly elderly population and prolonged life span of women in Japan, population of women older than 75 years of age has become 7.3% of all female population in 1995. According to this change, elderly patients with gynecologic malignancies, such as cervical cancer, endometrial cancer and ovarian cancer have increased markedly. Those patients tend to have progressed disease and therefore treatments should be less invasive and tailored based upon individual conditions to maintain their quality of life.     

Trans-species gene transfer for analysis of glucocorticoid-inducible transcriptional activation of transiently expressed human CYP3A4 and rabbit CYP3A6 in primary cultures of adult rat and rabbit hepatocytes

BACKGROUND: The sensitive detection of circulating tumor cells and micrometastases may have important therapeutic and prognostic implications. METHODS: The molecular detection of occult tumor cells can be accomplished by amplifying tumor specific abnormalities present in the DNA or mRNA of malignant cells with the polymerase chain reaction (PCR). This approach has been used mainly for hemato-lymphoid malignancies. The other main PCR strategy for the detection of minimal residual disease (MRD) involves amplification of tissue-specific mRNA. This method was applied for the detection of occult disease in solid tumors. RESULTS: PCR was shown to be superior to conventional techniques in detecting circulating tumor cells and micrometastases allowing the identification of 1 tumor cell diluted with 10(6)-10(7) normal cells. The central question of whether PCR positivity reliably predicts relapse remains unanswered for many tumor types. Serial analysis of a large number of samples is needed and currently undertaken in many institutions. CONCLUSIONS: PCR is a highly sensitive method for the detection of circulating tumor cells and micrometastases in solid and hematopoietic malignancies. If PCR positivity is found to be a reliable tool, this will likely have a major impact on the treatment of many cancers. Patients could be selected for systemic therapy at an earlier stage when the metastatic tumor burden is low. PCR may improve the preoperative staging of patients with epithelial malignancies and therefore help avoid unnecessary radical procedures. Furthermore, this test may be useful in monitoring the effectiveness of adjuvant therapy, the intensity and duration of which is tailored to the individual patient. The impact of this PCR based approach on clinical oncology is likely to be profound.     

Treatment for gynecologic cancer: A review of the effects on female sexuality.

Outlines treatments for gynecologic malignancies including radiation therapy or radical hysterectomy for cervical carcinoma, radical vulvectomy for vulvar carcinoma, and pelvic exenteration for recurrent disease. Research relating to their effects on female sexuality is critically reviewed. The relevant domains of treatment and patient characteristics that need assessment in this research area are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Noninfectious gene transfer and expression systems for cancer gene therapy

Gene therapy provides a significant opportunity to devise novel strategies for the control or cure of cancer. Success of this modality will ultimately depend on the ability to express a therapeutic gene of interest at high levels, and specific gene delivery to targeted tumor cells will minimize toxicities. Although current gene therapy trials typically use viral-based, infectious vectors to express suitable target genes in human cancer cells, these vectors have significant limitations in their expression characteristics, lack of specificity in targeting tumor cells for gene transfer, and safety concerns regarding induction of secondary malignancies and recombination to form replication-competent virus. These limitations have refocused efforts to develop noninfectious gene transfer technologies for in vivo gene delivery of plasmid-based expression vectors. This article reviews recent developments in non-infectious gene transfer techniques, including liposome and receptor-mediated methods, which can efficiently deliver plasmid vectors into tumor cells in vivo. Additionally, strategies are reviewed for efficiently expressing target genes in tumor cells, including use of tissue-specific promoters, inducible promoters, and replication-control sequences to regulate extrachromosomal amplification of vector DNA in human tumor cells. Optimal coupling of these noninfectious gene transfer and expression technologies have the potential to yield safe and effective gene therapies for patients with cancer.     

Risk factors associated with fluorosis in a non-fluoridated population in Norway

BACKGROUND: Expression of the HER-2/neu oncogene has been suggested to confer added virulence or aggressive behavior in gynecologic malignancies. The aim of this study is to determine the frequency of HER-2/neu expression in invasive cervical cancer and its impact on survival in women with cervical cancer. DESIGN: Archival tissue from 150 patients with cervical carcinoma was evaluated immunohistochemically for HER-2/neu oncoprotein expression. Survival information was retrieved retrospectively from patients' medical records. RESULTS: The HER-2/neu expression was observed in 34 out of 150 tumors (22%). The HER-2/neu positive tumors exhibited considerable heterogeneity in the distribution of immunoreactive tumor cells. Tumor grade and histology did not influence the pattern or intensity of HER-2/neu expression. There was no statistically significant difference in survival of patients with HER-2/neu positive and those with HER-2/neu negative tumors (P = 0.50). Tumor stage at diagnosis was the only covariate with prognostic significance in patient survival (P < 0.001). CONCLUSION: Expression of HER-2/neu oncogene is a rare event in cervical cancer. Immunohistochemical detection of HER-2/neu expression is neither a predictor of survival of patients with cervical cancer nor does it identify subgroups of patients at higher risk for recurrence of disease.     

