Preoperative Portal Vein Embolization For Hepatocellular Carcinoma

Preoperative hemihepatic portal vein embolization (PVE) has been introduced in an attempt to extend the indications for major hepatic resections and increase the safety of this procedure. PVE was first developed by Makuuchi et al. in 1990 (29) for the treatment of hilar cholangiocar-cinoma. PVE induces homolateral atrophy of the portion of the liver scheduled for resection and contralateral compensatory hypertrophy in the remnant liver, thereby decreasing the risk of postoperative liver...

Tumor Characteristics

SBA is most commonly found in the duodenum (57-64 ), followed by the jejunum (20-27 ) and ileum (14-15 ) (4-6). There are several explanations for the observation that such a large percentage of tumors arise in the duodenum. One, the duodenum is the first site exposed to a variety of potentially injurious agents, both those consumed and those produced within the GI tract (bile, pancreatic secretions, stomach acid) (4). Second, duodenal adenocarcinoma may develop in anywhere from 24 to 100 of...

Evaluation Of Newer Cytotoxic Agents For Hepatic Arterial Infusion Therapy

Based on the established activity of IV irinotecan and oxaliplatin in advanced colorectal cancer, these newer agents have also been evaluated for HAI therapy. van Riel et al. conducted a phase II trial in pretreated colorectal cancer patients where HAI irinotecan was given as a five-day continuous infusion at 20 mg m2 day every three weeks (76). Of the 22 evaluable patients, only 3 patients (14 ) had a PR. Major toxicities were vomiting and diarrhea. Fiorentini et al. reported the results of a...

Search Strategy OVID version of Medline 19802006

(esophag or esophag ) adj3 (cancer or carcinomas or neoplas or tumo r or malignan or adenocarcinoma or squamous or adenosquamous or carcinoid or basosquamous ) jnp. 6. exp drug therapy, combination 7. exp combined modality therapy 10. exp Antineoplastic Combined Chemotherapy Protocols 13. (multimod or adjuvant or neoadjuvant or adjunct or concurrent or combin or conjunct ).mp. 16. exp Randomized Controlled Trials 17. randomized controlled trial.pt. 21. limit 20 to (humans and english language...

Treatment Options

There are two objectives in the therapy of hilar cholangiocarcinoma complete tumor excision with negative margins and subsequent restoration of biliary-enteric continuity. Multiple studies from several centers around the world have shown that complete resection is associated with five-year survival rates of approximately 25 to 40 , clearly better than can be achieved with nonoperative therapies. Clearly, patients treated nonoperatively typically have more advanced disease, and no comparative...

Chemoradiation Effects on Qualityof Life

Despite the potential survival benefits for patients with locally advanced pancreatic cancer receiving radiation therapy and chemotherapy, these gains are modest. With rare exception, all patients will ultimately succumb to their disease. In spite of this, significant palliative benefit can be achieved by chemoradiation. Pain, anorexia, fatigue, and clinical wasting are relatively common symptoms, which significantly impact on the patient's quality of life. Although poorly documented in many...

References

Barrett's esophagus pathogenesis, epidemiology, functional abnormalities, malignant degeneration and surgical management. Dysphagia 1993 8(3) 276-288. 2. Shaheen NJ, Crosby MA, Bozymski EM, Sandler RS. Is there publication bias in the reporting of cancer risk in Barrett's oesophagus Gastroenterology 2000 199 333-338. 3. Jankowski JA, Provenzale D, Moayyedi P. Esophageal adenocarcinoma arising from Barrett's metaplasia has regional variations in the west. Gastroenterol 2002...

Evidence Summary

There is level 1 evidence for a survival benefit from preoperative chemotherapy, although this only becomes significant after five years. Two very similar large recent trials disagree about this outcome. There is no good evidence for a survival benefit from postoperative chemotherapy. There is level 1 evidence for a survival benefit and reduction of LRR after neoadjuvant chemoradiation. However, there is a strong trend toward increased operative mortality. There is no good evidence of survival...

