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Importance: Merkel cell carcinoma (MCC) is an aggressive cutaneous neuroendocrine carcinoma. Due to its relatively low incidence and limited prospective trials, current recommendations are guided by historical single-institution retrospective studies., Objective: To evaluate the overall survival (OS) of patients in Canada with head and neck MCC (HNMCC) according to American Joint Committee on Cancer 8th edition staging and treatment modalities., Design, Setting, and Participants: A retrospective cohort study of 400 patients with a diagnosis of HNMCC between July 1, 2000, and June 31, 2018, was conducted using the Pan-Canadian Merkel Cell Cancer Collaborative, a multicenter national registry of patients with MCC. Statistical analyses were performed from January to December 2022., Main Outcomes and Measures: The primary outcome was 5-year OS. Multivariable analysis using a Cox proportional hazards regression model was performed to identify factors associated with survival., Results: Between 2000 and 2018, 400 patients (234 men [58.5%]; mean [SD] age at diagnosis, 78.4 [10.5] years) with malignant neoplasms found in the face, scalp, neck, ear, eyelid, or lip received a diagnosis of HNMCC. At diagnosis, 188 patients (47.0%) had stage I disease. The most common treatment overall was surgery followed by radiotherapy (161 [40.3%]), although radiotherapy alone was most common for stage IV disease (15 of 23 [52.2%]). Five-year OS was 49.8% (95% CI, 40.7%-58.2%), 39.8% (95% CI, 26.2%-53.1%), 36.2% (95% CI, 25.2%-47.4%), and 18.5% (95% CI, 3.9%-41.5%) for stage I, II, III, and IV disease, respectively, and was highest among patients treated with surgery and radiotherapy (49.9% [95% CI, 39.9%-59.1%]). On multivariable analysis, patients treated with surgery and radiotherapy had greater OS compared with those treated with surgery alone (hazard ratio [HR], 0.76 [95% CI, 0.46-1.25]); however, this was not statistically significant. In comparison, patients who received no treatment had significantly worse OS (HR, 1.93 [95% CI, 1.26-2.96)]., Conclusions and Relevance: In this cohort study of the largest Canada-wide evaluation of HNMCC survival outcomes, stage and treatment modality were associated with survival. Multimodal treatment was associated with greater OS across all disease stages.

This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In this article we provide a critical review of the evidence available for surgical management of the nodal basin in melanoma, with an aim to ensure an understanding of risks and benefits for all lymph node surgery offered to patients, and alternatives to surgical management where appropriate., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Malignant adnexal tumors of the skin (MATS) are rare. We aimed to measure the survival of patients with MATS and identify predictors of improved survival., Methods: A retrospective review of MATS treated at our institution from 1990 to 2012., Results: There were 50 patients within the time period. Median age was 59.5 years (range 22-95); primary site was the head and neck (52%); most common histologic subtypes were skin appendage carcinoma (20%) and eccrine adenocarcinoma (20%); and the vast majority were T1 (44%). Most patients (98%) underwent surgical treatment. Chemotherapy and radiation were administered to 8 and 14% of patients, respectively. Recurrence rate was 12%. Median OS was 158 months (95% CI, 52-255). OS and recurrence-free survival at 5 years were 62.4 and 47.4% and at 10 years 56.7 and 41.5%, respectively. Five-year and 10-year disease-specific survival (DSS) was 62.9%. Age > 60 years was an unfavorable predictor of OS (HR 12.9, P < .0008) and recurrence-free survival (RFS) (HR 12.53, P < .0003). Nodal metastasis was a negative predictor of RFS (HR 2.37, P < 0.04) and DSS (HR 7.2, P < 0.03) while treatment with chemotherapy was predictive of poor DSS (HR 14.21, P < 0.03)., Conclusions: Younger patients had better OS and RFS. Absence of nodal metastasis translated to better RFS and DSS. Lymph node basin staging is worth considering in the workup and treatment.

