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There are few published data on aldosterone and cortisol co-secreting adrenal tumours. Failure to perform comprehensive preoperative endocrine investigations in patients with adrenal "incidentalomas" or in those thought to be secreting only one hormone may account for this. Clinically patients with such lesions may have evidence of hypertension and hypokalaemia with no features of cortisol excess. Preoperative diagnosis of such lesions with accurate endocrinological work up is essential to prevent adrenal insufficiency and haemodynamic crises following removal of such glands. We present a series of 4 patients with co-secreting tumours treated by laparoscopic adrenalectomy between September 2010 and March 2011. Our experience suggests that dual secretors are more common than originally thought. A high index of suspicion and adequate endocrine work up is paramount in diagnosing such tumours and in experienced hands, laparoscopic adrenalectomy with appropriate substitutive steroid cover is safe, feasible and curative for these functioning adrenal tumours.

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BACKGROUND: Stage IV colorectal cancer encompasses a broad patient population in which both curative and palliative management strategies may be used. In a phase II study primarily designed to assess the efficacy of capecitabine and oxaliplatin, we were able to prospectively examine the outcomes of patients with stage IV colorectal cancer according to the baseline resectability status. METHODS: At enrolment, patients were stratified into three subgroups according to the resectability of liver disease and treatment intent: palliative chemotherapy (subgroup A), conversion therapy (subgroup B) or neoadjuvant therapy (subgroup C). All patients received chemotherapy with capecitabine 2000 mg m(-2) on days 1-14 and oxaliplatin 130 mg m(-2) on day 1 repeated every 3 weeks. Imaging was repeated every four cycles where feasible liver resection was undertaken after four or eight cycles of chemotherapy. RESULTS: Of 128 enrolled patients, 74, 22 and 32 were stratified into subgroups A, B and C, respectively. Attempt at curative liver resection was undertaken in 10 (45%) patients in subgroup B and 19 (59%) in subgroup C. The median overall survival was 14.6, 24.5 and 52.9 months in subgroups A, B and C, respectively. For patients in subgroups B and C who underwent an attempt at curative resection, 3-year progression-free survival was 10% in subgroup B and 37% for subgroup C. CONCLUSIONS: This prospective study shows the wide variation in outcome according to baseline resectability status and highlights the potential clinical value of a modified staging system to distinguish between these patient subgroups.

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BACKGROUND: Oesophageal cancer with liver metastasis is rare and when diagnosed is usually advanced and surgical management is contraindicated.Method-Results: We report the case of a patient who presented with oesophageal cancer and liver metastasis. The patient received chemotherapy combined with RFA to liver tumour. Subsequently she was subjected to oesophagectomy and liver resection of segment 5 extended into segment 8. Patient underwent adjuvant chemotherapy post-operatively and remains disease-free until now, 29 months after operation. CONCLUSION: Oesophageal cancer with concomitant liver metastasis is a rare and lethal disease. Multimodal management including surgery may offer prolonged survival in highly selected patients.

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Pancreatic cancer is an aggressive malignancy, relatively resistant to chemotherapy and radiotherapy, which usually presents late. Disease specific mortality approaches unity despite advances in adjuvant therapy. We present the first reported case of complete pathological response following neoadjuvant therapy in a locally advanced pancreatic adenocarcinoma.

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BACKGROUND/AIMS: With recognition of its benefits, there has been a trend towards minimizing blood loss during hepatic parenchymal transection but no one technique has been shown to be superior to another. We analyzed our experience with using a novel combined technique of saline-linked radiofrequency precoagulation and ultrasonic aspiration for hepatic parenchymal transection. METHODOLOGY: This combined technique was used in 12 patients for parenchymal transection for metastatic hepatic disease and data was collected prospectively. Total blood loss, bile leaks, parenchymal transection time, hepatic pedicle clamp requirement and 30-day mortality were used as outcome measures. RESULTS: Four minor and 8 major hepatic resections were performed in twelve patients of who two underwent a synchronous resection of the rectum. The median blood loss was 525 mL (IQR 312.5-1150) in these patients who had a median postoperative stay of 7 days (IQR 7-14). The median parenchymal transection time was 120 minutes (IQR 100-153.75). No patient required portal triad clamping at anytime and there was no mortality. CONCLUSIONS: Combined technique of saline-link radiofrequency ablation and ultrasonic aspiration appears to be comparable to other techniques and should be considered as an alternative.

