- Email: [email protected]
JACS CME-1 featured article, Volume 202, March 2006
CONTINUING MEDICAL EDUCATION PROGRAM
JACS CME-1 FEATURED ARTICLE, VOLUME 202, MARCH 2006 Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy? Sturgeon C, Shen WT, Clark OH, et al J Am Coll Surg 2006;202:423–430 Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma Shah SA, Haddad R, Al-Sukhni W, et al J Am Coll Surg 2006;202:468–475
You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are: Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy? Sturgeon C, Shen WT, Clark OH, et al. Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma. Shah SA, Haddad R, Al-Sukhni W, et al. How time affects the risk of rupture in appendicitis. Bickell NA, Aufses AH, Rojas M, Bodian C. Age-dependent differences in survival after severe burns: a unicentric review of 1,674 patients and 179 autopsies in 15 years. Pereira CT, Barrow RE, Sterns AM, et al.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased under- standing of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the begin- ning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 1 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2006 by the American College of Surgeons Published by Elsevier Inc.
A49
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.12.011
A50
Continuing Medical Education Program
J Am Coll Surg
Learning Objectives: After studying this article, the surgeon should be able to describe preoperative factors that are suspicious for a malignant adrenal neoplasm and identify factors that should be considered when choosing a surgical approach for adrenalectomy.
presence of metastases, should be resected by the open approach if the patient is a surgical candidate. Imaging findings of irregular margins, heterogeneity, calcification and hyperdensity are associated with a higher risk of malignancy, but may also be seen in benign lesions, and are not definitive. The likelihood of adrenocortical carcinoma has been reported to increase with tumor size, and this study confirms those findings, with an almost 50% likelihood of cancer for adrenal tumors larger than 8 cm.
Question 1
Question 2
Which of the following statements regarding adrenal tumors is FALSE?
Which of the following statements regarding adrenalectomy is FALSE?
a) Approximately 5% of incidentally found adrenal neoplasms are malignant. b) Indications for adrenalectomy are: tumor size, imaging features, hormonal hypersecretion, and personal history of cancer. c) Adrenalectomy is not indicated for hormonal hypersecretion if the patient is asymptomatic. d) Local invasion, regional lymphadenopathy, and the finding of metastases are the most reliable accurate imaging features for adrenocortical carcinoma. e) Mean tumor size is larger for adrenocortical carcinoma than for benign adrenal cortical adenomas.
a) Laparoscopic adrenalectomy is the preferred surgical approach for benign functional and non-functional adrenal tumors. b) Long-term studies on the outcome of laparoscopic adrenalectomy for adrenocortical carcinoma have shown it to be superior to open adrenalectomy. c) Signs of local invasion found during laparoscopic adrenalectomy should prompt conversion to open adrenalectomy. d) The periadrenal fat should be resected during laparoscopic adrenalectomy. e) Surgeon experience, patient factors and tumor characteristics should be considered when selecting the best surgical approach (laparoscopic vs. open).
Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy?
Sturgeon C, Shen WT, Clark OH, et al J Am Coll Surg 2006;202:423–430
Critique: Adrenal tumors identified serendipitously by an imaging study performed for another indication are referred to as incidentalomas. The estimated frequency of incidentalomas is 1–4% on abdominal imaging studies. Most are small, nonfunctioning, benign cortical adenomas, but some are functional and/or malignant. With the increased use of abdominal imaging studies such as CT and MRI, incidentalomas are being brought more frequently to the surgeon’s attention. The overall risk of primary malignancy in incidentalomas is 4–5%. Because it is difficult or impossible to preoperatively differentiate a benign cortical adenoma from a carcinoma, indications for surgical resection are the presence of hormonal hypersecretion or imaging characteristics that are suggestive of malignancy. Hormonal hypersecretion is an absolute indication for adrenalectomy, regardless of the absence of associated symptoms. A personal history of cancer that spreads to the adrenals, such as lung cancer, may make resection unwarranted unless it is a solitary synchronous or metachronous metastasis. All adrenal tumors with imaging features characteristic of malignancy, such as local or vascular invasion or the
Critique: Laparoscopic adrenalectomy has become the preferred surgical approach for benign functioning and non-functioning adrenal neoplasms. Laparoscopic adrenalectomy is associated with less pain, shorter hospitalization, less blood loss, and fewer complications than open adrenalectomy. The long-term outcome of patients who have laparoscopic adrenalectomy for adrenocortical carcinoma is unknown and controversial,, however, because there are few data. The surgeon must be prepared to convert to open adrenalectomy for bleeding or to achieve negative margins for invasive malignancies. The principles of oncologic surgery should not be compromised, even for an adrenal neoplasm that appears benign. The periadrenal fat should be resected in continuity with the adrenal gland. If a complete resection cannot safely be performed, the operation should not be continued laparoscopically. Several factors should be considered when selecting the approach for adrenalectomy, such as surgeon experience and preference, history of prior upper abdominal operations, and tumor size, all of which may make the laparoscopic approach more diffi-
Vol. 202, No. 3, March 2006
Continuing Medical Education Program
A51
Question 1
are negative prognostic factors. In our study of patients who have undergone both liver and lung resections for colorectal metastases, neither the time to presentation of metastases (i.e. synchronous vs. metachronous), nor the number of metastases was a significant prognostic factor for overall survival. These factors should NOT prevent an otherwise eligible patient from being offered metastasectomy. Often, chemotherapy is administered following surgical resection of metastatic disease. This strategy of chemotherapy is called ‘pseudo-adjuvant’ chemotherapy, because it is analogous to adjuvant treatment following surgery for the primary colorectal cancer. There are no randomized controlled clinical trials that demonstrate a survival benefit for pseudo-adjuvant chemotherapy.
