Is the covering of the resection margin after distal pancreatectomy advantageous?

BACKGROUND: In recent years, many advances in pancreatic surgery have been achieved. Nevertheless, the rate of pancreatic fistula following pancreatic tail resection does not differ between various techniques, still reaching up to 30% in prospective multicentric studies. Taking into account contradictory results concerning the usefulness of covering resection margins after distal pancreatectomy, we sought to perform a systematic, retrospective analysis of patients that underwent distal pancreatectomy at our center. METHODS: We retrospectively analysed the data of 74 patients that underwent distal pancreatectomy between 2001 and 2011 at the community hospital in Neuss. Demographic factors, indications, postoperative complications, surgical or interventional revisions, and length of hospital stay were registered to compare the outcome of patients undergoing distal pancreatectomy with coverage of the resection margins vs. patients undergoing distal pancreatectomy without coverage of the resection margins. Differences between groups were calculated using Fisher’s exact and Mann–Whitney U test. RESULTS: Main indications for pancreatic surgery were insulinoma (n=18, 24%), ductal adenocarcinoma (n=9, 12%), non-single-insulinoma-pancreatogenic-hypoglycemia-syndrome (NSIPHS) (n=8, 11%), and pancreatic cysts with pancreatitis (n=8, 11%). In 39 of 74 (53%) patients no postoperative complications were noted. In detail we found that 23/42 (55%) patients with coverage vs. 16/32 (50%) without coverage of the resection margins had no postoperative complications. The most common complications were pancreatic fistulas in eleven patients (15%), and postoperative bleeding in nine patients (12%). Pancreatic fistulas occurred in patients without coverage of the resection margins in 7/32 (22%) vs. 4/42 (1011%) with coverage are of the resection margins, yet without reaching statistical significance. Postoperative bleeding ensued with equal frequency in both groups (12% with coverage versus 13% without coverage of the resection margins). The reoperation rate was 8%. The hospital stay for patients without coverage was 13 days (5–60) vs. 17 days (8–60) for patients with coverage. CONCLUSIONS: The results show no significant difference in the fistula rate after covering of the resection margin after distal pancreatectomy, which contributes to the picture of an unsolved problem

Coordinated activation of VEGFR-1 and VEGFR-2 is a potent arteriogenic stimulus leading to enhancement of regional perfusion

Objective: The process of arteriogenesis is driven by various growth factors including vascular endothelial growth factor (VEGF)-A, which mediates its activity through VEGFR-2 (Flk-1/KDR) on endothelial cells and through VEGFR-1 (Flt-1) on endothelial cells and monocytes. The purpose of this study was to identify which of the VEGF receptors are involved in arteriogenesis in vivo. Methods: Collateral vessel growth was induced by femoral artery ligation in a mouse model of hindlimb ischemia. Following ligation, Balb/c mice were treated with different growth factors (VEGF-A, VEGF-E, PlGF-2, VEGF-E plus PlGF-2 or VEGF-A plus PlGF-2, activating either VEGFR-1, VEGFR-2, or both). After 1 week of treatment, hindlimb perfusion was assessed by perfusion scintigraphy using Tc-99m-MIBI. Results: The strongest improvement of regional perfusion was achieved by simultaneous activation of VEGFR-1 and VEGFR-2, using either VEGF-A or VEGF-A plus PlGF-2, with elevation of relative perfusion in the ischemic limbs from 0.61 to 0.83. The partial restoration in perfusion was associated with morphological changes typical for arteriogenesis. Moreover, specific inhibition of both VEGF-receptors using ZK 202650 resulted in a significant inhibition of arteriogenesis, indicating an active role of the VEGF system in compensatory arteriogenesis. Conclusion: The coordinated activation of both VEGFR-1 and VEGFR-2 represents a more potent arteriogenic stimulus compared to the isolated activation of either one of these two receptors. These data imply that the activation of both monocytes and endothelial cells is necessary to obtain a maximal VEGF-induced activation of arteriogenesi

Leser-Trélat sign presenting in a patient with ovarian cancer: a case report

<p>Abstract</p> <p>Introduction</p> <p>Seborrheic keratoses are very common findings in elderly patients. However, a sudden onset and dramatic increase in the number and size of these benign lesions deserves special attention, since this may represent the Leser Trélat sign, a rare paraneoplastic cutaneous syndrome.</p> <p>Case presentation</p> <p>A 92-year-old female presented to our clinic with multiple eruptive seborrheic keratoses, which had dramatically increased in size and number over the past two years. A diagnostic work-up revealed an ovarian carcinoma. Hence, cutaneous findings in our patient were consistent with the diagnosis of the Leser-Trélat sign.</p> <p>Conclusion</p> <p>The Leser-Trélat sign may coincide with the diagnosis of occult cancer or follow or precede it by months or years. Practitioners should take cases of eruptive seborrheic keratoses seriously and perform thorough patient examinations.</p