Hepatocellular carcinoma: surgical treatment

Worldwide the hepatocellular carcinoma (HCC) is one of the most common malignancies. There is a coincidence with liver cirrhosis or chronic hepatitis B/C in most cases. HCC can be suspected by ultrasound and by rise of the tumor marker (AFP). Further investigations, like biopsies, are not necessary if angiography or computed tomography in combination with patient history and elevated AFP levels are positive. The prognosis of untreated HCC is extremely poor. Live expectancy of symptomatic patients is only a couple of weeks. Radical tumor removal by liver resection or transplantation is the only treatment with curative intent. However these options are only suitable for patients with limited disease. Five year survival after curative liver resection depends on the tumor stage, ranging from 25% to 67%. The results after liver transplantation are similar for small cancer. Large, symptomatic tumors are in most cases only suitable for palliative treatment (chemoembolisation, ethanol injection, chemotherapy, immunotherapy). The strong dependence of prognosis on tumor extent underlines the importance of screening patients with elevated risk of developing an HCC. The early recognition of small tumors allows curative therapy with good results.     

Synchronous and metachronous primary malignancies in organs other than the stomach in patients with early gastric cancer

BACKGROUND/AIMS: We investigated the outcomes of patients with early gastric cancer, with special reference to the prognosis of patients with synchronous or metachronous primary malignancies in organs other than the stomach. PATIENTS AND METHODS: Among 890 patients with early gastric cancer, 97 (10.9%) had synchronous or metachronous primary malignancies in organs other than the stomach. Ten-year survival rates were compared between patients who had additional malignancies and patients who had early gastric cancer but no other malignant disease (control group). RESULTS: Synchronous primary malignancies were detected in 32 patients and metachronous primary malignancies were detected in 65 patients (17 had developed before gastrectomy and 48 developed after gastrectomy). Hepatic cell carcinoma, lung cancer and colorectal cancer were frequently detected between 2 and 24 years after gastrectomy. The 10-year survival rate was 80.8% for 769 patients in the control group but it was only 49.7% for the 92 patients with additional malignancies. Moreover, metachronous malignant disease was found more over 10 years after gastrectomy in 30 of the 48 cases (62.5%). CONCLUSIONS: These results suggest the importance of long-term follow-up for detection of metachronous carcinomas at sites other than the stomach for patients with early gastric cancer.     

Immunotherapy of cancer with "immune" RNA. A preliminary report

A phase I clinical trial of immunotherapy with "Immune" RNA was undertaken fifteen months ago. Twenty-six cancer patients were treated with RNA extracted from the lymphoid organs of sheep immunized with either autologous tumor cells or allogeneic tumor cells of the same histologic type. Eighteen patients had gross disease and eight had minimum residual disease. RNA was administered weekly, intradermally, at doses up to 9 mg/week without any significant local or systemic toxicity. Four patients improved, thirteen achieved stability of disease or possible improvement, seven were treatment failures, and two are indeterminate. Lymphocyte-mediated cytotoxicity to allogeneic tumor target cells of the same histologic type were monitored in eleven patients. In seven patients, cytotoxicity increased after "Immune" RNA therapy; no change was observed in three patients; a decrease was noted in one patient. There appeared to be a possible correlation between cytotoxicity assessed in vitro and clinical response. There is some evidence that these responses may be specific for the particular tumor used to immunize the RNA donor.     

Magnetic resonance imaging of the female pelvis

Evaluation of pelvic pathology is an important part of most radiology practices. Magnetic resonance imaging (MRI) has proven itself to be a useful and cost-effective method in evaluating many of these diseases. This article reviews appropriate MR imaging techniques and findings of common gynecologic disorders. Uterine pathology is categorized into congenital anomalies, benign lesions (leiomyomas, adenomyosis, endometrial polyps, and nabothian cysts), and malignancies (endometrial and cervical carcinoma). Adnexal pathology reviewed includes endometriosis, polycystic ovaries, teratomas, and benign and malignant ovarian epithelial tumors.     

Radiation therapy-induced cardiac injury

Radiation therapy is currently standard treatment for a number of malignancies, including Hodgkin's disease. With the advent of techniques (e.g., subcarnial blocks) that limit the dose of radiation to which the heart is exposed, the incidence of radiation-induced heart disease can be minimized. However, a small percentage of patients will eventually suffer iatrogenic effects. Most commonly seen is pericardial disease, but valvular, conduction system, and coronary artery disease are also seen. Further, because these patients are now surviving longer after therapy, those effects with a longer latent period may be seen with increasing frequency.     

