Abstract: Background Patients with potentially curative oesophago-gastric cancer typically undergo neo-adjuvant chemotherapy prior to surgery. The majority of anti-cancer drugs have a narrow therapeutic index. The aim of this study was to determine if features of body composition, assessed using computed tomography (CT) scans, may be predictive of dose-limiting toxicity (DLT) in patients undergoing neo-adjuvant chemotherapy for oesophago-gastric cancer. The influence of sarcopenia and DLT on overall survival was also evaluated. Methods 89 Patients having potentially curative oesophago-gastric cancer surgery were studied. Patients studied had histologically confirmed oesophago-gastric cancer with no evidence of distant metastasis on pre-operative staging. CT scan was performed in all cases at diagnosis. DLT was defined as toxicity leading to postponement of treatment, a drug dose reduction or definitive interruption of drug administration. Results DLT occurred in 37 out of 89 patients (41.6%) undergoing chemotherapy. Sarcopenia (odds ratio, 2.95; 95% confidence interval, 1.23–7.09; p = 0.015) was associated with DLT on multivariate analysis. Median overall survival for patients who were sarcopenic was 569 days (IQ range: 357–1230 days) vs. 1013 days (IQ range: 496–1318 days) for patients who were not sarcopenic ( p = 0.04). There was no significant difference in overall survival in patients who experienced DLT compared with those that did not ( p = 0.665). Conclusions Sarcopenia is a significant predictor of DLT in oesophago-gastric cancer patients undergoing neo-adjuvant chemotherapy. These results raise the potential for use of assessment of skeletal muscle mass using CT scans to predict toxicity and individualize chemotherapy dosing.

Abstract: Purpose Studies regarding the effects of aesthetic outcomes after breast cancer surgery on quality of life (QoL) have yielded inconsistent results. This study analyzed the aesthetic outcomes and QoL of women who underwent breast conserving surgery (BCS) or total mastectomy with immediate reconstruction (TMIR) using objective and validated methods. Patients and methods QoL questionnaires (EORTC QLQ-C30, BR23, and HADs) were administered at least 1 year after surgery and adjuvant therapy to 485 patients who underwent BCS, 46 who underwent TMIR, and 87 who underwent total mastectomy (TM) without reconstruction. Aesthetic results were evaluated using BCCT.core software and by a panel of physicians. Patients' body image perception was assessed using the body image scale (BIS). Results QoL outcomes, including for social and role functioning, fatigue, pain, body image, and arm symptoms, were significantly better in the BCS and TMIR groups than in the TM group (p Conclusion In conclusion, BCS and TMIR enhanced QoL compared with TM. Among BCS and TMIR patients, objectively measured cosmetic results did not affect general QoL. S elf-perception of body image seems to be more important for QoL after breast cancer surgery.

Abstract: Radioembolization with yttrium-90 microspheres offers an alternative treatment option for patients with unresectable intrahepatic cholangiocarcinoma (ICC). However, the rarity and heterogeneity of ICC makes it difficult to draw firm conclusions about treatment efficacy. Therefore, the goal of the current study is to systematically review the existing literature surrounding treatment of unresectable ICCs with yttrium-90 microspheres and provide a comprehensive review of the current experience and clinical outcome of this treatment modality. We performed a comprehensive search of electronic databases for ICC treatment and identified 12 studies with relevant data regarding radioembolization therapy with yttrium-90 microspheres. Based on pooled analysis, the overall weighted median survival was 15.5 months. Tumour response based on radiological studies demonstrated a partial response in 28% and stable disease in 54% of patients at three months. Seven patients were able to be downstaged to surgical resection. The complication profile of radioembolization is similar to that of other intra-arterial treatment modalities. Overall survival of patients with ICC after treatment with yttrium-90 microspheres is higher than historical survival rates and shows similar survival to those patients treated with systemic chemotherapy and/or trans-arterial chemoembolization therapy. Therefore, the use of yttrium-90 microspheres should be considered in the list of available treatment options for ICC. However, future randomized trials comparing systemic chemotherapy, TACE and local radiation will be required to identify the optimal treatment modality for unresectable ICC.

