Publications

Differential diagnosis of hypoglycemic patients should include insulinoma. Plasma insulin-to-glucose ratio greater than 0.3 or C-peptide levels of 2 nmol/L or greater suggest insulinoma. Abdominal CT scan can exclude metastatic disease and identify uncommonly large islet cell tumors, but has poor sensitivity for localizing insulinomas; transgastric endoscopic ultrasound is the most sensitive technique. Palpation combined with intraoperative ultrasound identifies most tumors at operation and gives vital information about surrounding structures. If no tumor is found, blind distal pancreatectomy should not be performed, and the patient should be referred to an endocrinologist or endocrine surgeon for diagnostic confirmation and further localization. Laparoscopy is a viable alternative to open tumor resection; laparoscopic ultrasound can facilitate localization and guide safe resection.

Since the first minimally invasive colon resection 15 years ago, laparoscopic colectomy has been implemented as techniques have evolved. Like the laparoscopic approach for other operations, minimally invasive colectomy has potential benefits of improved short-term outcomes. Questions have been raised, however, regarding its use for colorectal cancer resection. Until recently, it was unclear whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. This review provides an overview of laparoscopic colectomy and techniques and examines recent data from randomized, controlled trials that report the short- and long-term outcomes after laparoscopic colectomy for cancer.

BACKGROUND

Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case series from selected centers. Population-based data can provide more realistic estimates of the risks and benefits of operations in this group.

STUDY DESIGN

We performed a retrospective cohort study of patients undergoing major resections for lung, esophageal, and pancreas cancer. Using the Nationwide Inpatient Sample (1994 to 2003), we examined operative mortality and discharge disposition in octogenarians (aged 80+ years), relative to younger patients (aged 65 to 69 years) (n = 272,662). We then used the Surveillance and End Results-Medicare-linked database (1992 to 2001) to measure late survival in the elderly (n = 14,088).

RESULTS

Operative mortality among octogenarians was substantially higher than that of younger patients (aged 65 to 69 years) for all three cancers (esophagectomy, 19.9% versus 8.8%, p < 0.0001; pancreatectomy, 15.5% versus 6.7%, p < 0.0001; lung resection, 6.9% versus 3.7%, p < 0.0001). A large proportion of octogenarians were transferred to extended care facilities after operation, ranging from 24% after lung resection to 44% after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11% after pancreatectomy, 18% after esophagectomy and 31% after lung cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbid diagnoses--10% versus 14% for pancreatectomy, 15% versus 23% for esophagectomy, and 27% versus 37% for lung resection.

CONCLUSIONS

Population-based outcomes after high-risk cancer operation in octogenarians are considerably worse than typically reported in case series and published survival statistics. Such information might better inform clinical decision making in this high-risk group.

Activated T cells may express FOXP3. It is thought that FOXP3 is not a specific marker to determine regulatory T cells (Treg) in humans. Here, we examined the functional phenotype and cytokine profile of the in vitro induced FOXP3(+) T cells, primary FOXP3(+) and FOXP3(-) T cells in patients with ulcerative colitis and tumors including colon carcinoma, melanoma, hepatic carcinoma, ovarian carcinoma, pancreatic cancer, and renal cell carcinoma. We observed similar levels of suppressive capacity of primary FOXP3(+) T cells in blood, tumors, and colitic tissues. Compared with primary FOXP3(-) T cells in the same microenvironment, these primary FOXP3(+) T cells expressed minimal levels of effector cytokines, negligible amount of cytotoxic molecule granzyme B, and levels of suppressive molecules interleukin-10 and PD-1. Although the in vitro activated T cells expressed FOXP3, these induced FOXP3(+) T cells expressed high levels of multiple effector cytokines and were not functionally suppressive. The data reinforce the fact that FOXP3 remains an accurate marker to define primary Tregs in patients with cancer and autoimmune disease. We suggest that the combination of FOXP3 and cytokine profile is useful for further functionally distinguishing primary Tregs from activated conventional T cells.