Background: In locally advanced rectal adenocarcinoma, 15% to 20% of patients treated with neoadjuvant chemoradiation (nCRT) achieve a pathologic complete response (pCR). The benefit of adjuvant chemotherapy is controversial in rectal cancer. Our objective was to evaluate the effect of clinical risk factors and adjuvant chemotherapy usage on the outcomes of the pCR patient population., Patients and Methods: We performed a retrospective study using the National Cancer Data Base from 2006 to 2013. The primary outcome was overall survival (OS). The association between OS and patient characteristics (demographics, tumor variables, and treatment) was examined using multivariable Cox regression modelling., Results: A total of 2891 patients were identified who had achieved a pCR. Of these 2891 patients, 2102 received nCRT and 789 received nCRT followed by adjuvant chemotherapy. The median follow-up duration was 43.2 months. The factors significantly associated with OS included age (P < .001), gender (P = .011), Charlson-Deyo comorbidity score (P < .001), grade (P = .029), clinical T stage (P = .030), carcinoembryonic antigen negativity (P = .002), and receipt of adjuvant chemotherapy (P < .001). Nodal status was not significantly associated with survival. The 5-year OS rate was 94% in the nCRT plus adjuvant group compared with 84% in the nCRT-alone group. Adjuvant chemotherapy was more likely to be given to younger patients (aged < 60 years), higher grade, lower Charlson-Deyo comorbidity score, elevated carcinoembryonic antigen level, higher clinical T stage, and higher clinical N stage., Conclusion: Our findings showed a significant improvement in OS for patients who received nCRT plus adjuvant chemotherapy compared with those who received nCRT alone. The nCRT plus adjuvant patients were more likely to be younger, have a lower comorbidity score, have clinical ≥ T3 disease, and have clinical node-positive disease. Thus, a selection bias could have been present. Nonetheless, even in the setting of already excellent outcomes, for patients with locally advanced rectal adenocarcinoma who achieve a pCR, the additional benefit of adjuvant chemotherapy should be weighed against the potential for toxicity., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

A negative sentinel lymph node biopsy (SLNB) for stage IB (T1b/T2a N0) melanoma would predict an excellent long-term prognosis. Combined with the concept of conditional survival, an "abbreviated" cancer surveillance strategy was implemented to reduce the number of visits and total length of follow-up. Retrospective review of all pathologic stage IB melanoma patients (negative SLNB) at a single institution between 2006 and 2008 after implementation of an "abbreviated" cancer surveillance; clinic visits every six months for five years followed by one annual visit (total follow-up six years). Patient demographics, tumor characteristics, and information regarding recurrences were obtained. Recurrence-free, disease-specific, and overall survival were calculated. Eighty-seven patients underwent the "abbreviated" cancer surveillance. Median age was 55.4 years and 50.6 per cent were male. Median Breslow thickness was 1.1 mm (range 0.5-2.0 mm) and 1.1 per cent were ulcerated. Primary tumor site was 49 per cent extremities, 39 per cent trunk, and 12 per cent head/neck. Median follow-up was 68.6 months. Five-year recurrence-free, disease-specific, and overall survivals were 89, 95, and 88 per cent, respectively. During surveillance, 10 patients had concerning symptoms or physical findings prompting subsequent workup, all of which were negative for recurrence/metastases. There were only three true melanoma recurrences; all were distant metastases and presented symptomatically between scheduled follow-up visits. In light of the excellent prognosis for pathologic (SLNB negative) stage IB melanoma, an "abbreviated" cancer surveillance schedule based on conditional survival would reduce both direct and indirect costs in this cohort. The few recurrences were symptomatic and unlikely to have changed with more intensive surveillance.

Background: Patients with stage IV cancer and bowel obstruction present a complicated management problem. The aim of this study was to evaluate the role of the palliative care service (PC) in the management of this complex disease process., Methods: A retrospective analysis was conducted of all patients admitted to Roswell Park Cancer Institute with stage IV cancer and bowel obstruction from 2009 to 2012 after the institution of a formal PC. This cohort was matched to similar patients from 2005 to 2008 (no palliative care service or NPC). Patient characteristics and outcomes included baseline demographics, comorbid conditions, do-not-resuscitate (DNR) status, laboratory parameters, medical and surgical management, length of stay, symptom relief, and disposition status., Results: A total of 19 patients were identified in the PC group. Based on the PC group baseline characteristics, 19 patients were identified for the NPC group using matched values. Regarding outcomes, there were significant differences in the medication regimens (narcotics, octreotide, and Decadron) between the 2 groups. In the PC group, 14 of 19 patients showed improvement compared to 9 of 19 in the NPC group. Nearly 60% of patients in the PC group had a formal DNR order versus 10.5% in NPC ( P = .002). A significantly higher percentage of patients were discharged to hospice in the PC group (47.4% vs 0.0%, P = .006)., Conclusion: Palliative care consultation improves the quality of care for patients with stage IV cancer and bowel obstruction, with particular benefits in symptom management, end-of-life discussion, and disposition to hospice.