Abstract: Background Strong evidence indicates that excessive adipose tissue distribution or reduced muscle influence short-, mid-, and long-term colorectal cancer outcomes Computerized tomography-based body composition (CTBC) analysis quantifies this in a reproducible parameter We reviewed the evidence linking computerized tomography (CT) based quantification of BC with short and long-term outcomes in colorectal cancer (CRC) Methods A systematic review was performed according to PRISMA guidelines A literature search was performed by two independent reviewers on all studies that included CTBC analysis in patients undergoing treatment for CRC using Medline, EMBASE, Google Scholar, and Cochrane databases Outcomes of interest included short-term recovery, oncological outcomes, and survival Results Seventy-five studies were identified; sixteen met the inclusion criteria None were randomized controlled trials and all were cohort studies of small sample size Several types of CTBC image analysis software were identified, reporting subcutaneous, visceral and skeletal muscle tissues Visceral obesity and reduced muscle mass were categorical parameters quantified by CTBC analysis Due to marked study heterogeneity, quantitative data synthesis was not possible High visceral adipose tissue and reduced skeletal muscle resulted in poorer short-term recovery (eleven studies), poorer oncological outcomes (six studies), and poorer survival (six studies) Conclusions CTBC techniques may be linked to outcomes in colorectal cancer patients, however larger studies are required CTBC based assessment may allow early identification of high-risk patients, allowing early optimisation of patients undergoing cancer treatments

Abstract: Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality. Methods Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9). Results Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% [0.21–0.77%]). RLV increased by 48.6% [−15.3 to 192%] 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227–19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome. Conclusions The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.

Abstract: Background Recent studies have implied a prognostic value of the prognostic nutritional index (PNI) in certain types of human cancers. However, the value of PNI for predicting survival in patients with pancreatic cancer remains unknown. The goal of this study was to investigate the predictive significance of PNI in patients with advanced pancreatic cancer. Methods A total of 321 consecutive patients with pathologically-confirmed locally advanced or metastatic pancreatic ductal adenocarcinoma (PDAC) were retrospectively recruited between January 2011 and August 2013. The patients were divided into a test set (n = 110) and a validation set (n = 211). We evaluated the association between PNI and overall survival (OS). The relationship between PNI and systemic inflammatory response markers, including the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) was also assessed. In addition, the associations between PNI and the TNF-α were analyzed. Results Kaplan–Meier analyses showed that a low PNI correlated significantly with a shorter OS in patients with advanced pancreatic cancer (190 days for patients with a low PNI vs. 290 days for patients with a high PNI, log-rank = 12.566, P Conclusions Our results confirm that PNI is associated with the systemic inflammatory response and can be used to predict survival in advanced pancreatic cancer.

Abstract: Introduction Surgery is the standard treatment of rectal cancer after neoadjuvant therapy. Some authors advocate a nonoperative management (NOM) after complete clinical response (cCR) following chemoradiotherapy (CRT). We compare our results with NOM to standard resection in a retrospective analysis. Methods Rectal adenocarcinomas submitted to NOM after CRT between September 2002 and December 2013 were compared to surgical patients that had pathological complete response (pCR) during the same period. Endpoints were Overall Survival (OS), Disease Free Survival (DFS), Local Relapse (LR) and Distant Relapse (DR). Results Forty-two NOM patients compared to 69 pCR patients operated after a median interval of 35 weeks after CRT. NOM tumors were distal (83.3% vs 59.4%, p = 0.011), less obstructive (26.2% vs 54.4%, p = 0.005) and had a lower digital rectal score (p = 0.024). Twelve (28.0%) recurrences in NOM group and eight (11.5%) in the surgical group occurred after a follow-up of 47.7 and 46.7 months respectively. Isolated LR occurred in five (11%) NOM patients and one (1.4%) in the surgical group. Four (80%) LR were surgically salvaged in NOM group. No difference in OS was found (71.6% vs 89.9%, p = 0.316) but there was a higher DFS favoring surgical group (60.9% vs 82.8%, p = 0.011). Distal tumors had worse OS compared to proximal tumors in surgical group (5-year OS of 85.5% vs 96.2%, p = 0.038). Conclusion The NOM achieved OS comparable to surgical treatment and spared patients from surgical morbidity but it resulted in more recurrences. This approach cannot be advocated routinely and controlled trials are warranted.

Abstract: Background: There is no consensus on the role of postoperative chemotherapy in patients with rectal cancer who have received preoperative radio(chemo)therapy. Materials and methods: A systematic re ...

