Incidence of lymph node recurrence after primary surgery for non-metastatic colon cancer: A systematic review

BackgroundThe extent of lymphadenectomy in colon cancer (CC) is a matter of debate. One argument of extensive surgery is that it may prevent lymph node recurrence (LNR). However, the incidence of LNR after surgery for CC is unknown. Here, we performed a systematic review of the incidence of LNR after either standard (D2) surgery or extensive resection (complete mesocolic excision, CME, D3).MethodsPubMed, Embase, Web of Science, and CENTRAL were searched for studies reporting on patients with primary stage I-III CC who developed locoregional or distant LNR. Methodological quality was scored using the QualSyst tool. The difference in overall and lymph node (LN) recurrence rate between CME/D3 and standard/D2 resection was statistically evaluated using non-parametric tests. Registered with PROPERO as CRD42020203288.ResultsFrom an initial 12.744 records, 24 studies were included, representing 13.521 CC patients. A majority of patients had right CC (64%), stage III disease (51%), and received adjuvant chemotherapy (57%). The mean number of examined nodes ranged from 14 to 30. The median overall recurrence rate was 14% in the CME/D3 group, and 19% in the standard/D2 group (P = 0.638). The median proportion of patients with any LNR was 1.7% in the CME/D3 group, and 1.2% in the standard/D2 group (P = 0.677). The median incidence of locoregional, potentially preventable LNR was 0% in the CME/D3 group and 0.4% in the standard/D2 group (P = 0.274).ConclusionsThe incidence of locoregional, potentially preventable LNR after surgery for CC is low (<1%), and is not affected by the extent of lymphadenectomy.     

Treatment for local control of retroperitoneal and pelvis sarcomas: A review of the literature

Retroperitoneal and pelvis sarcomas are uncommon tumors for which complete surgical resection is the mainstay of treatment. However, achieving complete gross resection with microscopically negative margins is challenging, and local recurrence rates can be high. Patients often succumb to uncontrolled local disease. Radiation therapy offers a potential means for sterilizing microscopic residual disease, although its use continues to be controversial. Chemotherapy alone or in combination with radiation continues to be investigated as an adjunct to surgery, along with immunotherapy and targeted therapies. In this review, we discuss the current management of retroperitoneal and pelvis sarcomas, focusing on studies of surgery and radiation therapy to maximize local control.     

Predicting loss of independence after high-risk gastrointestinal abdominal surgery: Frailty vs. NSQIP risk calculator

BackgroundLoss of independence (LOI) is a significant concern for patients undergoing high-risk abdominal surgery. Although the risk for morbidity and mortality has been well studied, there is a dearth of data on risk for LOI.MethodsThis study utilized NSQIP data from 2015 to 2018 in a retrospective cohort study of patients undergoing high-risk gastrointestinal surgery (e.g. gastric, colorectal, liver, and pancreatic).ResultsThe study included 229,573 patients who were preoperatively functionally independent. Of those, 5.3% experienced LOI. The median age for LOI patients was 74 (CI: 67–81), and 56% were female. The most common race was white (n = 9585), followed by African-American (n = 1223) and other (n = 369). The most common GI procedure was colorectal (65%), followed by the pancreas (23%), liver (8.2%), and gastric (3%). On univariate analysis, age, sex, BMI, race, frailty, and pancreatectomy were associated with LOI. On multivariate analysis age (≥85, OR 18.3 CI:16.9–19.9 p < 0.001), female sex (OR 1.24CI: 1.19–1.29 p < 0.001), BMI <18.5 (OR 1.66 CI:1.48–1.86 p < 0.001), BMI >40 (OR 1.43 CI:1.31–1.56 p < 0.001), African American race (OR 1.20 CI:1.12–1.28 p < 0.001), smoking (OR 1.21 CI:1.14–1.28 p < 0.001), frailty (MFI-5 > 2, OR 4.47 CI:2.63–7.31 p < 0.001), and pancreatectomy (OR 1.86 CI:1.74–1.98 p < 0.001) continued to be associated with LOI. To better define a predictive model, the NSQIP risk calculator was compared to the modified frailty index-5. AUC was 0.80 (CI: 0.797–0.805) and 0.76 (0.760–0.769), respectively.ConclusionLOI occurs in over five percent of patients undergoing high-risk abdominal surgery. LOI occurs more commonly after pancreatectomy or for those who are frail, underweight, or morbidly obese. Both frailty and the NSQIP risk calculator models similarly predicted LOI.     