Radical Surgery Gastrectomy with Systematic D2 Lymphadenectomy

The overall poor prognosis for gastric cancer led to a nihilistic approach by Western clinicians, which persisted for many years, but expert Japanese centers began to report much more favorable outcomes in terms of both perioperative mortality, and long-term prognosis in the 1970s, associated with the adoption of radical lymphadenectomy. Subsequently, several Western specialist centers have been able to report similar figures, stimulating great interest in radical surgery (69-71). Figures for...

Pierre Chan Ching Lung Lai and Man Fung Yuen

Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China Hepatocellular carcinoma (HCC) can be treated by surgical and nonsurgical means. However, only around 20 to 30 of patients with HCC are resectable on presentation because of advanced disease or impaired liver reserve secondary to underlying cirrhosis (1). Patients usually present late because HCC smaller than 8 cm is usually asymptomatic. The tumors are also often multifocal. Recurrence after complete...

Ascites

Malignant ascites represents only 10 of all cases of ascites, but in a patient with a GI malignancy ascites likely indicates peritoneal spread of disease. The distinction between malignant and nonmalignant ascites is important for prognostic reasons as well as treatment planning. Ascitic fluid should be sent for cytology and chemistries, as up to one-third of patients with malignancy will have nonmalignant ascites. Cytology often yields the diagnosis. In addition, the presence of an elevated...

Efficacy of Chemotherapy Regimens

In a series of prospectively designed, sequential nonrando mized studies, Cunningham et al. showed the combination of MMC and 5-FU given concomitantly with radiation therapy to be more effective than 5-FU and radiation alone with respect to five-year, disease-specific survival rates (76 vs. 64 ), local control (86 vs. 60 ), and the likelihood of conservation of anorectal function (29). The prospectively randomized phase III Eastern Cooperative Oncology Group (ECOG) Radiation Therapy Oncology...

Intrahepatic Chemotherapy

The rationale for administering intrahepatic arterial chemotherapy is that by delivering chemotherapy directly to the target organ, high levels of drug will reach the metastatic lesions. As 5-FU undergoes arterial extraction at first pass the concentrations will be far greater (up to 100 times) than that obtained with intravenous administration. This will be of particular benefit due to the steep dose-response curve seen with cytotoxic drugs. However, the procedure is complex and potentially...

Technical Aspects Of Hepatic Arterial Infusion Chemotherapy The Totally Implantable Pump

Early experience with regional chemotherapy involves the use of a percutaneously placed catheter attached to an external infusion device. Treatment required hospitalization and was often associated with a high incidence of complications such as catheter dislodgement, bleeding, thrombosis, and infection (19). Another approach is the implanted port which allows repeated access to the arterial system as well as attachment to an external portable pump for ambulatory treatment. However, these ports...

Neoadjuvant Chemotherapy

Disease that is felt to be inoperable initially may still be rendered potentially operable by the use of the newer chemotherapy agents with their improved rates of response. One of the first reports (38) investigated chronomodulated chemotherapy in unresectable liver metastases. They reported a trial in which 53 of 330 patients initially deemed to have unresectable liver disease (due to location, large size, multinodular lesions, or extrahepatic disease) were downstaged with systemic,...

Diagnosis

The diagnosis of hilar cholangiocarcinoma is usually made on evaluation of obstructive jaundice or elevated liver enzymes. Biliary cancers may be clinically silent for long periods of time and it may be many months before a patient bearing such a tumor presents with overt clinical features. Progressive and unremitting jaundice is usually the predominant clinical feature, and diagnostic investigations are largely related to elucidation of the cause of biliary tract obstruction. A minority of...

Targeted Nuclear Treatments

The holy grail of the treatment of inoperable solid cancers is a cytotoxic treatment that selectively targets the tumor cells, while having little or no effect on the surrounding normal host tissue. Because of their unique behavior, neuroendocrine tumors, carcinoid in particular, lend themselves perhaps more than any other to this approach. Two approaches are now being evaluated which find their way into the therapeutic armamentarium MIBG (36,37) and radiolabeled somatostatin analogs (34,35)....

Patterns Of Recurrence In Gastric Cancer

Early sites of recurrent gastric cancer are difficult to identify, even with current advances in imaging techniques. Most recurrent disease goes undetected until it is fairly advanced (14-16). Historical autopsy series outline late patterns of recurrence in gastric cancer, but typically demonstrate large volumes of disease obscuring the initial site of treatment failure (17). A valuable addition to our understanding of recurrence patterns was provided by studies from Wangensteen et al. at the...

