Carlo Staudacher

Objective: To compare the diagnostic performance of MR and diffusion-weighted imaging (DWI), multidetector CT, endoscopic ultrasonography (EUS) and 18F-FDG (fluorine-18 fludeoxyglucose) positron emission tomography CT (PET-CT) in the pre-operative locoregional staging of oesophageal cancer.Methods: 18 patients with oesophageal or Siewert I tumour (9 directly treated with surgery and 9 addressed to chemo-/radiotherapy before) underwent 1.5-T MR and DWI, 64-channel multidetector CT, EUS and PET-CT before (n = 18) and also after neoadjuvant treatment (n = 9). All images were analysed and staged blindly by dedicated operators (seventh TNM edition). Two radiologists calculated independently the apparent diffusion coefficient from the first scan. Results were compared with histopathological findings. After the population had been divided according to local invasion (T1–T2 vs T3–T4) and nodal involvement (N0 vs N+), sensitivity, specificity, accuracy, positive- and negative-predictive values were calculated and compared. Quantitative measurements from DWI and PET-CT were also analysed.Results: For T staging, EUS showed the best sensitivity (100%), whereas MR showed the highest specificity (92%) and accuracy (83%). For N staging, MR and EUS showed the highest sensitivity (100%), but none of the techniques showed adequate results for specificity. Overall, MR showed the highest accuracy (66%) for N stage, although this was not significantly different to the other modalities. The apparent diffusion coefficient was different between surgery-only and chemo-/radiotherapy groups (1.90 vs 1.30 × 10−3 mm2 s−1, respectively; p = 0.005)—optimal cut off for local invasion: 1.33 × 10−3 mm2 s−1 (p = 0.05). Difference in standardized uptake value was also very close to conventional levels of statistical significance (8.81 vs 13.97 g cm−3, respectively; p = 0.05)—optimal cut off: 7.97 g cm−3 (p = 0.44).Conclusion: In this pilot study, we have shown that MR with DWI could enrich the current pre-operative work-up for oesophageal cancer and could be used for T and N staging. However, larger studies will need to be carried out before introducing this technique in the standard diagnostic pathway, in order to understand if MR with DWI could change its management and replace more costly or invasive tests such as PET-CT or EUS.Advances in knowledge: This pilot study represents the first effort where the four techniques have been prospectively compared together for oesophageal cancer staging. The combination of MR and DWI could provide important, additional information for staging and initial treatment decision-making.

Purpose To assess whether changes in diffusion-weighted MRI (DW-MRI) and ¹⁸F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), correlate with treatment response to neoadjuvant therapy (NT), as expressed by tumor regression grade (TRG), from locally advanced gastric adenocarcinoma (GA). Materials and Methods Seventeen patients underwent both DW-MRI and ¹⁸F-FDG-PET/CT scans before and after the end of NT. Apparent diffusion coefficient (ADC) and mean standardized uptake value (SUV) corrected for partial volume effect (PVC-SUV_BW-mean) were evaluated and compared with histopathological TRG. Results Pre- and post-NT and percentage changes for ADC and PVC-SUV_BW-mean were assessed. Post-NT ADC and ΔADC showed a significant inverse correlation with TRG (r = −0.71; P = 0.0011 and r = −0.78; P = 0.00020, respectively) and significant differences in their mean values were found between responders (TRG 1–2-3) and nonresponders (TRG 4–5) (P = 0.0009; P = 0.000082, respectively). No correlations with TRG were found for pre-NT ADC and for all PVC-SUV_BW-mean values as well as between ΔADC and Δ PVC-SUV_BW-mean. Conclusion DW-MRI seems more accurate than ¹⁸F-FDG-PET/CT and ADC modifications may represent a reproducible tool to assess tumor response for GA. J. Magn. Reson. Imaging 2014;40:1147–1157.