Adjuvant radiation therapy reduces the risk of local recurrence of breast cancer. Our study identifies patient and tumor characteristics that guide the use of adjuvant radiation therapy and evaluates our adherence to recommended guidelines. A retrospective review was undertaken of 1,667 stage I-III breast cancer patients treated at a regional cancer center from 2004 to 2007. Univariate analysis was used to select factors for entry into a multivariate stepwise logistic regression model. Descriptive statistics was used to compare use of radiation therapy of 382 stage I-III breast cancer patients diagnosed in 2013 to those from 2004 to 2007. The primary indicators for any radiation therapy (n = 935) were breast conserving surgery (OR 79.5, 95% CI [47.6-132.9]), four to nine positive lymph nodes (71.9, [17.0-304.7]), and greater than nine positive lymph nodes (60.5, [7.9-460.8]). In post-mastectomy patients (n = 408), the indicators for radiation therapy were four to nine positive lymph nodes (29.4, [12.9-67.4]) and greater than nine positive lymph nodes (108.3, [14.5-807.5]). In breast conserving surgery patients (n = 1,081) 96.1% were offered radiation therapy. Patients offered local-regional radiation therapy were more likely to have any positive nodes (ORs 4.3-91.0), have had a mastectomy (4.3, [2.2-8.4]), and had larger tumors (1.6, [1.3-2.0]). Local-regional radiation therapy was recommended less frequently in node positive patients in 2004-2007 (35.0%) compared to in 2013 (70.5%) [p < 0.001]. Patients who had a breast conserving surgery or had four or more positive lymph nodes were more likely to receive radiation therapy. Patients with any positive lymph nodes, larger tumors, or who had a mastectomy were more likely to receive local-regional radiation therapy. Our institution was more likely to offer local-regional radiation therapy in node positive breast cancer in 2013 compare to 2004-2007., (© 2016 Wiley Periodicals, Inc.)

Introduction: The prognosis of appendiceal mucinous neoplasms (AMN) is directly related to their histopathology. Existing classification schemes encompass tumors with widely divergent clinical behaviors within a single diagnosis, making it difficult for clinicians to interpret pathology reports to counsel patients on optimal management. We sought to examine pathology reports generated for AMN for inclusion of essential histologic features., Methods: Pathology reports of appendectomy specimens with a diagnosis of AMN (2002-2015) at our center ("internal") and from referring institutions ("external") were retrospectively reviewed for inclusion of the following 5 essential items: layer of invasion, mucin dissection (low grade neoplasms only), perforation, margins, and serosal implants., Results: Sixty-nine patients were included, 54 with external reports available. Benign/low grade tumors comprised 29.0% and 27.8% of internal and external reports, respectively. Thirty-seven internal reports (53.6%) were signed out by specialist gastrointestinal pathologists. External reports were 66.7% complete for layer of invasion, 26.7% for mucin dissection, 64.8% for perforation, 68.5% for margins, 53.7% for serosal implants, and 18.5% for all items. Internal reports were 75.4% complete for layer of invasion, 40.0% for mucin dissection, 40.6% for perforation, 82.6% for margins, 69.6% for serosal implants, and 17.4% for all items. Eight external (14.8%) and 24 internal (34.8%) reports were synoptic. Synoptic reports were more likely to be complete for all key items both external and internal., Conclusion: Most pathology reports are incomplete for essential features needed for management and discussion of AMN with patients. Synoptic reports improve completeness of reporting for these tumors., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Sarcoma tumors are rare and heterogeneous, yet they possess many characteristics that may facilitate immunotherapeutic responses. Both active strategies including vaccines and passive strategies involving cellular adoptive immunotherapy have been applied clinically. Results of these clinical trials indicate a distinct benefit for select patients. The recent breakthrough of immunologic checkpoint inhibition is being rapidly introduced to a variety of tumor types including sarcoma. It is anticipated that these emerging immunotherapies will exhibit clinical efficacy for a variety of sarcomas. The increasing ability to tailor immunologic therapies to sarcoma patients will undoubtedly generate further enthusiasm and clinical research for this treatment modality.