Bowel Obstruction

Bowel obstruction is a common occurrence in patients with GI malignancy. The true incidence is unknown, but has been estimated to occur in 10 to 28 of patients (2). The management options for malignant bowel obstruction (MBO) include resection or bypass, ostomy formation, tube decompression (e.g., gastrostomy, jejunostomy, or cecostomy), stent placement, or medical management of the symptoms of obstruction. The presence of a bowel obstruction in a patient with a history of cancer does not...

Postoperative Chemotherapy

The potential advantage of using postoperative therapy is that one can be relatively selective, based on pathological factors, in the patients who receive treatment, and there is no delay in definitive surgical therapy. However, the selection of only fit postoperative patients for clinical studies of postoperative treatment should lead one to be cautious in interpreting the applicability of such treatment to the general population, for example, excluding patients with R1 or R2 resections...

Chemotherapy In Practice

For many years it was felt that advanced and metastatic colon cancer would not respond to active treatment, and palliative care was all that could be offered. However, with the widespread use of 5-FU in various modes of administration, increasing evidence of evaluable benefits gained from chemotherapy has emerged in terms of disease progression, overall survival, and quality of life. Several randomized trials have revealed chemotherapy to be valuable when compared to best supportive care (BSC)...

Epidemiology

The highest incidence rates of gallbladder cancer worldwide are found in cultures indigenous to the Andes Mountains of South America. In North America, high incidence rates are found among native American Indians and Mexican Americans. Gallbladder cancer occurs in women almost three times more often than in men across all populations studied (123). As with other biliary tract tumors, chronic inflammation is a common denominator of associated risk factors. The most common of these risk factors...

Followup After Surgical Resection For Colon Cancer

A number of recent studies have investigated the follow-up of colorectal cancer patients after surgery (17-20). Among the studies on the subject, there is a great variation between procedures, duration, intensity, and types of follow-up testing as a result, there is no consistent pattern of follow-up that seems to impact overall and cancer-related survival and no recommendations have been made. One Norwegian study looked into detection of asymptomatic curable recurrence, compliance, and cost of...

Adjuvant Chemotherapy

Adjuvant cytotoxic chemotherapy for gastric cancer has been studied over the last 40 years. This approach has demonstrated its usefulness in other diseases such as colon and breast cancers. Gastric cancer would seem to be a natural disease to test adjuvant chemotherapy, as there are a number of significantly active advanced disease chemotherapy programs that demonstrated activity in the treatment of disseminated stomach cancer. A variety of combination chemotherapy regimens have been widely...

Patients at Potentially Increased Risk for Treatment Related Adverse Events Elderly and Human Immunodeficiency Virus

Elderly patients, particularly those with poor performance status, may find it difficult to tolerate full-dose radiation and chemotherapy. Of the three randomized phase III studies in anal cancer, the EORTC trial was restricted to patients aged < 76 years, while both the UKCCCR ACT I and ECOG RTOG 87-04 trials had no age restriction. Neither of these latter studies specifically reports tolerance or outcome for the subset of elderly patients. In the UKCCCR study, frail elderly patients were...

Rationale For Hepatic Arterial Infusion Chemotherapy

Until recently, the pyrimidine analog 5-fluorouracil (5-FU) had been the palliative standard for patients with metastatic colorectal cancer. It resulted in response rates of approximately 20 (12). The addition of leucovorin (LV) to 5-FU results in a higher response rate without significant improvement in survival (13). Changing the method of administration of 5-FU from bolus to continuous infusion can modestly improve response rates, without significant impact on survival (12). Thus, the poor...

Procedure For Obstructed Leftsided Colon Cancer

The operation of choice is not clear with an obstructing left-sided colon cancer. There are several options, including resection with colostomy, also known as the Hartman's procedure, subtotal colectomy with or without an anastomosis, resection with on-table lavage, and followed by an anastomosis. Several studies have addressed each. A report by the Subtotal Colectomy versus On-table Irrigation and Anastomosis (SCOTIA) Study Group (13), was the first prospective randomized, multicenter trial to...