Abstract: Introduction Radical cystectomy and urinary diversion carries a high morbidity. Quality of life and body image are important considerations for urinary diversion (UD). We wanted to conduct a systematic review of literature to see which form UD offers a better quality of life (QoL). Methods We searched MEDLINE, Pubmed, EMBASE, CINAHL and the Cochrane library for studies using the following key words: ‘quality of life’ and ‘ileal conduit’, ‘orthotopic neobladder’, ‘continent diversion’ and ‘urinary diversion’. All English language articles on UD surgery were included in the original search from 1990 to 2014. To improve the quality of evidence, we stratified our inclusion criteria into studies that report on QoL in both forms of UD using at least one validated questionnaire. Results Twenty-one studies (2285 patients) were included in our study all of which used at least one validated tool. The most frequently used tools were the SF-36, EORTC QLQ-C30 and FACT BL (10, 8, 5 studies respectively). None of the studies were randomised and only 4 studies were prospectively designed. Sixteen studies reported no difference in QoL between the two types of urinary diversion and four studies reported a better QoL with orthotopic neobladder of which 2 studies had younger and fitter patients. On the other hand, one study reported a better QoL in ileal conduit patients. Conclusion Orthotopic neobladder urinary diversion shows a marginally better quality of life scores compared to ileal conduit diversion especially when considering younger and fitter patients.

Abstract: Background Preoperative injection of Tc99 is standardly performed before sentinel lymph node biopsy (SLN) for breast cancer. Multiple questions have arisen concerning appropriate technique for SLNBs including site of injection, timing and injection material. The aim of this study was to assess the concordance between a new method, superparamagnetic iron oxide (SPIO) and the Tc99 radiotracer to identify the SLN in early breast cancer. Material and methods Between July 2013 and March 2014, 120 patients with clinically node negative early breast cancer were included in the study. Patients were injected the day before the radiotracer for lymphoscintigraphy and injected the SPIO subareolar intraoperatively. SLN was excised if it was radioactive, magnetic or palpable. Patients signed an inform consent. Results There was no drainage by either technique in 2 patients, so this leaves 118 patients for further analysis. Detection rate by Tc 99 was successful in 113 (95.7%%) patients and by SPIO in 116 (98.3%). Concordance rates per patient between techniques was 98.2%. The SLN was positive in 36 (30%) patients. Of this, SLN positivity was detected by both techniques in 32 patients. Mean number of SLNs by 99Tc and SPIO were 1.9 and 2.21 respectively (p = 0.001). Discussion Detection of SLNs with SPIO allows for easy identification of axillary nodes, at a frequency not inferior to the radiotracer. It is an oncologically safe procedure, facilitates patients and operative room management and can be used to reliably identify SLNs in breast cancer.

Abstract: Background Quality of Life (QoL) plays an important role in patients with peritoneal metastasis and is deteriorating continuously until death. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is an innovative palliative treatment of peritoneal metastasis. We present the first QoL results under PIPAC therapy. Methods Retrospective analysis of QLQ30 questionnaire results during repeated courses of PIPAC applications in palliative patients with pretreated peritoneal metastasis. Results 91 patients (M:F = 40:51, median age 64 (34–77) years) with 158 PIPAC applications were analyzed. 86% patients had previously received systemic chemotherapy. Peritoneal metastasis was advanced (Peritoneal Carcinomatosis Index I = 16 ± 10). At admission, only moderate impairment of functioning (62–83%) and symptom scores (17–47%) was observed. 48 patients received at least 2 PIPAC every 6 weeks. After PIPAC # 1, the global physical score deteriorated slightly (from 82% to 75%), but improved after PIPAC # 2 (up to 89%). Gastrointestinal symptoms (nausea/vomiting, constipation, diarrhoea, anorexia) remained stable under PIPAC therapy. Conclusions Quality of life was relatively high in this group of patients with advanced, pretreated peritoneal metastasis, explaining their wish for further therapy. Functioning scores and disease-related symptoms were not altered for at least 3 months in the patients able to receive repeated PIPAC. Except for a transient moderate increase of pain scores, PIPAC did not cause therapy-related QoL deterioration, especially no gastrointestinal symptoms.

Abstract: Background Primary breast conserving treatment (BCT) is well known to have similar long-term survival as mastectomy in breast cancer patients. However, recent studies are suggesting better survival among women treated with BCT compared with mastectomy. More knowledge is needed to understand how disease specific survival is influenced by detection mode, prognostic and predictive tumor characteristics. We aimed to investigate this issue among women targeted by the Norwegian Breast Cancer Screening Program. Method Information about 9547 women aged 50–69 years diagnosed with primary invasive breast cancer without distant metastasis, who underwent either BCT or mastectomy, 2005–2011, were included in the study. Kaplan–Meier plots were used to estimate six years survival, while Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer death associated with surgical treatment. Information about molecular subtype, detection mode, age at diagnosis, tumor size, lymph node involvement, and histologic grade, in addition to radiation treatment, chemotherapy and endocrine therapy were included in adjusted analyses. Results BCT was performed among 61.9% of the women included in the study. Women treated with BCT had prognostic and predictive favorable tumor characteristics compared to women treated with mastectomy. Adjusted analyses revealed a 1.7 (95% CI: 1.3–2.4) higher risk of breast cancer death among women who underwent mastectomy compared with BCT. Conclusion Women treated with BCT have significantly better breast cancer-specific survival and a lower risk of dying from breast cancer compared to women treated with mastectomy, independent of detection mode, prognostic and predictive tumor characteristic.