Importance: The American Joint Committee on Cancer (AJCC) has proposed the inclusion of pretreatment serum carcinoembryonic antigen (CEA) levels (C stage) into the conventional TNM staging system of colon cancer. The latter proposal has yet to be widely adopted because of the lack of long-term survival estimates of after C-stage incorporation into AJCC staging., Objectives: To evaluate whether long-term overall and cancer-specific survival is affected by inclusion of C stage into the standard AJCC TNM staging and to study the implications on survival estimates., Design, Setting, and Participants: We performed a retrospective study of all patients diagnosed as having histologically proven colonic adenocarcinoma from January 1, 2004, through December 31, 2005, from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. We stratified each AJCC stage as C0 (normal) or C1 (elevated) based on the pretreatment serum CEA level. Median follow-up was 71 months., Main Outcome and Measures: Five-year estimates of overall and disease-specific survival and hazard ratios (HRs) for estimates of risk of overall and disease-specific mortality., Results: A total of 16 619 patients were evaluated, and of these, 8878 patients had C0 disease and 7741 had C1 disease. C1 stage was independently associated with a 51% and 59% increased risk of overall (HR, 1.51; 95% CI, 1.44-1.59; P < .001) and disease-specific mortality (HR, 1.59; 95% CI, 1.49-1.69; P < . 001) at a median follow-up of 71 months. Analysis of survival of the AJCC stages subdivided as C0 or C1 revealed a significant worse prognosis of C1 AJCC stages compared with the respective C0 AJCC stages. The magnitude of change in survival was large enough to cause clustering of survival estimates of C1 vs C0 cancers across various AJCC stages. Analysis of patients with stage I, II, and III cancer revealed that node-negative C1 disease was associated with prognosis similar or worse than node-positive C0 disease., Conclusions and Relevance: Inclusion of C stage into the AJCC TNM staging of colon cancer revealed significant differences dependent on C stage in terms of 5-year survival. C-stage inclusion resulted in substantial change in survival estimates, with C1 status portending a prognosis to certain stages similar to or worse than higher AJCC TNM stages with C0 status. We recommend routine pretreatment CEA testing as standard of care in colon cancer and use of C stage for multimodality treatment planning and risk stratification in prospective studies and randomized clinical trials.

Introduction: In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million)., Methods: Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review., Results: From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change., Conclusions: An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.

Background: In most jurisdictions, a minority of patients are discussed at multidisciplinary cancer conference (MCC) despite recommendations for such reviews. We assessed the impact of MCC review of gastrointestinal (GI) cancers at a stand-alone cancer center., Methods: Patient data were prospectively collected on consecutive cases presented at a GI MCC during a 6-month period. Original treatment plans were collected confidentially before presentation and compared to post-MCC treatment plans. We defined changes in management plans as major (change in treatment modality) or minor (testing prior to original plan)., Results: A total of 149 cases were evaluated: 115 upper GI (gastric/small bowel-10 %, liver-32 %, pancreaticobiliary-36 %), and 34 lower GI (23 %). Reasons for presentation were: questions regarding progression/metastases (44 %), management (26 %), diagnosis (21 %), pathology (15 %), and resectability (7 %). Physicians were certain of their original plans being the final recommendations in 84 % (n = 125). Change in management was recommended in 36 %; 72 % were major and 28 % were minor. Patients underwent all recommended treatments at our institution in 77 % of cases, a portion in 5 %, and no recommended treatments in 18 %. On multivariate analysis, physician degree of certainty for original management plan was not predictive of a change in management plan (p = 0.61)., Conclusions: Although certainty of prediscussion treatment plan is high, changes in treatment recommendations occurred in more than one-third of patients after GI MCC. This prospective study demonstrates the value of MCC in GI cancer sites, even at a stand-alone cancer center.