Which of the following statements concerning patients with metastatic colorectal disease is correct?
Question 2
cult. In addition, large tumors are not only more difficult to resect laparoscopically, but, as this study demonstrates, they are also more likely to be malignant. Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma
Shah SA, Haddad R, Al-Sukhni W, et al J Am Coll Surg 2006;202:468–475 Learning Objectives: After study of this article, the surgeon will be able to describe the indications for surgery, the rationale for patient selection, and the expected outcomes following aggressive surgical therapy for metastatic colorectal cancer to the liver and the lungs.
a) Surgical resection of metastatic lesions can provide good palliation for patients with symptoms, but does not offer potential for cure. b) Patients that present with synchronous metastases to the liver and/or lungs will not benefit from surgical resection, and should not be offered metastasectomy. c) Chemotherapy after surgical resection of metastatic colorectal cancer improves survival. d) The perioperative morbidity rate of liver and/or lung resection for metastatic colorectal cancer is 10–20%. e) Surgical resection of metastatic colorectal cancer should be offered only to patients with solitary lesions in lung and/or liver.
Critique: The role of aggressive surgical therapy for metastatic colorectal cancer has increased over the past decade. Unlike chemotherapy, surgical resection of metastatic lesions is the only treatment modality that offers the potential for cure. Liver and/or lung resections can be performed with acceptable morbidity rates (range 10–20%) and low mortality rates. Surgical resection of metastatic colorectal disease should be considered for all eligible patients. Several studies have examined the prognostic factors that might determine whether a patient will benefit from surgical resection of metastatic colorectal cancer in the liver and/ or lung. Negative prognostic factors may be associated with an increased risk of disease recurrence or death. These prognostic factors are generally not used to preclude surgery. For patients that have undergone liver resection for colorectal metastases soon after excision of the primary tumor, synchronous presentation of metastases and the number of metastases
Which of the following statements is true? a) The lung is the most common site of metastases from colorectal cancer. b) Staged resections for patient who present with simultaneous lung and liver metastases are highly morbid and should be avoided. c) Serial metastasectomies portend a poor prognosis and should be avoided. d) Patients who undergo more than 1 metastasectomy have significantly shorter survival than patients who undergo a single metastasectomy. e) Most patients having lung and liver resections for metastatic colorectal disease survive for longer than 5 years after excision of the primary tumor.
Critique: The liver is the most common site for colorectal metastases. Hepatic metastases are present in 33–60% of patients, whereas lung metastases are identified in 10–25% of patients. Staged resections for patient with simultaneous lung and liver metastases can be performed safely. The approach at our institution is to perform the liver resection initially, in order to rule out extra hepatic abdominal disease, and to maintain hepatic reserve. In this study, the combined perioperative morbidity rates of the lung and liver resections were 13%. Serial metastasectomies were common in this patient population. In this study, the mean number of metastasectomies performed was 2.6 per patient (range 1–4). Rather than portending a poor prognosis, patients who underwent more than 1 metastasectomy had a better survival then patients who underwent only 1 metastasectomy (i.e. the index liver resection). The 5-year overall survival
A52
Continuing Medical Education Program
rate from initial metastasectomy for patients who underwent both liver and lung resection was 74% compared to a 5-year overall survival rate of 42% for patients who only underwent a single metastasectomy (p ⫽ 0.05). We conclude that patients who are candidates for further surgical resection of recurrent colorectal cancer should undergo surgery, as aggressive surgical therapy can pro-
J Am Coll Surg
vide good longterm outcomes. Serial metastasectomy can result in prolonged survival following their diagnosis of cancer. In this study, the median overall survival from their initial diagnosis of colorectal cancer for patients who underwent both lung and liver resection was 117 (IQR: 74–120) months. Thus serial metastasectomy can result in excellent longterm survival.