Abstract: Objective To compare the incidence and severity of postoperative complications after oesophagectomy for carcinoma of the oesophagus and gastro-oesophageal junction (GOJ) after randomized accrual to neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiotherapy (nCRT). Background Neoadjuvant therapy improves long-term survival after oesophagectomy. To date, evidence is insufficient to determine whether combined nCT, or nCRT alone, is the most beneficial. Methods Patients with carcinoma of the oesophagus or GOJ, resectable with a curative intention, were enrolled in this multicenter trial conducted at seven centres in Sweden and Norway. Study participants were randomized to nCT or nCRT followed by surgery with two-field lymphadenectomy. Three cycles of cisplatin/5-fluorouracil was administered in all patients, while 40 Gy of concomitant radiotherapy was administered in the nCRT group. Results Of the randomized 181 patients, 91 were assigned to nCT and 90 to nCRT. One-hundred-and-fifty-five patients, 78 nCT and 77 nCRT, underwent resection. There was no statistically significant difference between the groups in the incidence of surgical or nonsurgical complications (P-value = 0.69 and 0.13, respectively). There was no 30-day mortality, while the 90-day mortality was 3% (2/78) in the nCT group and 6% (5/77) in the nCRT group (P = 0.24). The median Clavien-Dindo complication severity grade was significantly higher in the nCRT group (P = 0.001). Conclusion There was no significant difference in the incidence of complications between patients randomized to nCT and nCRT. However, complications were significantly more severe after nCRT. Registration trial database The trial was registered in the Clinical Trials Database (registration number NCT01362127 ).

Abstract: Background We compared clinical outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) against those of classical 2-stage hepatectomy in treating metastatic liver disease. Methods Short-term outcomes, serial changes in volume of the future liver remnant (FLR), functional FLR volume, and tumor growth activity during the treatment period, were compared between our first 11 consecutive patients treated with ALPPS and 54 patients treated with classical 2-stage hepatectomy. Results Mortality in the ALPPS group (9%) tended to be higher than in the classical 2-stage group (2%, P = 0.341). The FLR hypertrophy ratio (FLR volume after vs. before the procedure) 1 week after the first operation in the ALPPS group (1.54 ± 0.18) exceeded that in the classical 2-stage group (1.19 ± 0.29, P = 0.005), being similar to the ratio at 3 weeks after the first procedure in the classical 2-stage group (1.40 ± 0.43). However, functional volume of the FLR in the ALPPS group 1 week after the first procedure (52.1%) tended to be smaller than that in the classical group 3 weeks after the first procedure (59.2%). Conclusions ALPPS should be used with extreme caution, giving special attention to postoperative complications and grade of functional liver regeneration.

Abstract: Background The combination of advances in surgical technique and neoadjuvant therapy for rectal cancer has resulted in more patients undergoing sphincter-preserving surgery. Unfortunately, numerous patients subsequently experience bowel dysfunction, and may suffer from lifelong severe disability with major impact on their quality of life. The aim of the present study was to investigate whether the risk of severe LARS in patients was associated with the length of remnant rectum. Methods A total of 125 patients who underwent sphincter-preserving surgery for rectal cancer were included. Postoperative bowel function was assessed using the low anterior resection syndrome (LARS) score a minimum of one year following surgery. The length of remnant rectum was measured on postoperative MRI of the pelvis and was correlated with the risk of having major LARS. Results Overall, major LARS was observed in 38 per cent of patients. In the patients who underwent surgery alone, major LARS was reported by 27 per cent, and a larger remnant rectum was associated with a better functional outcome. In contrast, 80 per cent of patients who underwent combined preoperative chemoradiotherapy and surgery reported having major LARS. No association between the length of remnant rectum and the risk of major LARS was observed in patients treated with combined neoadjuvant therapy and surgery. Conclusion Both the length of remnant rectum and preoperative chemoradiotherapy had a major impact on the severity of bowel dysfunction after restorative rectal cancer surgery. No functional benefit from an irradiated rectal remnant was observed.