Introduction. Superficial soft tissue sarcomas (S-STS) are generally amenable to wide excision. We hypothesized that local recurrence (LR) should be low, even without radiation therapy (RT), and sought to examine the contribution of depth to LR and OS. Methods. Patients with S-STS were retrospectively reviewed. Demographics, tumor features, treatment received, and outcomes were analyzed. Results. 103 patients were identified. Median age was 55 years; 53% of patients were female. Tumor site was 39% in trunk, 38% in the lower extremity, 14% in the upper extremity, and 9% in other locations. The most common histology was 36% leiomyosarcoma. Median tumor size was 2.8 cm (range 0.2-14 cm). Sixty-six percent of tumors were of intermediate/high grade. RT was administered preoperatively in 6% of patients and postoperatively in 15% of patients. An R0 resection was accomplished in 92%. At a median follow-up of 34.2 months (range 2.3-176), 9 patients had a LR (8.7%). Tumor size and grade were not associated with LR. OS was not associated with any tumor or patient variables on univariate analysis. Conclusions. LR was low for S-STS, even with large or high grade tumors and selective use of RT. Surgical resection alone may be adequate therapy for most patients. Superficial location seems to supersede other factors imparting a good prognosis for this group of tumors.

Background: The Quality Initiative in Rectal Cancer (QIRC) trial targeted surgeon intraoperative technique and not radiation therapy (RT) use. We performed a post hoc analysis of RT use among patients in the QIRC trial, not by arm of trial but rather for the entire group. We wished to identify associations between local recurrence risk and use of preoperative, postoperative or no RT., Methods: We compared demographic, tumour and process of care measures among patients receiving preoperative, postoperative or no RT. A multivariable Cox regression model assessed local recurrence risk., Results: The QIRC trial enrolled 1015 patients at 16 hospitals between 2002 and 2004. Radiation therapy use did not differ between trial arms, and median follow-up was 3.6 years. For the preoperative, postoperative and no RT groups, respectively, the percentage of patients was 12.8%, 19.3% and 67.9%; the percentage of stage II/III tumours was 57.0%, 88.7% and 48.1%; and the local recurrence rate was 5.3%, 10.2% and 5.5% (p = 0.05). After controlling for patient and tumour characteristics, including tumour stage, the hazard ratio (HR) for local recurrence was increased in the postoperative RT versus the no RT group (HR 1.64, 95% confidence interval 1.04-2.58, p = 0.027)., Conclusion: Use of preoperative RT was low; most patients with stage II/III disease did not receive RT and, as expected, the postoperative RT group had the highest risk of local recurrence. Our results suggest opportunities to improve rectal cancer RT use in Ontario.

The clinical practice of hyperthermic intraperitoneal chemoperfusion (HIPEC) for carcinomatosis has lacked preclinical justification. A standardized mouse model was created to evaluate the independent effects of intraperitoneal chemotherapy. Diffuse colorectal carcinomatosis was generated in mice prior to intraperitoneal lavage with mitomycin C (MMC) at clinically comparable dosing for variable lengths of time. Tumor volumes, MMC tissue concentrations and survival were measured in comparison to saline lavage and intravenous MMC. Magnetic resonance imaging revealed a direct correlation between tumor volume, MMC dose and exposure time and survival. Intravenous MMC demonstrated a rapid clearance from the blood, lower peritoneal tissue concentrations, less tumor growth inhibition and decreased survival compared to intraperitoneal administration. Intraperitoneal chemotherapy inhibited tumor growth independent of cytoreduction or hyperthermia, demonstrated improved peritoneal tissue concentration and was associated with increased survival. These data support the clinical utility of the intraperitoneal chemotherapy component of HIPEC.

The risks and benefits of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CS/HIPEC) continue to be debated by the oncology community. A retrospective analysis of contemporary data (2003-2011) was performed to provide objective information regarding surgical morbidity, mortality, and survival for patients undergoing CS/HIPEC at a comprehensive cancer center. While procedure-associated morbidity was comparable to other major surgical oncology procedures, there was no operative or 30-day mortality and 60-day mortality was 2.7%. Increasing numbers of bowel resections were found to correlate to an increased incidence of deep surgical site infections (including abscess and enterocutaneous fistula) and need for reoperation which was in turn associated with a decreased overall survival (OS) and progression-free survival (PFS). Five-year OS rates varied by site of tumor origin and histology (disseminated peritoneal adenomucinosis [91.3%], Mesothelioma [80.8%], Appendiceal Adenocarcinoma [38.7%], and Colorectal Adenocarcinoma [38.2%]). With an acceptable morbidity and mortality rate, CS/HIPEC should be included as an effective treatment modality in the multidisciplinary care of select patients with peritoneal metastases.