Risk Factors and Pathogenesis

A number of epidemiologic studies have linked sexual practices and genital viral infections to the development of anal cancer. A case control study in women and heterosexual men demonstrated that the relative risk of anal cancer is highest in those with 10 or more sexual partners or a history of anal warts and sexually transmitted infections (1). Receptive anal sex is a risk factor in both men and women. Smoking increases the risk of anal cancer up to fivefold in premeno-pausal women (2). Human...

Microwave Coagulation Therapy

Microwave coagulation therapy (MCT) uses dithermic heat energy to cause thermal coagula-tive necrosis. MCT utilizes a much higher frequency electromagnetic field. Polarization of water molecules in the alternating electromagnetic field leads to heating of intracellular water. The higher frequency energy allows for more localized energy but, as is the problem with other thermal techniques, causes reduction in tissue penetration. The therapy can be delivered during laparotomy, laparoscopy, or by...

Cholangiocarcinoma Involving the Proximal Bile Ducts Hilar Cholangiocarcinoma Clinical Presentation

The early symptoms of hilar cholangiocarcinoma are nonspecific, with abdominal pain, discomfort, anorexia, weight loss, and or pruritus seen in about one-third of patients (7,16,35,36). Most patients come to attention because of jaundice or abnormal liver function tests. Although most patients eventually become jaundiced, this may not be present in cases of incomplete biliary obstruction (i.e., right or left hepatic duct), which may go unrecognized for months. These patients are often further...

Newer Chemotherapy Agents

The results of the numerous clinical trials of adjuvant therapy for pancreatic cancer leave many questions unanswered with no definitive answer as to the optimal treatment for these patients. In addition, newer chemotherapy agents such as gemcitabine and molecularly targeted agents have emerged, and the possible benefit of their addition to adjuvant therapy has yet to be reported in larger trials. Based on the results of a prospective randomized trial, gemcitabine has become the standard first...

Laparoscopicminimally Invasive Vs Openconventional Surgical Resection For Colon Cancer

In recent years, extensive discussions have been made of minimally invasive or laparoscopic techniques in addressing colon cancers. Initial concerns surrounded such issues as the appropriateness of the surgical margins, number of harvested lymph nodes, and port site recurrences, that is, tumor recurrence at the site of laparoscopic trocar insertion areas or specimen removal sites. Several large studies have addressed these concerns. A prospective but nonrandomized study reported by Franklin et...

How Does One Select Patients With Colorectal Cancer Of The Liver Who Will Benefit From Surgical Resection

The criteria for the selection of patients have evolved in last two decades. Ekberg et al. (20) proposed three general contraindications to liver resection for metastatic colorectal cancer (CRC) in their landmark article in 1986 the presence of four or more lesions, presence of additional extrahepatic disease, and resection margin of < 1 cm. In recent decades, as safety of hepatectomy has improved and long-term follow-up data have matured, surgeons have adopted a more aggressive approach...

Neoadjuvant And Adjuvant Treatment For Gastric Cancer

Surgical resection remains the primary curative treatment option in gastric cancer, with five-year survival rates of 58 to 78 and 34 reported for stage I and II disease, respectively (35). Despite this, the overall five-year survival rate for all patients remains poor and ranges between 15 and 38 . Recurrences are frequent after surgery. Recurrence rate and subsequent survival is dependent on the stage at diagnosis. Prospective randomized trials have evaluated the role of D1 or D2 resection in...

Alternative Diagnoses

The vast majority of patients with hilar strictures and jaundice have cholangiocarcinoma. However, alternative diagnoses are possible and can be expected in 10 to 15 of patients (40). The most common of these are gallbladder carcinoma, Mirizzi syndrome and idiopathic benign focal stenosis (malignant masquerade). Distinguishing gallbladder carcinoma from hilar cholangiocarcinoma can be difficult. A thickened, irregular gallbladder with infiltration into segments IV and V of the liver, selective...