Current aspects of biology, risk assessment, and treatment of neuroblastoma

Neuroblastoma is one of the most intensely studied solid malignancies that affect the pediatric age groups; its clinical presentation, treatment strategies and ultimate prognosis vary greatly. The biologic and genetic character of each tumor has an important impact on disease behavior, and clinical staging now incorporates these factors to generate an overall therapy plan. The clinical presentation of neuroblastoma is related to primary tumor location, production of metabolically active substances, and the presence of metastatic disease. There are also prognostically important associated syndromes including opsoclonus-myoclonus, Horner's syndrome, neurofibromatosis, and a variety of other neurocristopathies. The histologic features of the tumor are of prognostic significance and are utilized in treatment stratification. The International Neuroblastoma Staging System (INSS) has unified classic clinical staging. Features at diagnosis and those determined by initial operation are combined with biologic prognostic factors to achieve risk group assignment for virtually all patients. There are groups of children in which limited therapy is curative and intermediate-risk situations where standard multimodality treatment provides favorable outcomes. Unfortunately, there are many patients with high-risk disease that require intensive strategies, but success is still limited. It is in these most resistant patients that innovative approaches are being undertaken and novel strategies are being investigated.     

Transplant-lite: induction of graft-versus-malignancy using fludarabine-based nonablative chemotherapy and allogeneic blood progenitor-cell transplantation as treatment for lymphoid malignancies

PURPOSE: To investigate the use of a nonmyeloablative fludarabine-based preparative regimen to produce sufficient immunosuppression to allow engraftment of allogeneic stem cells and induction of graft-versus-leukemia/lymphoma (GVL) as the primary treatment modality for patients with chronic lymphocytic leukemia (CLL) and lymphoma. PATIENTS AND METHODS: Fifteen patients were studied. Six patients were in advanced refractory relapse, and induction therapy had failed in two patients. Patients with CLL or low-grade lymphoma received fludarabine 90 to 150 mg/m2 and cyclophosphamide 900 to 2,000 mg/m2. Patients with intermediate-grade lymphoma or in Richter's transformation received cisplatin 25 mg/m2 daily for 4 days; fludarabine 30 mg/m2; and cytarabine 500 mg/m2 daily for 2 days. Chemotherapy was followed by allogeneic stem-cell infusion from HLA-identical siblings. Patients with residual malignant cells or mixed chimerism could receive a donor lymphocyte infusion of 0.5 to 2 x 10(8) mononuclear cells/kg 2 to 3 months posttransplantation if graft-versus-host disease (GVHD) was not present. RESULTS: Eleven patients had engraftment of donor cells, and the remaining four patients promptly recovered autologous hematopoiesis. Eight of 11 patients achieved a complete response (CR). Five of six patients (83.3%) with chemosensitive disease continue to be alive compared with two of nine patients (22.2%) who had refractory or untested disease at the time of study entry (P = .04). CONCLUSION: These findings indicate the feasibility of allogeneic hematopoietic transplantation with a nonablative preparative regimen to produce engraftment and GVL against lymphoid malignancies. The ability to induce remissions with donor lymphocyte infusion in patients with CLL, Richter's, and low-grade and intermediate-grade lymphoma is direct evidence of GVL activity against these diseases. This approach appears to be most promising in patients with chemotherapy-responsive disease and low tumor burden.     

Salvage mitomycin/5-fluorouracil after platinum-based therapy for women with advanced ovarian cancer and related gynecologic malignancies

PURPOSE: to determine response rates, survival, and toxicity of a regimen of mitomycin-C and 5-fluorouracil in patients previously treated with platinum-based combinations for ovarian cancer and related gynecologic malignancies. PATIENTS AND METHODS: retrospective chart review of all cases of persistent or recurrent ovarian, fallopian tube, and peritoneal carcinoma treated with mitomycin-C 7 mg/m2 followed by continuous infusion of 5-fluorouracil 600 mg/m2/day over 4 days. RESULTS: 26 patients were treated after a median of 2 prior platinum-based regimens, 22 with ovarian cancer, 3 with peritoneal cancer, and one with fallopian tube cancer. Only 2 patients completed 6 or more cycles. 2 patients had partial responses (8%); no complete responses were seen. 24 patients died a median of 3 months after the initiation of therapy, while 2 patients were alive 4 and 8 months after beginning therapy. All deaths were attributable to disease, not complications of treatment. 8 patients required dose modification or treatment delay for toxicity. Nine patients required a total of 11 unscheduled admissions. CONCLUSIONS: toxicity attributable to mitomycin-C/5-fluorouracil therapy of ovarian cancer is acceptable, but responses are few. More effective alternative should be sought.     

Primary nonampullary/periampullary adenocarcinoma of the duodenum

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.