Background: Patients with stage IV cancer and bowel obstruction (BO) present a complicated management problem. We sought to determine if specific parameters could predict outcome after surgery., Methods: Records of patients with stage IV cancer and BO treated from 1991 to 2008 were reviewed. For surgical patients, 30-day morbidity and 90-day mortality were assessed using exact multivariable logistic regression methods., Results: Of 198 patients, 132 (66.7%) underwent surgery, 66 medical treatment alone, and demographics were similar. A total of 41 patients (20.7%) were diagnosed with stage IV cancer and BO synchronously, all treated surgically; the remaining presented metachronously. Medically managed patients were more likely to have received chemotherapy in the 30 days prior to BO (45 of 66 [68.2%] vs 40 of 132 [30.3%], p < .01). In the surgical group, 30-day morbidity was 35.6%, while 90-day mortality was 42.3%. Median overall survival for synchronous patients was 14.1 months (95% confidence interval [95% CI] 7.6-23.2), and 3.7 months (95% CI 2.5-5.2) and 3.6 months (95% CI 1.5-5.2) for metachronous patients treated surgically and medically, respectively. A multivariate model for 90-day surgical mortality identified low serum albumin, metachronous presentation, and ECOG > 1 as predictors of death (p < .05). A model for 30-day surgical morbidity yielded low hematocrit as a predictive factor (p < .05)., Conclusions: This cohort identifies characteristics indicative of morbidity and mortality in stage IV cancer and BO. Low serum albumin, ECOG > 1, and metachronous presentation predicted for 90-day surgical mortality. These data suggest factors that can be used to frame treatment discussion plans with patients.

Soft-tissue sarcomas are a heterogeneous group of tumors that are capable of generating host immune responses. Historically the role of antitumor immunity was first studied in soft-tissue sarcomas. Subsequent in vitro studies, preclinical models, and clinical observations have provided ample evidence for an immunologic approach to sarcoma treatment. Initial clinical trials involving vaccines and adoptive immunotherapy have demonstrated promising results. The continued search for sarcoma tumor-associated antigens as specific targets is central to the clinical translation of effective immunotherapies., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Pneumatosis intestinalis (PI) occurs when inter-luminal air enters the bowel wall of the gastrointestinal tract via a mucosal defect. The condition is caused by numerous disease states, direct trauma, and various drugs. When PI is secondary to drug therapy, discontinuation of the offending agent results in the resolution of PI. We report on the case of a 73-year-old male with a history of refractory gastrointestinal stromal tumor experiencing PI while on sunitinib treatment. PI was noted via computed tomography (CT) scans 68 days after starting sunitinib therapy and showed near complete resolution on a follow up CT performed one month after discontinuing sunitinib. Given that a CT scan performed five months prior to the initiation of sunitinib did not show PI, lack of abdominal symptoms in our patient, and resolution of PI after discontinuing sunitinib, the cause of PI in our patient was likely due to sunitinib treatment.