Oxaliplatin

Oxaliplatin is a third-generation platinum CT agent that has been demonstrated to offer good response rates and valuable improvements in life expectancy in patients with metastatic colorectal cancer (Chapter 17). Interest is now growing in using this agent in the adjuvant setting. The Multicentre International Study of Oxaliplatin 5-Fluorouracil Leucovorin in the Adjuvant Treatment of Colon Cancer (MOSAIC) investigators have recently published their findings (16). A large trial randomizing 2246...

Combining Hepatic Arterial Infusion Therapy With Contemporary Systemic Chemotherapy

Irinotecan is a topoisomerase I poison with proven efficacy in first- and second-line treatment of metastatic colorectal cancer (6,7,70). Systemic treatment with oxaliplatin, a third-generation platinum, in combination with 5-FU and LV (FOLFOX) has now been approved by the Food and Drug Administration for the adjuvant treatment of resected Stage III colorectal cancer as well as for the first- and second-line treatment of metastatic disease (8,71,72). With the availability of 5-FU and these two...

Combined Modality Therapy as Salvage Treatment

Approximately 10 to 20 of patients will have residual disease after primary chemoradio-therapy. Anal cancer may continue to regress for weeks or months following therapy (29). Outside a clinical trial, as practiced in many instances, if residual disease is present at six-week post-treatment evaluation, patients are followed for a further six weeks. If there is no further response or progression, then salvage therapy is performed otherwise, observation is continued, if the lesion is regressing....

Systemic Chemotherapy

Systemic chemotherapy is not used routinely for advanced HCC. There are factors related to the tumors. HCC is relatively chemoresistant, partly due to the presence of drug-resistant genes, including p-glycoprotein, glutathione-S-transferase, heat shock proteins and mutations in p53. There are also factors related to the patients. Patients often do not tolerate chemotherapy well because of the underlying liver dysfunction and liver cirrhosis. Several chemotherapy agents, including doxorubicin,...

Introduction

Chemoprevention of esophageal adenocarcinoma in Barrett's esophagus (BE) is an expanding area of research. This chapter will briefly discuss the histopathologic background of BE and its association with esophageal cancer. It will explore up-to-date research, looking at the potential chemotherapeutic drug groups, namely proton pump inhibitors (PPIs) and cyclo-oxygenase (COX) inhibitors, particularly focusing on the molecular basis of their action and any current evidence to support their use....

Detecting Metastatic Disease

In many cases, metastatic disease will be overt at presentation (1,4). Patients with known primary carcinoid tumors will develop symptoms of the carcinoid syndrome, or are found to have metastases at investigation or laparotomy for their primary tumor. Following apparently curative surgery for primary carcinoid tumor(s), it is good practice to establish radiologic and biochemical baseline parameters with which comparisons can be made as symptoms evolve in the future. We would advocate a full...

Irinotecan

Irinotecan is similarly being developed for adjuvant use, having been shown to be active in metastatic colorectal disease both alone and in combination with 5-FU. It is a topoisomerase I inhibitor. (This enzyme is involved in DNA supercoiling.) The advantage over oxaliplatin is a relative lack of long-term side effects, although short-term side effects include diarrhea, myelo-suppression, and alopecia. Saltz et al. (17) recently reported a phase III randomized study, which assessed the role of...

Neoadjuvant Therapy In Rectal Cancer

The goals for surgical approaches to rectal cancer should be to develop improved local control and overall survival, while maintaining quality of life and preserving sphincter, genitourinary, and sexual function. Much has been made of neoadjuvant therapy and its application for mid- to lower-lying rectal tumors. The effects of downstaging possibly enhance the rate of curative surgery and may increase sphincter preservation. The Swedish rectal trial reported its five-year follow-up data on a...

Graeme J Poston and Louise E Jones

Department of Surgery, University Hospital Aintree, Liverpool, U.K. The clinical course of patients with nonresectable metastatic carcinoid is highly variable and largely unpredictable (1-4). Patients with high tumor burden can remain relatively asymptomatic for years, totally oblivious to their disease. Others with minimal residual (but nonresect-able) disease in the small-bowel mesentery can suffer all the symptoms of the carcinoid syndrome without having disease in the liver (vide supra)....