BACKGROUND

Patients with obstructive sleep apnea syndrome (OSAS) are known to have an increased risk for motor vehicle crashes. They suffer from sleep-related respiratory abnormality causing repetitive arousal leading to daytime sleepiness. In turn, it has been demonstrated that sleepiness can impair human psychomotor performance causing slowing of reaction times (RTs). Patients with OSAS present with RTs comparable to young adults under the influence of blood alcohol concentrations above the legally permitted level to drive a motor vehicle. Vigilance related risk levels in patients with upper airway resistance syndrome (UARS) and potential deficits in psychomotor performance are unknown.

METHODS

We designed a study to compare psychomotor performance in UARS and compared it to patients with OSAS. Forty-seven UARS patients were matched by gender and age with 47 OSAS patients. All subjects completed a standardized vigilant attention task utilizing reaction time before undergoing polygraphic sleep studies.

RESULTS

Patients with UARS presented worse psychomotor performance on most test metrics than patients with OSAS.

CONCLUSIONS

Our study results may suggest that patients with UARS may also present an increased risk for motor vehicle crashes as previously demonstrated in OSAS patients.

Th17 cells play an active role in autoimmune diseases. However, the nature of Th17 cells is poorly understood in cancer patients. We studied Th17 cells, the associated mechanisms, and clinical significance in 201 ovarian cancer patients. Tumor-infiltrating Th17 cells exhibit a polyfunctional effector T-cell phenotype, are positively associated with effector cells, and are negatively associated with tumor-infiltrating regulatory T cells. Tumor-associated macrophages promote Th17 cells through interleukin-1beta (IL-1beta), whereas tumor-infiltrating regulatory T cells inhibit Th17 cells through an adenosinergic pathway. Furthermore, through synergistic action between IL-17 and interferon-gamma, Th17 cells stimulate CXCL9 and CXCL10 production to recruit effector T cells to the tumor microenvironment. The levels of CXCL9 and CXCL10 are associated with tumor-infiltrating effector T cells. The levels of tumor-infiltrating Th17 cells and the levels of ascites IL-17 are reduced in more advanced diseases and positively predict patient outcome. Altogether, Th17 cells may contribute to protective human tumor immunity through inducing Th1-type chemokines and recruiting effector cells to the tumor microenvironment. Inhibition of Th17 cells represents a novel immune evasion mechanism. This study thus provides scientific and clinical rationale for developing novel immune-boosting strategies based on promoting the Th17 cell population in cancer patients.

PURPOSE

Black patients have worse prognoses than whites with breast or colorectal cancer. Mechanisms underlying such disparities have not been fully explored. We examined the role of hospital factors in racial differences in late mortality after surgery for breast or colon cancer.

METHODS

Patients undergoing surgery after new diagnosis of breast or colon cancer were identified using the Surveillance Epidemiology and End Results-Medicare linked database (1995 to 2005). The main outcome measure was mortality at 5 years. Proportional hazards models were used to assess relationships between race and late mortality, accounting for patient factors, socioeconomic measures, and hospital factors. Fixed and random effects models were used to account for quality differences across hospitals.

RESULTS

Black patients, compared with white patients, had lower 5-year overall survival rates after surgery for breast (62.1% v 70.4%, respectively; P < .001) and colon cancer (41.3% v 45.4%, respectively; P < .001). After controlling for age, comorbidity, and stage, black race remained an independent predictor of mortality for breast (adjusted hazard ratio [HR] = 1.25; 95% CI, 1.16 to 1.34) and colon cancer (adjusted HR = 1.13; 95% CI, 1.07 to 1.19). After risk adjustment, hospital factors explained 36% and 54% of the excess mortality for black patients with breast cancer and colon cancer, respectively. Hospitals with large minority populations had higher late mortality rates independent of race.

CONCLUSION

Hospital factors, including quality, are important mediators of the association between race and mortality for breast and colon cancer. Hospital-level quality improvement should be a major component of efforts to reduce disparities in cancer outcomes.