Locally advanced cervical carcinoma patients treated with chemoradiation followed by radical surgery: clinical response and oncological outcomes according to histotype after propensity score analysis

IntroductionThe aims of this study were to analyze the pathological response, and survival outcomes of adenocarcinoma/adenosquamous (AC/ASC) versus squamous cell carcinoma (SCC) in patients with locally advanced cervical cancer (LACC) managed by chemoradiotherapy followed by radical surgery.MethodsRetrospective, multicenter, observational study, including patients with SCC and AC/ACS LACC patients treated with preoperative CT/RT followed by tailored radical surgery (RS) between 06/2002 and 05/2017. Clinical-pathological characteristics were compared between patients with SCC versus AC/ASC. A 1:3 ratio propensity score (PS) matching was applied to remove the variables imbalance between the two groups.ResultsAfter PS, 320 patients were included, of which 240 (75.0%) in the SCC group, and 80 (25.0%) in the AC/ASC group. Clinico-pathological and surgical baseline characteristics were balanced between the two study groups. Percentage of pathologic complete response was 47.5% in SCC patients versus 22.4% of AC/ASC ones (p < 0.001). With a median follow-up of 51 months (range:1–199), there were 54/240 (22.5%) recurrences in SCC versus 28/80 (35.0%) in AC/ASC patients (p = 0.027). AC/ASC patients experienced worse disease free (DFS), and overall survival (OS) compared to SCC patients (p = 0.019, and p = 0.048, respectively). In multivariate analysis, AC/ACS histotype, and FIGO stage were associated with worse DFS and OS.ConclusionIn LACC patients treated with CT/RT followed by RS, AC/ASC histology was associated with lower pathological complete response to CT/RT, and higher risk of recurrence and death compared with SCC patients. This highlights the need for specific therapeutic strategies based on molecular characterization to identify targets and develop novel treatments.     

DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema

IntroductionLymphedema is a condition which heavily impacts patients QoL. For patients who desire autologous breast reconstruction, lymph nodes can be included in the Deep Inferior Epigastric Artery (DIEP) flap combining vascularized lymph node transfer and autologous breast reconstruction.Material and methodsPatients who received autologous breast reconstruction with a DIEP flap in combination with vascularized lymph nodes were included in this study. Volume measurements pre and post-surgery were analyzed and surveys including two versions of the ULL-27 questionnaire to measure QoL before and after surgery were send.ResultsIn total, 45 out of 64 patients returned the questionnaires. The average follow up was 51 months. The total ULL-27 score increased with 12.6 points on average (p = 0.00). The subdomain scores (physical, psychological and social) also significantly increased (p = 0.00). In addition 69% of patients were able to decrease physiotherapy, 63% of patients were able to decrease compression garment usage and the incidence of skin infections decreased in 6 patients out of 7 patients who had recurrent skin infections prior to surgery. The volume difference between the affected and the healthy arm did not significantly change (407 ml–406 ml, p = 0.988).ConclusionsVascularized lymph node transfer in combination with DIEP flap breast reconstruction can cause a significant improvement on lymphedema related QoL, even when a volume difference decrease is absent. It can also decrease compression garment usage and reduce the need for physiotherapy. Future prospective studies should evaluate these findings and identify patients that benefit most from such procedures.     

Combined hepatic and portal vein embolization as preparation for major hepatectomy: a systematic review

BackgroundSome patients remain deemed unsuitable for resection after portal vein embolization (PVE) because of insufficient hypertrophy of the future remnant liver (FRL). Hepatic and portal vein embolization (HPVE) has been shown to induce hypertrophy of the FRL. The aim of this study was to provide a systematic review of the available literature on HPVE as preparation for major hepatectomy.MethodsThe literature search was performed on online databases. Studies including patients who underwent preoperative HPVE were retrieved for evaluation.ResultsSix articles including 68 patients were published between 2003 and 2017. HPVE was performed successfully in all patients with no mortality and morbidity-related procedures. The degree of hypertrophy of the FRL after HPVE ranged from 33% to 63.3%. Surgical resection after preoperative HPVE could be performed in 85.3% of patients, but 14.7% remained unsuitable for resection because of insufficient hypertrophy of the FRL or tumor progression. Posthepatectomy morbidity and mortality rates were 10.3% and 5.1%, respectively. The postoperative liver failure rate was nil.ConclusionHPVE as a preparation for major hepatectomy appears to be feasible and safe and could increase the resectability of patients initially deemed unsuitable for resection because of absent or insufficient hypertrophy of the FRL after PVE alone.