Sequelae and Limitations of Chemoradiotherapy for Squamous Cell Anal Cancer

Chemoradiotherapy has replaced surgical resection as the treatment of choice for anal cancer, based on local disease control rates of 60 to 90 with sphincter preservation. The untested assumption is that the impact of sphincter preservation on quality-of-life (QOL) outweighs any acute and late morbidity relating to combination chemoradiotherapy. In practice, many patients are unable to tolerate or require dose modification of one or both components of the chemoradiotherapy. Furthermore,...

Summary

Chemoprevention of esophageal adenocarcinoma by PPIs and NSAIDs remains a highly promising and rapidly developing field of medical research. Despite popular opinion and common practice amongst medical practitioners, expert consensus recently rejected the statement that normalization of esophageal acid exposure by acid suppression reduces the risk of developing esophageal adenocarcinoma from Barrett's epithelium (4). The same expert opinion did, however, unanimously accept that epidemiologic...

Suppression

Oncogenes (Ras & src) Interleukin 1 Hypoxia Benzo a pyrene uv light Epidermal growth factor Transforming growth factor beta TNF alpha FIGURE 1 Induction and suppression of cyclo-oxygenase-2. Abbreviations ras, reticular activating system TNF, tumor necrosis factor. metastases, IL-6 with cancer cell invasion and haptoglobin with implantation and angiogenesis. These processes, some of which are discussed in more detail later in this chapter, provide a basis for our understanding of both...

Surgical Harms Postoperative Complications

The mortality of gastrectomy remains high in nonspecialist settings, and appears to be higher in low-volume units (73), in elderly or unfit patients (47), and perhaps in males. Gastrectomy shares many postoperative complications with other major abdominal operations. In addition to the major complications leading to postoperative mortality, there are a variety of others of importance shown in the following table. Bleeding and wound dehiscence are relatively rare, as are deep vein thrombosis and...

T3n0 T4n0

With 3- to 5-cm margins Not indicated for T1, as above for body of pancreas ( tail) Medial L hemidiaphragm, adjacent body of pancreas ( tail) As for T2N0 plus sites of adherence with 3- to 5-cm margins Not indicated for T1, as above for T2 into subserosa Based on T stage Body of pancreas ( tail) Body of pancreas ( tail) As for T3N0 Pylorus distal 1 3 Yes, spare 2 3 of one Based on T stage kidney (usually L) T2N0 with invasion in Variable subserosa

Patterns Of Metastases

Disease dissemination can occur from the primary tumor either by local infiltration, lymphatic spread, or via the bloodstream. The most common site of spread of disease is to the liver, and approximately 80 of patients will have hepatic involvement at the time of death. The liver has a dual blood supply from the hepatic portal circulation, along which most metastases are thought to spread, as well as from the hepatic artery. Isolated lesions confined to anatomic segments can frequently be...

Nutrition And Esophageal Adenocarcinoma

The increasing incidence of esophageal adenocarcinoma over the course of the past 30 years has provoked scientific and epidemiologic interest. Most relevant, nutrition-based research to date consists of case-controlled studies. Nonetheless, certain dietary associations with the disease have emerged (Fig. 3). Obesity and a high fat diet have been seen to increase the risk of esopha-geal cancer, whereas several nutrients appear to reduce its incidence. These are discussed individually. Obesity is...

How Can Morbidity Be Minimized When Delivering Radiotherapy To A Patient With Rectal Cancer

The small benefits from the addition of SCPRT to TME surgery necessitate that additional toxicity from radiotherapy is minimized if the therapeutic ratio favors such treatment. In locally advanced and inoperable rectal cancer, it is also important to minimize the toxicity of combined chemo-radiotherapy followed by surgery. Patient selection and the radiotherapy technique employed are likely to be important factors in reducing acute and late radiation toxicity. A review of the toxic-ity seen in...

Pancreato Duodenal Carcinoids

Pancreatic carcinoids account for just over 1 of all cases (94), and exhibit a far higher metastatic rate than all other carcinoids apart from those arising in the ileo-cecal region (94). Five-year survival is extremely less (29 ) when compared to other sites of carcinoid tumors (2327,94). Since these tumors behave more like noncarcinoid pancreatic neuroendocrine tumors, the surgical management should therefore be analogous to that for exocrine pancreatic carcinoma (95). Lymph node metastases...