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The incidence of metastatic osteosarcoma is increasing because of improved results following multi-agent chemotherapy and resection of the primary tumour. Metastases occur most commonly in the lungs, whereas bowel metastases are rare. We describe a 25-year-old female who presented with melaena six years after successful resection of an osteosarcoma of her right femur, and one year after resection of a solitary pulmonary metastasis. Imaging revealed a lesion arising within both the duodenum and the pancreas for which a Whipple's pancreatoduodenectomy was carried out, achieving complete resection. Histological examination confirmed the diagnosis of metastatic osteosarcoma. We believe this is only the second such case reported. At 11 months post-operatively she had no detectable disease. Although rare, osteosarcoma can metastasise to the intestine. The surgeon must be aware of this complication, and that bowel metastases are potentially resectable.

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BACKGROUND: Gastrointestinal sarcomas are rare stromal tumors and most are classifiable as malignant gastrointestinal stromal tumors. They have a high propensity for intraabdominal recurrence. It is unclear whether there is a survival advantage from reoperation for recurrent disease or if surgery should be confined to symptom relief. The authors have attempted to identify features that may allow the selection of patients most likely to benefit from reoperation. METHODS: Retrospective univariate and multivariate analyses of 60 patients with recurrent gastrointestinal sarcoma, accrued from a prospective data base between July 1982 and September 1995, were performed. RESULTS: Initial recurrence was evident by a median of 20 months from primary resection. Most patients (85%) had an initial symptomatic recurrence. Local recurrence was seen in 76% of patients, but in half of these synchronous hepatic metastases were present. None had disease outside of the abdomen. Complete resection of recurrent disease was possible in only one-third of cases. Median survival after surgery for recurrence was 15 months, but was longest for patients whose recurrence took the form of liver metastases in the absence of disease elsewhere. In multivariate analysis of post-recurrence survival, the only significant determinant of survival was the length of the disease free interval between the initial operation and recurrence. CONCLUSIONS: Survival following recurrence of a gastrointestinal sarcoma is largely determined by the tumor biology, one manifestation of which is the disease free interval. Except for patients with a long disease free interval, surgery should be reserved largely for symptom control.

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OBJECTIVE: To analyze the outcome of 200 patients with gastrointestinal stromal tumor (GIST) who were treated at a single institution and followed up prospectively. SUMMARY BACKGROUND DATA: A GIST is a visceral sarcoma that arises from the gastrointestinal tract. Surgical resection is the mainstay of treatment because adjuvant therapy is unproven. METHODS: Two hundred patients with malignant GIST were admitted and treated at Memorial Hospital during the past 16 years. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor recurrence and factors that predict survival. RESULTS: Of the 200 patients, 46% had primary disease without metastasis, 47% had metastasis, and 7% had isolated local recurrence. In patients with primary disease who underwent complete resection of gross disease (n = 80), the 5-year actuarial survival rate was 54%, and survival was predicted by tumor size but not microscopic margins of resection. Recurrence of disease after resection was predominantly intraabdominal and involved the original tumor site, peritoneum, and liver. CONCLUSIONS: GISTs are uncommon sarcomas. Tumor size predicts disease-specific survival in patients with primary disease who undergo complete gross resection. Tumor recurrence tends to be intraabdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.

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In this study, 56 women who presented to the breast clinic with nipple discharge have been reviewed. Patients were selected for surgery by a triple assessment of clinical examination, discharge cytology and breast imaging. Surgical intervention was required in 17 women. Significant pathology was found in 11 cases including five with carcinoma (in situ or invasive). Those women who did not have carcinoma detected at their initial presentation have been reviewed after a minimum of 5 years. None has gone on to develop breast cancer. We conclude that women with nipple discharge, but no positive findings on triple assessment, are not at an increased risk of the development of carcinoma. In addition, nipple discharge spontaneously resolves in 73% of women over a 5 year period.

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