PURPOSE:Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases.METHODS:Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators.RESULTS:Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected.CONCLUSIONS:Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

Hereditary diffuse gastric cancer (HDGC) is associated with E-cadherin 1 (CDH1) germline mutations. In the present study, two unusual HDGC cases are described. Case 1 was a female with no family history of gastric cancer who developed Hodgkin's lymphoma at 19 years of age, and DGC at 32 years of age. Due to her young age (32 years), the patient was examined for CDH1 abnormalities and a deleterious mutation was identified. Her father and younger sister were identified to be carriers of the mutation. Case 2 was a 36-year-old female diagnosed with lobular breast cancer (LBC); her mother had LBC, and her grandmother had LBC and DGC. The molecular test was wild-type for breast cancer susceptibility genes 1 and 2; however, a large deletion in CDH1 was identified. At prophylactic gastrectomy, early DGC was identified. Early onset of DGC and LBC justifies testing for CDH1. A better knowledge of tumor natural history in carrier subjects is important to aid genetic counseling, in order to assess the surveillance time required prior to carrying out prophylactic surgery.

Purpose: Several studies have demonstrated the oncologic equivalence of laparoscopic (LS) and open (OS) rectal cancer surgeries and have shown how challenging LS may become. Robotic surgery (RS) has emerged as a practical alternative, offering interesting advantages in comparison to both LS and OS. The aim of this study is to resolve the clinicopathologic outcome advantages of RS with respect to OS and LS techniques.Methods: Patients with rectal cancer undergoing OS, RS, or LS were evaluated within the period from April 2009 to August 2011. The evaluations were carried out in 4 Italian hospitals. Perioperative clinicopathologic data, postoperative complications, and 3-year overall and disease-free survival (DFS) rates were analyzed.Results: A total of 160 patients (94 male, 66 female) were included. A total of 105 patients underwent mini-invasive procedure (40 LS; 65 RS), whereas OS was performed in 55 patients. Anterior resection of rectal cancer was the most performed surgical procedure (139; 87%). Median operation time was significantly longer in the RS group (p<0.01). Regarding complication rates and quality of the surgical specimen evaluation, no statistical difference was found among the 3 groups. The shortest hospital stay (p<0.01) was obtained from the LS and RS groups. The median follow-up was 33 months without any significant difference in overall and DFS rates.Conclusions: Although RS for rectal cancer requires more time to be performed than LS and OS techniques, the analysis shows comparatively the feasibility and safety of RS in terms of perioperative clinicopathologic and medium-term outcomes.

Introduction: Purpose of this work was to assess surgical morbidity and mortality in a modified D-2 resection for gastric cancer with avoidance of splenectomy and distal pancreatectomy.Methods: A series of 915 (517 males, 398 females; median age: 62 ± 23 years) consecutive patients with histology-proven gastric cancer underwent gastrectomy and extended D-2 lymphadenectomy for treatment of their disease during an 18-year period (1994-2012) at the European Institute of Oncology in Milano, Italy. Distal pancreas and spleen were routinely preserved, unless the tumor was not closely adjacent to or directly invading these organs. Morbidity, per-operative mortality, and length of hospital stay were recorded.Results: 559 total and 356 subtotal gastrectomies were performed. Splenectomy was performed in 14 cases and spleno-pancreatectomy in 21. The postoperative morbidity rate was 15%, the mortality rate was 1.4%. The median length of stay was 10.8 days.Conclusion: These results compete favourably with those reported after standard D-1 gastrectomy in Western series. D-2 gastrectomy with spleen and pancreas routine preservation can be considered a safe treatment of this disease. Introduction: Purpose of this work was to assess surgical morbidity and mortality in a modified D-2 resection for gastric cancer with avoidance of splenectomy and distal pancreatectomy. Methods: A series of 915 (517 males, 398 females; median age: 62 ± 23 years) consecutive patients with histology-proven gastric cancer underwent gastrectomy and extended D-2 lymphadenectomy for treatment of their disease during an 18-year period (1994-2012) at the European Institute of Oncology in Milano, Italy. Distal pancreas and spleen were routinely preserved, unless the tumor was not closely adjacent to or directly invading these organs. Morbidity, per-operative mortality, and length of hospital stay were recorded. Results: 559 total and 356 subtotal gastrectomies were performed. Splenectomy was performed in 14 cases and spleno-pancreatectomy in 21. The postoperative morbidity rate was 15%, the mortality rate was 1.4%. The median length of stay was 10.8 days. Conclusion: These results compete favourably with those reported after standard D-1 gastrectomy in Western series. D-2 gastrectomy with spleen and pancreas routine preservation can be considered a safe treatment of this disease.