Lawrence D Wagman

Liver Tumor Program, Division of Surgery, City of Hope National Medical Center, Duarte, California, U.S.A. Palliation has been part of surgical practice since the dawn of medicine, yet the meaning of palliative surgery has evolved over time and varies from surgeon to surgeon. In the past, palliative surgery simply meant not curative. Today, we define palliative surgery as any operation that removes symptom(s) or impending symptom(s). Thus, a palliative operation that completely eradicates...

Cholangiocarcinoma Involving the Distal Bile Duct

Tumors of the lower bile duct are classified according to their anatomical location, although there may be considerable overlap. Mid-bile duct tumors arise below the confluence in the common bile duct between the upper border of the duodenum and the cystic duct distal bile duct tumors are those arising anywhere from the duodenum to the papilla of Vater (6). Tumors of the distal bile duct represent approximately 20 to 30 of all cholangiocarcinomas and 5 to 10 of all periampullary tumors...

Hepatic Arterial Infusion Chemotherapy as Second Line Treatment

Leonard et al. have recently reviewed the response rates and survival data from trials evaluating second-line chemotherapy after irinotecan or oxaliplatin failure. The response rates were generally less than 20 and median survival is around 10 months (85). For example, Tournigand et al. reported response rates of 15 with FOLFOX6 and 4 with FOLFIRI, respectively (86). As described above, HAI therapy when combined with newer cytotoxic agents has demonstrated encouraging second-line activity (up...

Intergroup 0116 Trial

The well-designed INT 0116 study reported by MacDonald in 2001, established postoperative chemoradiotherapy as the standard of care for patients with resectable gastric cancer (13). Patients who underwent a complete resection with negative margins were stratified according to tumor node metastases (TNM) staging and then randomized to surgery alone (275 patients) versus surgery plus adjuvant therapy (281 patients). The treatment protocol in the adjuvant arm consisted of chemotherapy beginning 20...

Neoadjuvant And Adjuvant Treatment For Esophageal Cancer

Surgery remains the standard approach in resectable esophageal cancer. Many patients still die from metastases or from locoregional relapse. This has resulted in an interest in combined therapeutic modalities. Attempts to improve cure rates through the use of systemic chemotherapy alone, radiotherapy alone, or the combination chemoradiotherapy have been extensively studied during the last 20 years. Over the last decade, the use of neoadjuvant (induction) protocols aiming at downsizing or...

Valrie Boige and David Malka

Gastrointestinal Tract Oncology Service, Gustave Roussy Institute, Villejuif, France Biliary tract neoplasms account for 1 to 2 of all cases of cancer, with only approximately 7000 cases presenting in the United States annually. They include intrahepatic, perihilar, and distal cholangiocarcinomas ( 20-25 , 50-60 , and 20-25 of cases, respectively), and gallbladder carcinomas, the more common of the two types (1). More than 95 of cases are adenocarcinomas, often well-differentiated and...

What Is The Role Of Radiotherapy In The Treatment Of Rectal Cancer And How Is This Role Influenced When Total

The investigation of the potential role of radiotherapy in rectal cancer was prompted by the unacceptable risk of local recurrence following conventional surgery when total excision of the mesorectum was not performed. This risk varied between 15 and 50 (1). In addition, when local recurrence occurred, it was associated with significant morbidity and was almost always fatal (1,2). Prior to the Dutch Total Mesorectal Excision (TME) trial which examined the role of short-course preoperative...

Liver Resection Vs Transplantation For Hepatocellular Carcinoma

Liver transplantation is the optimal treatment for HCC because it provides the widest possible resection margins for the cancer, removes the underlying cirrhotic liver tissue that is at risk for the development of de novo HCC, and restores normal hepatic function (41). With the refinement of the selection criteria mentioned in the previous section, several studies have shown TABLE 1 Proposed Criteria for Selection of Hepatocellular Carcinoma Candidates for Liver Transplantation Criteria for...

