RESUMEN
For many patients with GI malignancies, the seeding of the abdominal cavity with tumor cells, called peritoneal carcinomatosis, is a common mode of metastases and disease progression. Prognosis for patients with this aspect of their disease remains poor, with high disease-related morbidity and complications. Uniform and proven practices that provide optimal palliative care and quality of life for these patients are needed. The objective of this review is to critically assess the current literature regarding palliative strategies in the management of peritoneal carcinomatosis and associated symptoms in patients with advanced GI cancers. Despite encouraging results in the select population where cytoreductive surgery and intraperitoneal chemotherapy are indicated, the majority of patients who develop peritoneal carcinomatosis in the setting of GI cancers have poor prognosis, with malignant bowel obstruction representing a common terminal phase of their disease process. For all patients with peritoneal carcinomatosis, aggressive symptom control and early multimodality palliative care as further outlined should be sought.
Asunto(s)
Neoplasias Gastrointestinales/terapia , Obstrucción Intestinal/terapia , Ascitis/diagnóstico , Ascitis/terapia , Neoplasias Gastrointestinales/tratamiento farmacológico , Neoplasias Gastrointestinales/cirugía , Humanos , Obstrucción Intestinal/tratamiento farmacológico , Obstrucción Intestinal/cirugía , Desnutrición/prevención & control , Manejo del Dolor , Cuidados PaliativosRESUMEN
PURPOSE: Although mucinous adenocarcinomas represent 6% to 19% of all colorectal adenocarcinomas, little is known about the genome-wide alterations associated with this malignancy. We have sought to characterize both the gene expression profiles of mucinous adenocarcinomas and their clinicopathologic features. METHODS: Tumors from 171 patients with primary colorectal cancer were profiled using the Affymetrix HG-U133Plus 2.0 GeneChip with characterization of clinicopathologic data. Gene ontology software was used to identify altered biologic pathways. RESULTS: Twenty (11.7%) mucinous adenocarcinomas and 151 (89.3%) nonmucinous adenocarcinomas were identified. Mucinous adenocarcinomas were more likely to be diagnosed with lymph node (LN) metastases (75% vs 51%, P = .04) and at a more advanced stage (85% vs 54%, P = .006) but long-term survival (5-y survival 58.9% vs 58.7%, P = NS) was similar. Mucinous adenocarcinomas displayed 182 upregulated and 135 downregulated genes. The most upregulated genes included those involved in cellular differentiation and mucin metabolism (eg, AQP3 + 4.6, MUC5AC +4.2, MUC2 + 2.8). Altered biologic pathways included those associated with mucin substrate metabolism (P = .002 and .02), amino acid metabolism (P = .02), and the mitogen-activated protein kinase cascade (P = .02). DISCUSSION: Using gene expression profiling of mucinous adenocarcinomas, we have identified the differential upregulation of genes involved in differentiation and mucin metabolism, as well as specific biologic pathways. These findings suggest that mucinous adenocarcinomas represent a genetically distinct variant of colorectal adencarcinoma and have implications for the development of targeted therapies.
Asunto(s)
Adenocarcinoma Mucinoso/genética , Adenocarcinoma/genética , Neoplasias Colorrectales/genética , Perfilación de la Expresión Génica , Adenocarcinoma/patología , Adenocarcinoma Mucinoso/patología , Análisis de Varianza , Acuaporina 3/genética , Distribución de Chi-Cuadrado , Neoplasias Colorrectales/patología , Humanos , Metástasis Linfática , Análisis por Micromatrices , Mucina 5AC/genética , Mucina 2/genética , Modelos de Riesgos Proporcionales , Tasa de SupervivenciaRESUMEN
BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is less common than classic invasive ductal adenocarcinoma of the pancreas but is being diagnosed with greater frequency since its clinicopathologic features are now clearly defined. Often multifocal in its existence along the pancreatic duct, IPMN is associated with a significant risk for recurrence and warrants vigilant surveillance, even after a margin-negative resection. METHODS: The authors present a case highlighting important features in the diagnosis, workup, and management of IPMN. They also review existing literature highlighting epidemiology, findings of molecular studies, and current treatment recommendations. RESULTS: Physicians and patients must carefully weigh the risks and benefits associated with treatment options. Limited resection in a patient with a high likelihood of multifocal disease preserves pancreatic parenchyma and reduces the risk of developing pancreatic endocrine and exocrine insufficiency. Though the risk of developing invasive cancer in the remnant is small, the prognosis is worse if it does develop. Conversely, total pancreatectomy eliminates the risk of future malignancy but involves life-long insulin and exogenous pancreatic enzyme dependence and significant associated morbidity. CONCLUSIONS: Decision making for effective treatment of IPMN is complex and requires attention to detail by an interdisciplinary team with experience in the diagnosis and management of these tumors. Treatment must be individualized based on patient life expectancy in terms of remaining years and overall quality. Molecular profiling of these lesions may allow for more precise tailoring of treatment in the future.
Asunto(s)
Adenocarcinoma Mucinoso/terapia , Carcinoma Ductal Pancreático/terapia , Carcinoma Papilar/terapia , Neoplasias Pancreáticas/terapia , Anciano , Femenino , HumanosRESUMEN
INTRODUCTION: Traditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NCR) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NCR. MATERIAL AND METHODS: Between July 1994 and August 2006, 44 patients were identified as having undergone full-thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NCR. Fifteen patients were deemed medically unfit for radical resection, and 29 would have required abdominoperineal resection but were opposed to colostomy. RESULTS: Our patient population consisted of 26 men and 18 women, with a median age of 69 (range, 43-89) and a median follow up of 64 months (6-153). Thirty-one patients had a clinical complete response (cCR) to NCR of which 19 (61%) had a pathologic CR (pCR). Seven (16%) of 44 patients sustained disease recurrence of which two were local only, two local and systemic, and three systemic only. Only four (9%) patients had died of disease at current follow up. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively. Five patients underwent radical resection immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE. CONCLUSIONS: TAE of T2 and T3 rectal cancers following NCR is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multi-center trials.