JACS CME-1 FEATURED ARTICLE, VOLUME 202, MARCH 2006 Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy? Sturgeon C, Shen WT, Clark OH, et al J Am Coll Surg 2006;202:423–430 Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma Shah SA, Haddad R, Al-Sukhni W, et al J Am Coll Surg 2006;202:468–475
You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are: Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy? Sturgeon C, Shen WT, Clark OH, et al. Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma. Shah SA, Haddad R, Al-Sukhni W, et al. How time affects the risk of rupture in appendicitis. Bickell NA, Aufses AH, Rojas M, Bodian C. Age-dependent differences in survival after severe burns: a unicentric review of 1,674 patients and 179 autopsies in 15 years. Pereira CT, Barrow RE, Sterns AM, et al.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased under- standing of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the begin- ning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of 1 Category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
© 2006 by the American College of Surgeons Published by Elsevier Inc.
A49
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.12.011
A50
Continuing Medical Education Program
J Am Coll Surg
Learning Objectives: After studying this article, the surgeon should be able to describe preoperative factors that are suspicious for a malignant adrenal neoplasm and identify factors that should be considered when choosing a surgical approach for adrenalectomy.
presence of metastases, should be resected by the open approach if the patient is a surgical candidate. Imaging findings of irregular margins, heterogeneity, calcification and hyperdensity are associated with a higher risk of malignancy, but may also be seen in benign lesions, and are not definitive. The likelihood of adrenocortical carcinoma has been reported to increase with tumor size, and this study confirms those findings, with an almost 50% likelihood of cancer for adrenal tumors larger than 8 cm.
Question 1
Question 2
Which of the following statements regarding adrenal tumors is FALSE?
Which of the following statements regarding adrenalectomy is FALSE?
a) Approximately 5% of incidentally found adrenal neoplasms are malignant. b) Indications for adrenalectomy are: tumor size, imaging features, hormonal hypersecretion, and personal history of cancer. c) Adrenalectomy is not indicated for hormonal hypersecretion if the patient is asymptomatic. d) Local invasion, regional lymphadenopathy, and the finding of metastases are the most reliable accurate imaging features for adrenocortical carcinoma. e) Mean tumor size is larger for adrenocortical carcinoma than for benign adrenal cortical adenomas.
a) Laparoscopic adrenalectomy is the preferred surgical approach for benign functional and non-functional adrenal tumors. b) Long-term studies on the outcome of laparoscopic adrenalectomy for adrenocortical carcinoma have shown it to be superior to open adrenalectomy. c) Signs of local invasion found during laparoscopic adrenalectomy should prompt conversion to open adrenalectomy. d) The periadrenal fat should be resected during laparoscopic adrenalectomy. e) Surgeon experience, patient factors and tumor characteristics should be considered when selecting the best surgical approach (laparoscopic vs. open).
Risk assessment in 457 adrenal cortical cancers. How much does tumor size predict the likelihood of malignancy?
Sturgeon C, Shen WT, Clark OH, et al J Am Coll Surg 2006;202:423–430
Critique: Adrenal tumors identified serendipitously by an imaging study performed for another indication are referred to as incidentalomas. The estimated frequency of incidentalomas is 1–4% on abdominal imaging studies. Most are small, nonfunctioning, benign cortical adenomas, but some are functional and/or malignant. With the increased use of abdominal imaging studies such as CT and MRI, incidentalomas are being brought more frequently to the surgeon’s attention. The overall risk of primary malignancy in incidentalomas is 4–5%. Because it is difficult or impossible to preoperatively differentiate a benign cortical adenoma from a carcinoma, indications for surgical resection are the presence of hormonal hypersecretion or imaging characteristics that are suggestive of malignancy. Hormonal hypersecretion is an absolute indication for adrenalectomy, regardless of the absence of associated symptoms. A personal history of cancer that spreads to the adrenals, such as lung cancer, may make resection unwarranted unless it is a solitary synchronous or metachronous metastasis. All adrenal tumors with imaging features characteristic of malignancy, such as local or vascular invasion or the
Critique: Laparoscopic adrenalectomy has become the preferred surgical approach for benign functioning and non-functioning adrenal neoplasms. Laparoscopic adrenalectomy is associated with less pain, shorter hospitalization, less blood loss, and fewer complications than open adrenalectomy. The long-term outcome of patients who have laparoscopic adrenalectomy for adrenocortical carcinoma is unknown and controversial,, however, because there are few data. The surgeon must be prepared to convert to open adrenalectomy for bleeding or to achieve negative margins for invasive malignancies. The principles of oncologic surgery should not be compromised, even for an adrenal neoplasm that appears benign. The periadrenal fat should be resected in continuity with the adrenal gland. If a complete resection cannot safely be performed, the operation should not be continued laparoscopically. Several factors should be considered when selecting the approach for adrenalectomy, such as surgeon experience and preference, history of prior upper abdominal operations, and tumor size, all of which may make the laparoscopic approach more diffi-
Vol. 202, No. 3, March 2006
Continuing Medical Education Program
A51
Question 1
are negative prognostic factors. In our study of patients who have undergone both liver and lung resections for colorectal metastases, neither the time to presentation of metastases (i.e. synchronous vs. metachronous), nor the number of metastases was a significant prognostic factor for overall survival. These factors should NOT prevent an otherwise eligible patient from being offered metastasectomy. Often, chemotherapy is administered following surgical resection of metastatic disease. This strategy of chemotherapy is called ‘pseudo-adjuvant’ chemotherapy, because it is analogous to adjuvant treatment following surgery for the primary colorectal cancer. There are no randomized controlled clinical trials that demonstrate a survival benefit for pseudo-adjuvant chemotherapy.