Methylene Blue Dye Color Variation Esophageal Cancer

There has been an improvement in the outcome of surgical resection for esophageal carcinoma in recent years (1). In a review of publications of esophagectomy performed during the decade 1990-2000, the overall mortality from surgery was 6.7 , compared with 13 for the period 1980-1988 (2). Overall five-year survival for those undergoing resection currently ranges from 23 for Western series to 30.5 for Eastern patients (2). This may be in part due to better selection of cases through more accurate...

Surgery For Residual And Recurrent Anal Squamouscell Carcinoma

Previous studies on the outcomes of salvage surgery after initial CRT for anal SCCa are retrospective, and the majority of these are small. Residual disease has been determined by positive biopsy less than six months following the end of treatment. Recurrence is usually determined by positive biopsy more than six months after cessation of treatment. Some information on salvage surgery after CRT can be gleaned from studies reporting the overall experience of single institutions in treating anal...

Contributors

Arciero Fox Chase Cancer Center, Philadelphia, Pennsylvania, U.S.A. Stephen Attwood Department of Upper GI Surgery, North Tyneside General Hospital, North Shields, U.K. Dimitra G. Barabouti James H. Quillen VA Medical Center, Mountain Home, Tennessee, U.S.A. Hugh Barr Cranfield Health, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, U.K. Johanna Bendell Division of Oncology and Transplantation, Duke University Medical Center, Durham, North Carolina, U.S.A. Val rie Boige...

Hepatic Reserve

In general, patients considered for hepatic resection for colorectal metastases do not have viral hepatitis or cirrhosis. Thus, a good rule of thumb is that such resections can be performed safely if two segments of functional liver can be preserved. Some clinicians will rely on volumetric assessment radiologically for patient selection 25 . It is generally accepted that if greater than 20 functional residual liver can be preserved, a liver resection can be performed safely. The only TABLE 1...

Preoperative Evaluation and Assessment of Resectability

Cholangiocarcinoma And Surgery

Evaluation of patients with hilar cholangiocarcinoma is principally an assessment of resecta-bility, since resection is the only effective therapy. First and foremost, the surgeon must assess the patient's general condition and fitness for operation, which usually includes partial hepatectomy. The presence of significant comorbid conditions, chronic liver disease, and or portal hypertension generally precludes resection. In these patients, biliary drainage is the most appropriate intervention,...

Surgery For Inguinal Lymph Node Disease

Radiation Therapy Groins

Inguinal lymph nodes are usually included in the RT field when anal SCCa patients are treated with CRT. Lee et al. reported on the University of Florida experience with elective inguinal lymph node RT in 164 patients with pelvic malignancies at risk for inguinal nodal metastases 30 . Primary sites included the anal canal, distal rectum, and the distal genitourinary GU tract. In 148 patients, both groins were clinically negative 16 patients had unilateral clinical lymphadenopa-thy. The authors...

Results Of The Eortc-gtcct Phase Iii Trial Of Irradiation Vs Irradiation And Cddp In Inoperable Esophageal Cancer

1 Kelsen DP, Ginsberg R, Pajak TF, et al. Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer. N Engl J Med 1998 339 27 1979-1984. 2. Medical Research Council Oesophageal Cancer Working Group. Surgical resection with or without preoperative chemotherapy in oesophageal cancer a randomised controlled trial. Lancet 2002 359 9319 1727-1733. 3. Wang C, Ding T, Chang L. A randomized clinical study of preoperative chemotherapy for esophageal carcinoma. Zhonghua...

Extent of Resection Hemicolectomy Vs Segmental Resection

The extent of surgical resection for tumors located in the left side of the colon was evaluated by a prospective, randomized study conducted by Rouffet et al. 12 from the French Association for Surgical Research. They compared left hemicolectomy with left segmental colectomy in 270 consecutive patients with colonic carcinoma located from the left third of the transverse colon up to the colorectal junction. Patients were randomly assigned to undergo either left hemi-colectomy, where the entire...

M0 M0 M0 M0 M0

The Japanese Research Society for Gastric Cancer JRSGC took a quite different approach to staging and classification, and set out a detailed set of clinical rules to accurately describe gastric cancer in 1963. They have published multiple subsequent editions of their initial set of rules, and in 1998 published their second English edition, based on the thirteenth Japanese edition 19 . The position within the stomach of the primary tumor is assigned to three locations C-area proximal stomach...