BACKGROUND/AIMS:Recently, pelvic anatomy has been taken into consideration and related to surgical outcome indicators after low anterior resection (LAR). Several pelvimetric parameters have been matched with conversion rate, postoperative complications and duration of surgery in laparoscopic series, and with the quality of specimen and pathologic outcomes in further open surgical series.METHODOLOGY:In 97 consecutive patients submitted to sphincter-saving LAR with total mesorectal excision (TME) five pelvic dimensions were measured by abdominal computed tomography scan: anteroposterior and transverse diameters in the pelvic inlet (IAP and ITRA), anteroposterior and transverse diameters in the pelvic outlet (OAP and OTRA), and the pelvic depth. The endpoint evaluated was anastomotic leakage (AL) rate.RESULTS:There were 51 open, 12 laparoscopic and 34 robotic LARs. The sum of IAP OAP and OTRA (Pelvic Index) significantly predicted AL showing that starting from the cut-point of 290 mm down to a PI of 278 mm the odds-ratio of having an AL increased from 2.63 (95% CI: 1.10,5.47) to 5.07 (95% CI: 1.35,8.02).CONCLUSIONS:The sum of the 3 pelvic dimensions which we termed “Pelvic Index” was associated to AL following sphinctersaving LAR. This may be considered in planning the surgical strategy for rectal cancer patients.

Sustainability, as defined by the Brundtland Commission, which mentions the needs of present and future generations, is a concept that transcends concern with the environment, though this consideration remains important. Sustainability also relates to culture, way of living and economy. Applied to tourist destinations, sustainability offers guidance of great clarity. Tourism brings significant impacts, physical, economic and cultural, with important positive and negative aspects. A study of the subject reveals that the guidelines for sustainable tourism are exactly the guidelines for economic development and healthy living - non-sustainable tourist destinations actually tend to decline and even perish. A qualitative research was conducted in a tourist destination in Brazil, typical in several respects. Such destination has developed after the publication of the Brundtland report did not inherit certain prejudicial attitudes. The results show that the major players involved are not aware of all the challenges posed to a sustainable development, but this can be changed for the better with relative ease and highly positive consequences.

Background. Pancreatic neuroendocrine tumors (PNETs) present in more than 50% of cases with liver metastases. as the only systemic localization. Liver metastases are unresectable in 80% of cases at diagnosis. In the context of a metastatic disease, the benefit of primary tumor removal in terms of survival is controversial.Methods. A single-center series of Patients with PNETs presenting with synchronous unresectable hepaticmetastases and treated within a framework of a multidisciplinary team was analyzed retrospectively to assess the prognostic factors and the potential. benefit of primary tumor resection on long-term survival.Results. At the time of diagnosis, 12 of 43 patients (28%) underwent primary tumor resection. After a median follow-up of 5 years (range, 0.6-14 years), 22 disease-related deaths were observed. The corresponding 5-year survival and median disease-specific duration of survival were 58% and 77 months, respectively. In the operated and nonoperated patients the 5-year disease-specific survival was 82% and 50%, respectively (P = .027). At multivariate analysis, patients with primary tumor removed had an improved survival compared with patients who did not (hazard ratio 0.18; 95% CI 0.05-0.66; P = .010). Other important factors associated with improved survival at multivariate analysis were lesser age, lesser Ki-67 index, and 25% less liver tumor burden.Conclusion. In the present series of patients with PNETs and unresectable liver metastases, resection of the primary tumor was associated with an improved survival. This observation suggests that resection of the primary tumor should be part of a global therapeutic strategy and its indication and timing should be discussed within a multidisciplinary team.

