Lymphadenectomy for gastric cancer: still a matter of debate?

Ann Ital Chir. 2012 May-Jun;83(3):199-207.

Doglietto GB, Rosa F, Bossola M, Pacelli F.

BACKGROUND:
For more than a century the extent of surgical treatment of gastric cancer is a matter of debate. Through experience, evaluation and research, the outcome of gastric cancer has improved. Many aspects are of influence of outcome, but only a radical resection can offer long-term outcomes. In this review, we will discuss the history and current status of the extent of lymph node dissection.

MATERIALS AND METHODS:
Some issues about the extent of gastric resection seem to have been settled. For survival it is not necessary to perform a total gastrectomy if free resection margins can be obtained with a subtotal gastrectomy. In the context of postoperative morbidity and mortality a subtotal gastrectomy is to be preferred. Microscopic resection line involvement has shown to be of great influence on prognosis.

DISCUSSION:
At this moment the main discussion centres around the extent of lymph node dissection, locoregional recurrence and to the influence of additional treatment. For many years it has been debated whether an extended lymph node dissection for gastric cancer is beneficial. Theoretically, removal of a wider range of lymph nodes by extended lymph node dissection increases the chances for cure. Such resection, however, may be irrelevant if there are no lymph nodes affected or if the cancer has developed into a systemic disease, or if it increases morbidity and mortality substantially.

CONCLUSION:
Relapse after curative surgery because of local recurrence or regional lymph node metastasis have been shown in up to 87.5% of patients. The extent of surgery, however, may be of influence on the locoregional recurrence rate.

Short-Course Accelerated Radiotherapy in Palliative Treatment of Advanced Pelvic Malignancies: A Phase I Study.

Int J Radiat Oncol Biol Phys. 2012 May 12.

Caravatta L, Padula GD, Macchia G, Ferrandina G, Bonomo P, Deodato F, Massaccesi M, Mignogna S, Tambaro R, Rossi M, Flocco M, Scapati A, Scambia G, Pacelli F, Valentini V, Cellini N, Morganti AG.

Department of Radiation Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II,” Università Cattolica del S. Cuore, Campobasso, Italy.

PURPOSE:
To define the maximum tolerated dose of a conformal short-course accelerated radiotherapy in patients with symptomatic advanced pelvic cancer.

METHODS AND MATERIALS:
A phase I trial in 3 dose-escalation steps was designed: 14 Gy (3.5-Gy fractions), 16 Gy (4-Gy fractions), and 18 Gy (4.5-Gy fractions). The eligibility criteria included locally advanced and/or metastatic pelvic cancer and Eastern Cooperative Oncology Group performance status of ?3. Treatment was delivered in 2 days with twice-daily fractionation and at least an 8-hour interval. Patients were treated in cohorts of 6-12 to define the maximum tolerated dose. The dose-limiting toxicity was defined as any acute toxicity of grade 3 or greater, using the Radiation Therapy Oncology Group scale. Pain was recorded using a visual analog scale. The effect on quality of life was evaluated according to Cancer Linear Analog Scale (CLAS).

RESULTS:
Of the 27 enrolled patients, 11 were male and 16 were female, with a median age of 72 years (range 47-86). The primary tumor sites were gynecologic (48%), colorectal (33.5%), and genitourinary (18.5%). The most frequent baseline symptoms were bleeding (48%) and pain (33%). Only grade 1-2 acute toxicities were recorded. No patients experienced dose-limiting toxicity. With a median follow-up time of 6 months (range 3-28), no late toxicities were observed. The overall (complete plus partial) symptom remission was 88.9% (95% confidence interval 66.0%-97.8%). Five patients (41.7%) had complete pain relief, and six (50%) showed >30% visual analog scale reduction. The overall response rate for pain was 91.67% (95% confidence interval 52.4%-99.9%).

CONCLUSIONS:
Conformal short course radiotherapy in twice-daily fractions for 2 consecutive days was well tolerated up to a total dose of 18 Gy. A phase II study is ongoing to confirm the efficacy on symptom control and quality of life indexes.

Copyright © 2012 Elsevier Inc. All rights reserved.

Early Proctoscopy is a Surrogate Endpoint of Late Rectal Toxicity in Prostate Cancer Treated With Radiotherapy.

Int J Radiat Oncol Biol Phys. 2012 Jun 1;83(2):e191-5. Epub 2012 Feb 22.

Ippolito E, Massaccesi M, Digesù C, Deodato F, Macchia G, Pirozzi GA, Cilla S, Cuscunà D, Di Lallo A, Mattiucci GC, Mantini G, Pacelli F, Valentini V, Cellini N, Ingrosso M, Morganti AG.

Radiotherapy Unit, Fondazione di Ricerca e Cura Giovanni Paolo II, Università Cattolica del S. Cuore, Campobasso, Italy.

PURPOSE:
To predict the grade and incidence of late clinical rectal toxicity through short-term (1 year) mucosal alterations.

METHODS AND MATERIALS:
Patients with prostate adenocarcinoma treated with curative or adjuvant radiotherapy underwent proctoscopy a year after the course of radiotherapy. Mucosal changes were classified by the Vienna Rectoscopy Score (VRS). Late toxicity data were analyzed according to the Kaplan-Meier method. Comparison between prognosis groups was performed by log-rank analysis.

RESULTS:
After a median follow-up time of 45 months (range, 18-99), the 3-year incidence of grade ?2 rectal late toxicity according to the criteria of the European Organization for Research and Treatment of Cancer and the Radiation Therapy Oncology Group was 24%, with all patients (24/24; 100%) experiencing rectal bleeding. The occurrence of grade ?2 clinical rectal late toxicity was higher in patients with grade ?2 (32% vs. 15 %, p = 0.02) or grade ?3 VRS telangiectasia (47% vs. 17%, p ? 0.01) and an overall VRS score of ?2 (31% vs. 16 %, p = 0.04) or ?3 (48% vs. 17%, p = 0.01) at the 1-year proctoscopy.

CONCLUSIONS:
Early proctoscopy (1 year) predicts late rectal bleeding and therefore can be used as a surrogate endpoint for late rectal toxicity in studies aimed at reducing this frequent complication.

Copyright © 2012 Elsevier Inc. All rights reserved.

A very advanced case of a T cell peritoneal lymphomatosis.

Ann Ital Chir. 2012 Jan-Feb;83(1):71-3.

Ridolfini MP, Caprino P, Berardi S, Rotondi F, Cusumano G, Sofo L, Pacelli F, Doglietto GB.

Unit of Surgical Oncology, Centro di Ricerca e Cura “Giovanni Paolo II”, Campobasso, Italy.

Small-bowel lymphoma is not a common disease, accounting for 15-20% of primary extranodal gastrointestinal lymphomas. Peritoneal lymphomatosis is considered a rare and aggressive presentation. We describe the case of a 55 years-old man affected by T-cell intestinal lymphoma, presenting with diffuse abdominal involvement, bowel dysfunction, severe ascites and pleural effusion, who underwent surgery. Clinical course led dramatically to death. Preoperative cytology and radiologic investigations did not yield diagnosis and were unable to differentiate between peritoneal carcinosis and lymphomatosis. It is suggested that, in such advanced cases, with rapidly deteriorating clinical conditions and huge systemic involvement, surgery is not indicated. On the contrary, maximum effort has to be spent to obtain a preoperative diagnosis.