Which of the following statements concerning patients with metastatic colorectal disease is correct?
Question 2
cult. In addition, large tumors are not only more difficult to resect laparoscopically, but, as this study demonstrates, they are also more likely to be malignant. Surgical resection of both hepatic and pulmonary metastases from colorectal carcinoma
Shah SA, Haddad R, Al-Sukhni W, et al J Am Coll Surg 2006;202:468–475 Learning Objectives: After study of this article, the surgeon will be able to describe the indications for surgery, the rationale for patient selection, and the expected outcomes following aggressive surgical therapy for metastatic colorectal cancer to the liver and the lungs.
a) Surgical resection of metastatic lesions can provide good palliation for patients with symptoms, but does not offer potential for cure. b) Patients that present with synchronous metastases to the liver and/or lungs will not benefit from surgical resection, and should not be offered metastasectomy. c) Chemotherapy after surgical resection of metastatic colorectal cancer improves survival. d) The perioperative morbidity rate of liver and/or lung resection for metastatic colorectal cancer is 10–20%. e) Surgical resection of metastatic colorectal cancer should be offered only to patients with solitary lesions in lung and/or liver.
Critique: The role of aggressive surgical therapy for metastatic colorectal cancer has increased over the past decade. Unlike chemotherapy, surgical resection of metastatic lesions is the only treatment modality that offers the potential for cure. Liver and/or lung resections can be performed with acceptable morbidity rates (range 10–20%) and low mortality rates. Surgical resection of metastatic colorectal disease should be considered for all eligible patients. Several studies have examined the prognostic factors that might determine whether a patient will benefit from surgical resection of metastatic colorectal cancer in the liver and/ or lung. Negative prognostic factors may be associated with an increased risk of disease recurrence or death. These prognostic factors are generally not used to preclude surgery. For patients that have undergone liver resection for colorectal metastases soon after excision of the primary tumor, synchronous presentation of metastases and the number of metastases
Which of the following statements is true? a) The lung is the most common site of metastases from colorectal cancer. b) Staged resections for patient who present with simultaneous lung and liver metastases are highly morbid and should be avoided. c) Serial metastasectomies portend a poor prognosis and should be avoided. d) Patients who undergo more than 1 metastasectomy have significantly shorter survival than patients who undergo a single metastasectomy. e) Most patients having lung and liver resections for metastatic colorectal disease survive for longer than 5 years after excision of the primary tumor.
Critique: The liver is the most common site for colorectal metastases. Hepatic metastases are present in 33–60% of patients, whereas lung metastases are identified in 10–25% of patients. Staged resections for patient with simultaneous lung and liver metastases can be performed safely. The approach at our institution is to perform the liver resection initially, in order to rule out extra hepatic abdominal disease, and to maintain hepatic reserve. In this study, the combined perioperative morbidity rates of the lung and liver resections were 13%. Serial metastasectomies were common in this patient population. In this study, the mean number of metastasectomies performed was 2.6 per patient (range 1–4). Rather than portending a poor prognosis, patients who underwent more than 1 metastasectomy had a better survival then patients who underwent only 1 metastasectomy (i.e. the index liver resection). The 5-year overall survival
A52
Continuing Medical Education Program
rate from initial metastasectomy for patients who underwent both liver and lung resection was 74% compared to a 5-year overall survival rate of 42% for patients who only underwent a single metastasectomy (p ⫽ 0.05). We conclude that patients who are candidates for further surgical resection of recurrent colorectal cancer should undergo surgery, as aggressive surgical therapy can pro-
J Am Coll Surg
vide good longterm outcomes. Serial metastasectomy can result in prolonged survival following their diagnosis of cancer. In this study, the median overall survival from their initial diagnosis of colorectal cancer for patients who underwent both lung and liver resection was 117 (IQR: 74–120) months. Thus serial metastasectomy can result in excellent longterm survival.