Introduction: This study was designed to investigate whether the number of lymph nodes (LNs) removed offers protection against recurrence and exerts a potentially decisive impact on cancer-specific survival and disease-free survival in patients undergone curative resection for gastric cancer.Methods: A consecutive series of 915 patients (517 males; 398 females; median age: 62 ± 22 years) who underwent gastrectomy and extended lymph node D-2 dissection for gastric cancer between 1994 and 2012, were analyzed. Standard survival methods and restricted cubic spline multivariable Cox regression models were applied.Results: Median number of dissected LNs was 23. Patients who had <15 nodes removed had significantly worse distant disease-free survival, and overall survival at multivariable analysis than other patients. The results did not change when pT1 and pT2-3 cancer patients were analysed separately. The risk of distant metastases decreased as the number of dissected lymph nodes increased (≥15).Conclusion: More extended lymph node resection offered survival benefit even in the subgroup of patients with early stage disease. Lymphadenectomy involving more than 15 lymph nodes should be performed for the treatment of also clinically node-negative gastric cancer. Introduction: This study was designed to investigate whether the number of lymph nodes (LNs) removed offers protection against recurrence and exerts a potentially decisive impact on cancer-specific survival and disease-free survival in patients undergone curative resection for gastric cancer. Methods: A consecutive series of 915 patients (517 males; 398 females; median age: 62 ± 22 years) who underwent gastrectomy and extended lymph node D-2 dissection for gastric cancer between 1994 and 2012, were analyzed. Standard survival methods and restricted cubic spline multivariable Cox regression models were applied. Results: Median number of dissected LNs was 23. Patients who had <15 nodes removed had significantly worse distant disease-free survival, and overall survival at multivariable analysis than other patients. The results did not change when pT1 and pT2-3 cancer patients were analysed separately. The risk of distant metastases decreased as the number of dissected lymph nodes increased (≥15). Conclusion: More extended lymph node resection offered survival benefit even in the subgroup of patients with early stage disease. Lymphadenectomy involving more than 15 lymph nodes should be performed for the treatment of also clinically node-negative gastric cancer.

e15147 Background: Neuroendocrine tumors (NETs) that originate in the distal jejunum and ileum are commonly diagnosed in stage IV, with liver metastases in 50%-75% of cases. The aim of this study was to ascertain the impact of surgery in a consecutive series of patients with small bowel NET and synchronous liver metastases treated at a single institute. Methods: Ninety-one patients managed between 1995 and 2011 were extracted from the institutional tumor registry. All patients had diagnosis by histology of small bowel NET and synchronous liver metastases. Results: Among the 91 patients 28 (30.8%) underwent primary tumor removal and liver metastases resection or intraoperative termal ablation (Group 1), 54 (59.3%) underwent resection of only the primary tumor (Group 2), and the remaining 9 (9.9%) did not receive any surgery (Group 3). After a median follow-up of 64 months an overall survival (OS) of 93.1%, 81.8% and 76.2% at 3, 5 and 8 years was registered for the whole group. Cancer-specific survival (CSS) was 93.1%, 83.3% and 77.6% at 3, 5 and 8 years, respectively. Five-years OS differed significantly according to the surgical approach (96.0% for Group 1 vs 79.8% for Group 2 vs 48.6% for Group 3, p=0.02). During the course of the illness octreotide was administered in 78 patients (85.7%), peptide receptor radiotherapy in 61 (67.0%), systemic chemotherapy in 21 (23.1%), hepatic artery embolization in 17 (18.7%), interferon in 11 (12.1%), molecular targeted agents in 2 (2.2%). For patients who underwent any surgery (Group 1 and Group 2) the multidisciplinary approach was associated with a better OS (85.7% vs 77.2% 5-years OS, p=0.04). In the multivariate analysis only age was associated with OS, HR: 1.05 (C. I.: 1.01-1.10). The results of CSS were comparable to those of OS. Conclusions: In this metastatic setting of small bowel NETs the 5 year OS was as high as 82% with a maximum benefit achievable for patients who had primary tumor resection and liver disease amenable to surgical or thermal ablation. However, the potential impact of age in prognosis should be carefully considered when choosing the treatment to be delivered in such patients.

Read the full review for this Faculty Opinions recommended article: Efficacy and safety of abiraterone acetate in an elderly patient subgroup (aged 75 and older) with metastatic castration-resistant prostate cancer after docetaxel-based chemotherapy.

Read the full review for this Faculty Opinions recommended article: Safety and efficacy of weekly nab®-paclitaxel in combination with carboplatin as first-line therapy in elderly patients with advanced non-small-cell lung cancer.

For patients with Stage II colon cancer, the use of adjuvant chemotherapy remains controversial. The purpose of this study was to identify clinical and/or pathological findings related to a worse prognosis in this category of patients.