Abstract: Background Laparoscopic trans-abdominal total mesorectal excision is technically demanding. Transanal Total Mesorectal Excision (taTME) is a new technique which seems to provide technical advantages. This study describes the results of taTME in a consecutive series of patients with low rectal cancer. Methods From January 2012 to December 2013, a consecutive series of 26 patients with low rectal cancer underwent laparoscopic taTME with coloanal anastomosis. cT4 or Type II-III rectal cancer (according to Rullier's classification) were contraindications to taTME. After anal sleeve mucosectomy, the rectal wall was transected at the ano-rectal junction. A single-access multichannel port was inserted in the anal canal. taTME was performed from down to up until the sacral promontory posteriorly and the Pouch of Douglas anteriorly were reached. A laparoscopic trans-abdominal approach was used to complete the left colon mobilization. Results Sixteen patients (61.5%) were male. The mean distance of the rectal cancer from the anal verge was 4.4 cm (range 3–6). Nineteen patients (73.1%) received long-course neoadjuvant radiotherapy. At final pathology, resection margins were negative in all the patients: the mean distal and radial resection margins were 19 mm and 11.2 mm, respectively. TME was complete in 23 patients (88.5%) and nearly complete in three. Postoperative mortality was 3.8%. The overall morbidity rate was 26.9% (7 patients): two patients (7.7%) had an anastomotic leakage (Dindo I-d). After a mean follow up of 23 months, no patients have developed a local recurrence. Conclusions laparoscopic taTME allow wide resection margins and good quality TME.

Abstract: Background Anastomotic leakage is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. The aim was to investigate the inflammatory and angiogenic responses in patients undergoing surgery for colorectal cancer who had postoperative intra-abdominal infection, and to compare the results with patients without complications. Methods Consecutive patients undergoing surgery for colorectal cancer with curative intent were included. Patients who had an anastomotic leak or intra-abdominal abscess were included in the infection group and matched with patients who had an uncomplicated postoperative course. IL-6 and VEGF were measured in serum and peritoneal fluid. Results Serum concentration of IL-6 was higher in the infection group (n = 30) compared with the control group (n = 30) on day 4 (infection: 42.3 [27.6–1473.2] versus control: 0.6 [0.6–17.1] pg/ml; p = 0.008). IL-6 in peritoneal fluid was higher in the infection group at 48 h and day 4 (infection: 1000.2 [995.4–1574.0] versus control: 90.3 [35.2.6–106.1] pg/ml; p = 0.001). Serum VEGF was higher in the infection group on day 4 (infection: 1128.6 [427.3–10000.0] versus control: 438.3 [214.1–677.6] pg/ml; p = 0.001). Peritoneal VEGF concentration was higher in the infection group at 48 h and day 4 (infection: 10000.0 [2563.0–10000.0] versus control: 477.8 [313.5–814.4] pg/ml; p = 0.001). Two-year recurrence rate was higher in patients with infection (infection: 30% versus control: 4%; p = 0.001). Conclusions Intra-abdominal infection increases IL-6 and VEGF after surgery for colorectal cancer. Amplification of inflammation and angiogenesis might be one of the mechanisms responsible for the higher recurrence rate observed in patients with anastomotic leakage or intra-abdominal abscess.

Abstract: Background To improve the diagnostic accuracy for hepatic tumors on the liver surface, we investigated the usefulness of an indocyanine green-photodynamic eye (ICG-PDE) system by comparison with Sonazoid intraoperative ultrasonography (IOUS) in 117 patients. Hepatic segmentation by ICG-PDE was also evaluated. Methods ICG was administered preoperatively for functional testing and images of the tumor were observed during hepatectomy using a PDE camera. ICG was injected into portal veins to determine hepatic segmentation. Results Accurate diagnosis of liver tumors was achieved with ICG-PDE in 75% of patients, lower than with IOUS (94%). False-positive and false-negative diagnosis rates for ICG-PDE were 24% and 9%, respectively. New small HCCs were detected in 3 patients. The ICG fluorescent pattern in tumors was strong staining in 41%, weak staining in 13%, rim staining in 20% and no staining in 26%. Hepatocellular carcinoma predominantly showed strong staining (61%), while rim staining predominated in cholangiocellular carcinoma (60%) and liver metastasis (55%). Hepatic segmental staining was performed in 28 patients, proving successful in 89%. Conclusion ICG-PDE is a useful tool for detecting the precise tumor location at the liver surface, identifying new small tumors, and determining liver segmentation for liver resection.

