Update and review of the multidisciplinary management of stage IV colorectal cancer with liver metastases

<p>Abstract</p> <p>Background</p> <p>The management of stage IV colorectal cancer with liver metastases has historically involved a multidisciplinary approach. In the last several decades, there have been great strides made in the therapeutic options available to treat these patients with advancements in medical, surgical, locoregional and adjunctive therapies available to patients with colorectal liver metastases(CLM). As a result, there have been improvements in patient care and survival. Naturally, the management of CLM has become increasingly complex in coordinating the various aspects of care in order to optimize patient outcomes.</p> <p>Review</p> <p>A review of historical and up to date literature was undertaken utilizing Medline/PubMed to examine relevant topics of interest in patients with CLM including criterion for resectability, technical/surgical considerations, chemotherapy, adjunctive and locoregional therapies. This review explores the various disciplines and modalities to provide current perspectives on the various options of care for patients with CLM.</p> <p>Conclusion</p> <p>Improvements in modern day chemotherapy as allowed clinicians to pursue a more aggressive surgical approach in the management of stage IV colorectal cancer with CLM. Additionally, locoregional and adjunctive therapies has expanded the armamentarium of treatment options available. As a result, the management of patients with CLM requires a comprehensive, multidisciplinary approach utilizing various modalities and a more aggressive approach may now be pursued in patients with stage IV colorectal cancer with CLM to achieve optimal outcomes.</p

Comprehensive molecular characterization of gastric adenocarcinoma

Gastric cancer is a leading cause of cancer deaths, but analysis of its molecular and clinical characteristics has been complicated by histological and aetiological heterogeneity. Here we describe a comprehensive molecular evaluation of 295 primary gastric adenocarcinomas as part of The Cancer Genome Atlas (TCGA) project. We propose a molecular classification dividing gastric cancer into four subtypes: tumours positive for Epstein–Barr virus, which display recurrent PIK3CA mutations, extreme DNA hypermethylation, and amplification of JAK2, CD274 (also known as PD-L1) and PDCD1LG2 (also knownasPD-L2); microsatellite unstable tumours, which show elevated mutation rates, including mutations of genes encoding targetable oncogenic signalling proteins; genomically stable tumours, which are enriched for the diffuse histological variant and mutations of RHOA or fusions involving RHO-family GTPase-activating proteins; and tumours with chromosomal instability, which show marked aneuploidy and focal amplification of receptor tyrosine kinases. Identification of these subtypes provides a roadmap for patient stratification and trials of targeted therapies

Major pancreatic resections for suspected cancer in a community-based teaching hospital: lessons learned.

BACKGROUND: The literature reports 4-10% mortality rate, 30-60% morbidity rate, and 9-29% anastomotic leak rate after pancreaticoduodenectomy (PD) performed for periampullary tumors. These data demonstrate a linear relationship between surgical volume and outcome. METHODS: The objective of this study was to evaluate the experience of a high-volume hospital with low-volume pancreatoduodenectomy for suspected cancer. The study was designed as a retrospective review of medical records of all patients who underwent pancreatoduodenal resection or total pancreatectomy for a suspected periampullary carcinoma between January 1994 and December 2003. The setting of the study was a community-based teaching hospital with a general surgery residency training program. RESULTS: A total of 63 patients underwent pancreatoduodenal resection or total pancreatectomy. All procedures were performed by a total of 15 different surgeons; however, 27 operations were performed by one surgeon. Pre-operative diagnosis in most cases was either a known malignancy-27 cases (43%) or a tumor of the head of the pancreas, suspicious for malignancy-36 cases (57%). One patient underwent a total pancreatectomy. In 62 patients a pancreatoduodenal resection (Whipple procedure) was performed. Post-operative 30-day mortality was 4.7% (three patients). Overall in-hospital mortality was 9.5% (six patients). Ten (16.1%) had a leak of the pancreato-jejunal anastomosis, six of which resolved with non-operative management. Of the remaining four patients, three died from peritonitis or consequences of erosive hemorrhage. CONCLUSIONS: Post-operative leak of the pancreatic anastomosis represents a technical challenge. Although most of the leaks can be treated non-operatively, those that lead to peritonitis or erosive hemorrhage warrant operative intervention. Major pancreatic resections can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital

Hepatic resection at a major community-based teaching hospital can result in good outcome.

BACKGROUND: The relationship between volume and outcome has been established in the literature for several complex surgical procedures. Improved outcome has been suggested at high-volume hospitals or with high-volume surgeons. METHODS: The objective of this study was to evaluate the experience of a low-volume hospital with major liver resections. The setting of the study was a community-based teaching hospital with a surgical residency training program. RESULTS: A total of 46 major liver resections were performed between January 1992 and December 2002. Procedures performed were hepatic lobectomies (n = 15; right, n = 11; left, n = 4), trisegmentectomies (n = 5; right, n = 3; left, n = 2), segmentectomies (n = 16; left lateral, n = 12; right posterior, n = 4), and wedge resections (n = 10). Operations were performed by 14 different surgeons; however, 23 operations were performed by 1 surgeon. Sixteen patients (34%) developed 23 complications. The average length of hospital stay was 9.7 days. There were no 30-day postoperative mortalities. Out of 46 patients who underwent major liver resection over the last 10 years, 13 patients are still alive. Overall survival ranged from 3 to 84 months, with a median survival of 30.6 months. The actual 5-year survival was 36% (8 of 22) for all patients operated on \u3e5 years ago, and the actual 2-year survival was 61% (20 of 33). CONCLUSIONS: Major liver resection can be performed safely with low rates of morbidity and operative mortality with careful selection of patients at a low-volume community-based teaching hospital

Comprehensive molecular characterization of gastric adenocarcinoma

Gastric cancer is a leading cause of cancer deaths, but analysis of molecular and clinical characteristics has been complicated by histological and aetiological heterogeneity. Here we describe a comprehensive molecular evaluation of 295 primary gastric adenocarcinomas as part of The Cancer Genome Atlas (TCGA) project. We propose a molecular classification dividing gastric cancer into four subtypes: tumours positive for Epstein-Barr virus, which display recurrent PIK3CA mutations, extreme DNA hypermethylation, and amplification of JAK2, CD274 (also known as PD-L1) and PDCD1LG2 (also known as PD-L2); microsatellite unstable tumours, which show elevated mutation rates, including mutations of genes encoding targetable oncogenic signalling proteins; genomically stable tumours, which are enriched for the diffuse histological variant and mutations of RHOA or fusions involving RHO-family GTPase-activating proteins; and tumours with chromosomal instability, which show marked aneuploidy and focal amplification of receptor tyrosine kinases. Identification of these subtypes provides a roalmap for patient stratification and trials of targeted therapiesclose19