Effects of Radiotherapy in the treatment of multiple myeloma: a retrospective analysis of a Single Institution

Background: Palliative irradiation of osteolytic lesions is a considerable component in the treatment for patients with multiple myeloma. In this study, we analyzed the efficacy of irradiation in these patients. Patients and methods: We retrospectively analyzed 153 patients with multiple myeloma who were admitted to our department between 1989 and 2013. According to the staging system of Durie & Salmon 116 patients were classified as stage III. 107/153 patients were treated with radiotherapy of at least one and up to 6 bony lesions at different times. In order to evaluate the effect of local radiotherapy on pain relief and bone recalcification a uni-and multivariate analysis was performed using a binary logistic regression model to correct for multiple measurements. Complete information on dose, fractionation and volume of radiotherapy was available from 81 patients treated in 136 target volumes for pain relief, and from 69 patients treated in 108 target volumes for recalcification. Total radiation doses varied between 8 Gy to 50 Gy (median dose 25 Gy in 2.5 Gy fractions, 5 times a week). Results: Radiotherapy resulted in complete local pain relief in 31% and partial local pain relief in 54% of the patients. In the univariate analysis, higher total radiation doses (p = 0.023) and higher age (p = 0.014) at the time of radiotherapy were significantly associated with a higher likelihood of pain relief, whereas no significant association was detected for concurrent systemic treatment, type and stage of myeloma and location of bone lesions. The same variables were independent predictors for pain relief in the multivariate analysis. Recalcification was observed in 48% of irradiated bone lesions. In the uni-and multivariate analysis higher radiation doses were significantly associated (p = 0.048) with an increased likelihood of recalcification. Side effects of radiotherapy were generally mild. Conclusions: Higher total biological radiation doses were associated with better pain relief and recalcification in this retrospective evaluation of multiple myeloma patients. In addition, in the elderly the therapeutic measures appear to develop a better analgesic effect

The benefit of adjuvant radiotherapy after breast conserving surgery in older patients with low risk breast cancer- a meta- analysis of randomized trials

Purpose/Objective(s): It is currently unclear whether patients with low risk breast cancer receiving adjuvant endocrine therapy need adjuvant radiation therapy after breast conserving surgery. The data of randomized trials are available. Materials/Methods: In a database search 5 randomized trials including in total 3766 mostly elderly patients with early stage breast cancer treated either with adjuvant endocrine therapy or with endocrine therapy and additional whole breast radiation after breast conserving surgery were identified. Published hazard ratios for time to local recurrence were the basis of our meta-analysis. Meta-analysis of the effect sizes on local recurrence was performed using a random effects model based on parameter estimates of log hazard ratios in Cox models and their standard errors. Furthermore, overall survival was examined. Results: Adjuvant hormone therapy alone in mostly older patients with low risk breast cancer resulted in significantly shorter time to local relapse compared to radiation therapy combined with hormone therapy (Hazard Ratio: 6.8, 95% CI: 4.23-10.93, p < 0.0001). There was no significant difference for overall survival. Conclusion: Additional radiation therapy to hormone therapy did improve local relapse in breast cancer patients but did not show significant impact on overall survival

Definitive radiotherapy and Single-Agent radiosensitizing Ifosfamide in Patients with localized, irresectable Soft Tissue Sarcoma: A retrospective analysis

<p>Abstract</p> <p>Background and Purpose</p> <p>Standard therapy for soft-tissue sarcomas remains complete resection. For primary radiotherapy local control rates of 30-45% have been reported. We analyzed retrospectively 11 cases of radiochemotherapy with single-agent ifosfamide in patients with macroscopic soft-tissue sarcomas.</p> <p>Patients and Methods</p> <p>The patients were treated in irresectable high risk situations. Radiation therapy was performed with median 60 Gy. During the first and fifth week the concomitant chemotherapy with ifosfamide was added. Two patients received trimodal therapy with additional regional hyperthermia.</p> <p>Results</p> <p>The therapy was completed in 73% of the patients. Average local control time was 91 months, median disease-free-survival/overall-survival was 8/26 months. Five-year rates for local control/disease free survival/overall survival were 70%/34%/34%. The limited prognosis is mainly caused by systemic treatment failure.</p> <p>Conclusions</p> <p>The data strongly suggest a better outcome of radiochemotherapy with ifosfamide compared to radiotherapy alone and radiotherapy in combination with other radiosensitizers.</p