Abstract: Objective Pelvic exenteration requires complete resection of the tumor with negative margins to be considered a curative surgery. The purpose of this review is to assess the optimal preoperative evaluation and surgical approach in patients with recurrent cervical cancer to increase the chances of achieving a curative surgery with decreased morbidity and mortality in the era of concurrent chemoradiotherapy. Methods Review of English publications pertaining to cervical cancer within the last 25 years were included using PubMed and Cochrane Library searches. Results Modern imaging (MRI and PET-CT) does not accurately identify local extension of microscopic disease and is inadequate for preoperative planning of extent of resection. Today, only half of pelvic exenteration procedures obtain uninvolved surgical margins. Conclusion Clear margins are required for curative pelvic exenterations, but are poorly predictable by pre-operative assessment. More extensive surgery, i.e. the infra-elevator exenteration with vulvectomy, is a logical surgical choice to increase the rate of clear margins and to improve patient survival following surgery for recurrent cervical carcinoma.

Abstract: Background The role of systemic chemotherapy (CT) in the multimodality treatment strategy for retroperitoneal sarcomas (RPS) remains controversial. We hypothesized that chemotherapy does not improve overall survival for patients with surgically resected RPS. Methods The National Cancer Database was used to identify all patients with RPS that underwent surgical resection from 1998 to 2011. Univariate and multivariable Cox proportional hazards modeling were used to assess overall survival (OS) and logistic regression was used for associations. Propensity score (PS) modeling was performed to create balanced cohorts for analysis. Results A total of 8653 patients with surgically resected RPS were identified; 1525 (17.6%) received CT; 10.6% of patients (n = 163) in the neoadjuvant setting. Factors associated with receipt of CT included moderate (OR 2.3) to poorly differentiated (OR 4.3) tumors, leiomyosarcoma (OR 1.8) or undifferentiated pleomorphic sarcoma (OR 2.3) histology, and R2 resection status (OR 2.2) (all p p p = 0.002). Receipt of chemotherapy was not associated with improved long term survival in adjusted models for the raw and propensity matched cohorts (HR 1.17, 95% CI: 1.04–1.31; p = 0.009). Conclusion Current available chemotherapy regimens for RPS do not confer a survival benefit. Routine use of chemotherapy for RPS should be discouraged until new effective systemic agents become available.

Abstract: Rectal cancer treatment has witnessed several changes in the past decades resulting into improved outcomes. Preoperative radiotherapy is much better tolerated than postoperative radiotherapy, and the combination with chemotherapy has proven to be very effective in downstaging rectal cancer. Implementation of standard baseline MRI staging has enabled a better selection of high risk patients who will benefit from neoadjuvant (chemo) radiation (ChRT). The recognition that histological features of the resection specimen are powerful prognostic tools helped to optimize the surgical technique into the current standard of Total Mesorectal Excision (TME). Additionally, auditing and feeding back the performance has improved surgical quality and decreased the local relapse rate. With all these changes, local control is no longer the Achilles heel in rectal cancer treatment. It is now time to shift our focus from improving oncological endpoints to reducing long-term morbidity and to improving functional outcomes. Especially for the elderly and for those with several comorbidities, rectal resections are major procedures with substantial morbidity and mortality. More than half of patients undergoing TME surgery and neoadjuvant therapies will have long-term anorectal and urogenital dysfunction. Although very low anastomoses can avoid a permanent stoma for distal tumours, there is difficult trade-off between a good-functioning stoma with a life-changing body image and the risk of a poorfunctioning intra-anal anastomosis. Surgeons have tried to minimize surgical trauma in several ways. Transanal local excision can work well for cT1 lesions with favourable features resulting in good functional recovery. Larger tumours and those with unfavourable features show higher failure rates because of residual cancer cells within the bowel wall and lymph nodes.

Abstract: Background Pseudomyxoma peritonei (PMP) usually originates from perforated mucinous appendiceal tumours and may present unexpectedly at surgery, or be suspected at cross sectional imaging. The optimal treatment involves macroscopic tumour removal by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The 10-year Kaplan–Meier predicted disease-free survival is 61%. Some patients with recurrence are amenable to further CRS and HIPEC. Aim To evaluate the outcomes of re-do surgery in a large single centre series of reoperation for recurrence of peritoneal surface malignancy. Method Retrospective analysis of prospective database of 752 patients undergoing CRS for perforated appendiceal tumours analysed. Routine follow up involved annual CT scans and serum tumour marker measurement. The survival and recurrence in the 512/752 (68.1%) who had complete cytoreduction between March 1994 and January 2012 was calculated by Kaplan–Meier univariate analysis. Results Overall 137/512 (26.4%) developed recurrence and of those 35/137 (25.5%) underwent repeat surgery. Complete tumour removal was again achieved in 20/35 (57.1%). There were no postoperative deaths and no significant difference in early postoperative complications and length of stay compared to primary CRS surgery. The 5-year survival in the 375 without recurrence, the 35 who had re-do surgery and the 102 who had recurrence with no surgery was 90.9%, 79.0% and 64.5% respectively. Conclusion Approximately one in four patients develops recurrence after complete CRS and HIPEC for PMP of appendiceal origin. Selected patients can undergo salvage surgery with good outcomes.