We report the case of a 40-year-old male patient who presented with melaena and acute anaemia. Endoscopic ultrasound examination revealed a lesion with a central depression measuring 2.5 cm, arising from the lateral wall of the second portion of the duodenum. Because of this rare location, a very invasive procedure (duodenopancreatectomy) might have been required for tumour resection. We avoided this operation and implemented an alternative solution. A laparoscopic wedge resection of the duodenal tumour was successfully completed. Operating time was 200 min and blood loss 50 ml. The patient was discharged on postoperative day 3, after an uneventful postoperative recovery. Histopathologically, the tumour was diagnosed as a low-risk gastrointestinal stromal tumour. Despite the fact that laparoscopic surgery requires more complex technique than open surgery and the acquisition of advanced laparoscopic skills depending on prior laparoscopic experience, laparoscopic wedge resection should be considered as a valid treatment for duodenal stromal tumour.

To evaluate oncological and surgical outcome of patients submitted to neoadjuvant therapy for advanced rectal cancer. One hundred thirty eight patients (86 male, 52 female, mean age 61.4 years), with tumour of lower (58; 42%), middle (66; 48%), upper rectum (14; 10%), showing a clinical stage II (23; 17%) or III (115; 83%) and with an average distance from anal verge of 6.5 cm, submitted to fractionated "long-course" RT with CT locally staged by US and MR before and after neoadjuvant therapy and operated on after 4-6 weeks by its end. Surgical procedures (71 of which laparoscopic) were: 114 AR (83.8%), 19 APR (14%) and 3 TEM (2.2%). Mean nodal-sampling was 14.9. A complete or partial response was observed in 48.5% of the patients (67/138). With a mean follow-up of 30 months, local recurrence rate was 5.7%. Five-years overall survival and disease-fee-survival were respectively 73% and 60%. We observed a significant clinical (p < 0.004) and pathological (p < 0.005) downstaging. Pre-treatment clinical stage was not significant. On the contrary, postoperative yTNM was significant for yT (p < 0.001) and yN (p < 0.0003). Non-responder patients had worse prognosis (5-years survival 30%). The variable with higher prognostic significance was yN (p < 0.0003), especially if we distinguish N1 by N2 (p < 0.0004). The response to neoadjuvant therapy represents a significant prognostic variable.

To analyze retrospectively the operative results and five-year survival after single-stage resection and primary anastomosis for right- or left-sided colonic malignant obstruction. From 1994 to 2002, 83 patients with acute obstruction due to primary cancer underwent a one-stage procedure, 36 (43.3%) for cancer of the right and 47 (56.7%) of the left colon. Of the 47 patients with left acute obstruction, 45 were treated with intraoperative colonic on-table lavage for decompression and wash-out before resection and anastomosis. Long-term survival was compared with the outcome of 369 patients with colonic cancer without obstruction 144 (39%) right and 225 (61%) left. Overall operative morbidity and mortality were 25.3% and 6%, respectively. Overall anastomotic leakage rate was 6%. Kaplan-Meier curves showed five-year survival rates poorer for patients operated on for obstructing malignancy than those observed for patients without obstruction (p=0.0001, Log-Rank test), obstructing malignancy was associated with more advanced age (p<0.0005) and staging of the cancer. One-stage resection and primary anastomosis can be applied to the majority of patients with malignant colonic obstruction and it allows achieving excellent operative results. Obstructing colonic cancer proved to be associated to a worse long-term survival.

In the past few years, minimally invasive therapy for pancreatic diseases has made significant strides but the role of laparoscopic pancreaticoduodenectomy is still controversial.

The aim of the study was to evaluate the results of laparoscopic pancreatectomy for pancreatic tumours. Four women and three men underwent laparoscopic pancreatectomy and were recruited into the study retrospectively over the period from June 2002 to February 2004. Pancreaticoduodenectomy (n = 4), intermediate pancreatectomy (n = 1) and distal pancreatic resection with splenectomy (n = 2) were successfully performed. Operative mortality was nil. The postoperative morbidity included two low-output pancreatic leaks. Mean operating time, blood loss and hospital stay were 342 minutes, 289 mL and 14 days, respectively. The pathological diagnosis was ductal adenocarcinoma in one, neuroendocrine tumour in five and metastatic melanoma in one. All patients are still well after a median follow-up of 7 months (range: 1-20 months). The patients appear to benefit from laparoscopic pancreatectomy for pancreatic tumours. The minimally invasive approach ensures adequate treatment but requires the expertise of highly skilled laparoscopic surgeons.