Purpose: Adjuvant therapy reduces the risk of recurrence of breast cancer. This study was undertaken to determine characteristics guiding choice of adjuvant therapy., Methods: A retrospective review was completed of characteristics of patients with breast cancer (stages I-III) at a regional center from 2004 to 2007. Univariate analysis was used to select factors (P < 0.1) for entry into multivariate stepwise logistic regressions. Odds ratios with 95% confidence intervals were calculated. A P value of <0.05 was significant, and comparisons were two-tailed., Results: Model 1 (n = 744) assessed the prescription of any adjuvant regimen (hormonal or chemotherapy). Indicators of choice of any regimen were positive lymph nodes [OR 16.5, CI (6.2, 44.0)], grade [4.0, (2.5, 6.0)], size [3.2, (2.1, 4.6)], PR [0.3, (0.1, 0.6)], and multicentricity [0.2 (0.04, 0.66)]. Model 2 (n = 663) assessed chemotherapy in ER+ patients. Indicators of addition of chemotherapy were stage [8.9 (4.3, 18.6), grade [5.5 (3.1, 9.6)], positive nodes [2.7 (1.1, 6.4)], physician experience [1.1 (1.0, 1.2)], age [0.8 (0.79, 0.86)], and year of treatment [0.8, (0.4, 0.9)]. Model 3 (n = 867) assessed prescription of a more aggressive chemotherapy regimen and indicators were treatment by a breast specialist oncologist [8.6 (1.7, 43.1)], stage [3.6 (2.4, 5.4)], positive nodes [2.6 (1.7, 4.1)], year of treatment [1.5 (1.3, 1.8)], size [1.2 (1.1, 1.4)], age [0.91 (0.89, 0.93)], and PR [0.4 (0.3, 0.6)]., Conclusions: This study verifies known factors for choice of adjuvant therapy, excludes others thought to be important, and quantifies effects at our center. Further studies are required to compare these models where risk stratification is different.

Laparoscopic gastrectomy is safe for benign lesions; however, such surgery for cancer remains controversial. The aim of this study is to compare outcomes in open versus laparoscopic gastrectomy. Data on patients undergoing open (n = 15) or laparoscopic (n = 52) gastrectomy revealed a mean age of 61.7 and 70.5 years, respectively (P = .06). Mean operative time was 32.3 minutes longer in the laparoscopic group (P = .24). The difference in median length of hospital stay was 3 days (open 12 days, laparoscopic 9 days). Postoperative morbidity (< 30 days) was not different; however, there were more early respiratory complications in the open group (P = .009). There were 4/6 (66.7%) open and 2/29 (6.9%) cancer recurrences. Laparoscopic approach for treatment of gastric lesions is safe and does not have a deleterious effect on cancer-related outcome.

Previous work has shown that phorbol esters modulate chemotaxis. Here, we demonstrate that PKC activation via phorbol 12-myristate 13-acetate (PMA) treatment of MDA-MB-231 cells inhibits EGF-induced cell spreading, the initial event of motility and chemotaxis. Of five PKC isoforms (alpha,iota,lambda,delta,and epsilon) identified in this cell line, PMA treatment only induced PKCalpha translocation from the cytosol to the membrane, an event that correlated with the development of the rounded morphology. Cell recovery was linked to PKCalpha downregulation in part via the proteasome pathway since treatment with MG101 in the presence of PMA did not lead to PKCalpha degradation and cell recovery. Co-immunoprecipitation and immunolocalization demonstrated that EGF co-localized with PKCalpha and EGFR, however, PMA did not abrogate EGFR transactivation. This work suggests that PKCalpha is the primary target of PMA acting as a transient negative regulator of cell spreading and motility in MDA-MB-231 breast cancer cells.

Docosahexaenoate (DHA) has been increasingly recognized as an important fatty acid for neural and visual development during the first 6 mon of life. One important point of controversy that remains is the degree to which adequate levels of DHA can be acquired from endogenous synthesis in infants vs. what should be provided as dietary DHA. We have approached this problem by a retrospective analysis of published body composition data to estimate the actual accumulation of DHA in the human infant brain, liver, adipose tissue, remaining lean tissue, and whole body. Estimating whether infants can synthesize sufficient DHA required comparison to and extrapolation from animal data. Over the first 6 mon of life, DHA accumulates at about 10 mg/d in the whole body of breast-fed infants, with 48% of that amount appearing in the brain. To achieve that rate of accumulation, breast-fed infants need to consume a minimum of 20 mg DHA/d. Virtually all breast milk provides a DHA intake of at least 60 mg/d. Despite a store of about 1,050 mg of DHA in body fat at term birth and an intake of about 390 mg/d alpha-linolenate (alpha-LnA), the brain of formula-fed infants not consuming DHA accumulates half the DHA of the brain of breast-fed infants while the rest of the body actually loses DHA over the first 6 mon of life. No experimental data indicate that formula-fed infants not consuming DHA are able to convert the necessary 5.2% of alpha-LnA intake to DHA to match the DHA accumulation of breast-fed infants. We conclude that dietary DHA should likely be provided during at least the first 6 mon of life.