Abstract: Aim The combination of surgery and chemotherapy (CTx) is increasingly accepted as an effective treatment for patients with colorectal liver metastases (CRLM). However, controversy exists whether all patients with resectable CRLM benefit from perioperative CTx. We investigated the impact on overall survival (OS) by neo-adjuvant CTx in patients with resectable CRLM, stratified by the clinical risk score (CRS) described by Fong et al. Methods Patients who underwent surgery for CRLM between January 2000 and December 2009 were included. We compared OS of patients with and without neo-adjuvant CTx stratified by the CRS. The CRS includes five prognosticators and defines two risk groups: low CRS (0–2) and high CRS (3–5). Results 363 patients (64% male) were included, median age 63 years (IQR 57–70). Prior to resection, 219 patients had a low CRS (neo-adjuvant CTx: N = 65) and 144 patients had a high CRS (neo-adjuvant CTx: N = 88). Median follow-up was 47 months (IQR 25–82). In the low CRS group, there was no significant difference in median OS between patients with and without CTx (65 months (95% CI 39–91) vs. 54 months (95% CI 44–64), P = 0.31). In the high CRS group, there was a significant difference in OS between patients with and without CTx (46 months (95% CI 24–68) vs. 33 month (95% CI 29–37), P = 0.004). Conclusion In our series, patients with a high CRS benefit from neo-adjuvant CTx. In patients with a low risk profile, neo-adjuvant CTx might not be beneficial.

Abstract: Objective To analyse the impact of liver resection (LR) in patients with Hepatocellular Carcinoma (HCC) within the Barcelona-Clinic-Liver-Cancer (BCLC)-B stage. Methods Analysis of patients with BCLC-B HCC treated with LR or transarterial chemoembolization (TACE) between 2007 and 2012 in our hospital. Survival/recurrence analyses were performed by log-rank tests and Cox multivariate models. Further analyses were specifically obtained for the HCC subclassification (B1–2–3–4) proposed recently. Results Eighty patients were treated (44-TACE/36-LR). Number of nodules was [1.8(1.1)], being multinodular in 50% of cases. Although resected patients had a higher hospital stay than those who underwent TACE (14 ± 13 vs 7 ± 6; P = 0.004), the rate and severity of complications was lower measured by Dindo–Clavien scale (P Conclusions Management of Intermediate BCLC-B HCC stage should be more complex and include updated criteria regarding B-stage subclassifications, VI and tumour differentiation. Modern surgical resection would offer improved survival benefit with acceptable safety in selected BCLC-B stage patients.

Abstract: Objective To compare different techniques of minimally invasive surgery (laparoscopy and robotics) to abdominal surgery in order to identify the optimal surgical technique in the treatment of endometrial cancer. Methods and materials A single-institutional, matched, retrospective, cohort study was performed. All patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy, bilateral salpingo-oophorectomy ± lymphadenectomy from August 2010 and December 2013 were identified. Surgical and oncological outcomes were compared with patients matched by age, body mass index, tumor histology, and grade, who underwent abdominal or laparoscopic surgery between January 2001 and December 2013. Results Three groups were identified: 177 laparotomies (group A), 277 laparoscopies (group B) and 72 robotics (group C). There were no statistically significant differences between the three groups in terms of age, BMI and FIGO stage. The operative time was shortest in group B (p = 0.0001). Blood loss and transfusions were equivalent in group B and C, while they were greater in group A (p = 0.0001). The intra-operative, early and late postoperative complications, rate of conversion, the re-intervention and median hospital stay were lower in group C. The rate of recurrence and death from disease was similar in all three groups. Conclusions Minimally invasive surgery was superior to abdominal surgery in terms of surgical outcomes. Robotic surgery was superior to laparoscopy in terms of intra- and post-operative complications, conversion rates, length of hospital stay and re-interventions. In terms of oncological outcomes the three groups were equivalent.

Abstract: Background Few papers deal with pathologic characteristics and outcome of the 3 different cholangiocarcinomas based on location (intrahepatic, peri-hilar, distal). There is little evidence regarding similarity and differences. Patients and Methods From two tertiary referral Italian Centers (in Bologna and Verona), 479 patients with cholangiocarcinoma were evaluated between 1980 and 2011. Several pathologic characteristics and their impact on survival were analyzed among resected patients for cholangiocarcinomas depending on the site of origin. Results Tumour location was intrahepatic in 172 cases (36%), peri-hilar in 243 (51) and distal in 64(13%). Curative resection was performed in 339 (70%) patients. Intrahepatic cholangiocarcinoma showed higher probability to achieve R0 resection (81%), but was more frequently associated with presence of microvascular invasion (71%). Distal cholangiocarcinoma presented less R0 resections (58%), higher lymphnode involvement (60%) and lower microvascular invasion (49%). Hilar cholangiocarcinoma had intermediate characteristics (R0: 65% of cases). Median follow up was 30.2 ± 38 months; the 5 years overall survival was 31% in the resected population. Overall survival curves were similar among the three groups. At univariate analysis surgical margins, lymphnode status, perineural invasion, T category, TNM stage, microvascular invasion, tumour grading had significant impact on survival. At multivariate analysis, only microvascular invasion was significantly related to long term results (HR = 1,7; 95% CI = 1,0–2,5)”. Conclusion Micro-vascular invasion has the strongest impact on survival in all three types of cholangiocarcinoma. In case of comparable pathologic characteristics and stage, the three tumors show similar outcome; depending on location, it shows a different tendency to invade bordering structures which affect the outcome.

Abstract: Background In early breast cancer patients with sentinel node metastasis, the effect of axillary lymph node dissection (ALND) is controversial. The purpose of this study is to compare the safety and efficacy of sentinel lymph node biopsy (SLNB) alone versus ALND in patients with early breast cancer and sentinel node metastasis. Methods We searched PubMed, Embase, Web of Science, and Cochrane Library databases from 1965 to February 2014. All data were analyzed using Review Manager Software 5.2. Results 12 studies, which included 130,575 patients from five randomized controlled trials and seven observational studies, met our inclusion criteria. 26,870 early breast cancer patients underwent SLNB alone and 103,705 underwent ALND. Patients underwent ALND had more paresthesia (risk ratio [RR] 0.26, 95% confidence interval [CI] 0.20-0.33; p Conclusion Current evidence indicates that axillary dissection may be omitted in early breast cancer patients with sentinel lymph metastasis.

Abstract: Background Recent advances in gastric cancer chemotherapy have made macroscopic complete resection possible in some patients with stage IV disease. Methods We retrospectively investigated the efficacy of multimodal therapy with combined docetaxel, cisplatin, and S-1 (DCS) and conversion gastrectomy in 57 patients with stage IV gastric cancer. Results Of the 57 patients, 15 patients were categorized into potentially resectable case, which is defined as patients with single incurable factor including the upper abdominal para-aortic lymph node metastasis (16a2b1 PAN metastasis) or fewer than three peripheral liver metastases. The other 42 were categorized as initially unresectable. All of patients underwent DCS therapy, and then 34 patients underwent conversion gastrectomy. The 3-year overall survival (OS) rate among the patients who underwent conversion gastrectomy was 50.1% with MST of 29.9 months. They had significantly longer OS than patients who underwent DCS therapy alone (p p = 0.021). In contrast, clinical response was selected as the only independent prognostic factor in the subgroup of initially unresectable cases (HR 0.354, 95%CI 0.151-0.783, p = 0.021). Conclusion Patients with potentially resectable disease had a remarkably good prognosis among stage IV gastric cancer patients, and might be ideal candidates for conversion gastrectomy following DCS therapy.

Abstract: Background Several prognostic scores were designed in order to estimate the risk of postoperative adverse events. None of them includes a component directly associated to the nutritional status. The aims of the study were the evaluation of performance of risk-adjusted models for early outcomes after oesophagectomy and to develop a score for severe complication prediction with special consideration regarding nutritional status. Methods A comparison of POSSUM and Charlson score and their derivates, ASA, Lagarde score and nutritional index (PNI) was performed on 167 patients undergoing oesophagectomy for cancer. A logistic regression model was also estimated to obtain a new prognostic score for severe morbidity prediction. Results Overall morbidity was 35.3% (59 cases), severe complications (grade III–V of Clavien–Dindo classification) occurred in 20 cases. Discrimination was poor for all the scores. Multivariable analysis identified pulse, connective tissue disease, PNI and potassium as independent predictors of severe morbidity. This model showed good discrimination and calibration. Internal validation using standard bootstrapping techniques confirmed the good performance. Conclusions Nutrition could be an independent risk factor for major complications and a nutritional status coefficient could be included in current prognostic scores to improve risk estimation of major postoperative complications after oesophagectomy for cancer.