A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients

Background

The gold-standard for surgical excision of peri-ampullary tumours has not been established despite numerous studies, due to conflicting outcomes.

Aim

To consolidate the published evidence and compare outcomes between pancreaticoduodenectomy (PD) and pylorus preserving pancreaticoduodenectomy (PPPD) across all published comparative studies.

Methods

Using meta-analytical techniques the study compared: operative details, post-operative adverse events and survival following PD and PPPD. Comparative studies published between 1986 and 2005 of PD versus PPPD were included. A random effect model was employed, with significance reported at the 5% level.

Results

32 studies comprising 2822 patients (1335 PD and 1487 PPPD), including 5 randomized controlled trials with 421 patients (215 PD and 206 PPPD) were included. Patients undergoing PPPD were found to have smaller tumours (weighted mean difference (WMD) −0.54 cm, p = 0.030), although no significant difference in the number of patients with stage III or IV disease existed between the groups (odds ratio, OR 1.55, p = 0.320). Decreased operating times (WMD −41.3 min, p = 0.010) and fewer blood transfusions (WMD −0.9 units, p < 0.001) were observed in the PPPD group. There was no difference in post-operative complications, including pancreatic and biliary leaks or fistulae, between the two groups. It was suggested that peri-operative mortality was decreased in the PPPD group (OR 1.7, p = 0.040), and overall survival was better (hazard ratio (HR) 0.66, p = 0.02), although this did not remain significant on subgroup analysis.

Conclusions

Both PD and PPPD had similar peri-operative adverse events, however, in overall analysis PPPD has lower mortality and improved long-term patient survival, although this was not reflected in the sub-group analysis.     

Impact of hospital volume on outcomes for pancreaticoduodenectomy: A single UK HPB centre experience

Background

High hospital volume has a favorable impact on outcomes for complex procedures including pancreaticoduodenectomy (PD); however, the temporal relationship has not been evaluated in a single centre.

Aim

To evaluate the impact of UK cancer outcome guidelines (COG) on outcomes for PD in a single UK HPB specialist centre.

Patients and methods

All patients with pancreatic pathologies undergoing surgery at our institution from 1999 to 2006 were identified, of which 140 underwent PD. The annual caseload for PD and corresponding outcomes for length of hospital stay, morbidity, mortality and survival were analysed during the period around the implementation of UK COG with an increase in the surgical workload correlating with catchment’s population increase from 1.6 to 3.1 million.

Results

Between January 1999 and December 2006, 140 patients underwent a PD (M:F 1.06:1; median age 64 (range 34–84) years). Median hospital stay was 16 days (range 7–318). The 30-day mortality was 2.8%, in-hospital mortality was 6.4% and morbidity was 37.1%. Pancreatic leak/fistula rate was 8.6%. Over the 7-year period, PDs per year increased 5.3 fold from 6 procedures in 1999 to 32 in 2006. Analysis of the data for 1999–2002-(pre-COG) and 2003–2006-(post-COG) showed a trend towards decrease in mortality (from 9.7% to 5.0%, p = 0.448: OR = 2.74 (95% CI, 0.58–12.88); Fisher’s exact test) and morbidity (from 41.6% to 35.3%; OR = 1.29 (95% CI, 0.74–3.56); p = 0.565).

Conclusion

With COG implementation within a single UK pancreatic unit, the PD volume and staffing levels increased with a trend towards decreased morbidity and mortality.     

Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma

Background

The most accepted treatment for locally advanced pancreatic adenocarcinoma (LAPA) is chemoradiotherapy (CRT). We sought to determine the benefit of pancreaticoduodenectomy (PD) in patients with LAPA initially treated by neoadjuvant CRT.

Methods

From January 1996 to December 2006, 64 patients with LAPA (borderline, n = 49; unresectable, n = 15) received 5-fluorouracil-cisplatin-based CRT. Of the 64 patients, 47 had progressive disease at restaging. Laparotomy was performed for 17 patients, and PD was performed in 9 patients (resected group). Fifty-five patients had CRT followed by gemcitabine-based chemotherapy (unresected group).

Results

The median survival and overall 5 years survival duration of all 64 patients were 14 months and 12%, respectively. The mean delay between diagnosis and surgical resection was 5.5 months. Mortality and morbidity from PD were 0% and 33%, respectively. The median survival of the resected group vs. the unresected group was 24 months vs. 13 months. Three specimens presented a major pathological response at histological examination. No involved margins were found and positive lymph nodes were found in one patient. Resected patients developed distant metastases.

Conclusions

PD after CRT was safe and resected patients had interesting survival rates. However, resected patients developed metastatic disease and new neoadjuvant regimens are needed to improve the survival of these patients.     

Primary tumour resection and survival in the palliative management of metastatic colorectal cancer

Aim

To examine whether surgical resection of the primary tumour confers a survival benefit and to identify the predictive factors of outcome in patients presenting with asymptomatic metastatic colorectal cancer (CRC).

Materials and methods

A review of a hospital database in a tertiary institution over a 6-year period (1999–2005) revealed 70 patients with asymptomatic primary CRC and unresectable liver metastases treated initially by systemic chemotherapy. A multivariate regression analysis model was used to determine the relative influence of multiple tumours, single/multiple liver metastases, tumour site, differentiation, response of liver and primary tumour to chemotherapy, biochemical response to chemotherapy, age at presentation, performance status and surgical intervention for the CRC primary.

Results

In 67 cases (3 lost to follow-up), 63 had multiple and 4 single surgically irresectable liver metastases. A total of 41 deaths were recorded. All patients received systemic chemotherapy and surgery was performed for bowel obstruction, bleeding or stable disease (n = 32). Surgery (OR 0.26; p = 0.00013) and clinical response of the primary tumour (OR 0.53; p = 0.012) were independently associated with prolonged survival. Proximal tumours (OR 2.61; p = 0.0075) and multiple primaries (OR 3.37; p = 0.02) were associated with poor outcome.

Conclusions

Surgical resection and response of the primary tumour to chemotherapy may be associated with improved survival, but proximal or multiple cancers predict poor outcome in patients with asymptomatic CRC and unresectable metastatic disease.     

Predictors of PEG dependence after IMRT ± chemotherapy for oropharyngeal cancer

Purpose

To prospectively assess predictors of PEG dependence after IMRT with/without concomitant chemotherapy (CHT).

Methods and materials

One-hundred-seventy-one patients were considered (exclusive RT: 58, RT+CHT: 113; 159/171 treated at a median dose of 70 Gy, 2 Gy/fr). Patients treated with RT+CHT underwent prophylactic PEG insertion; PEG was as needed for the others. A number of clinical factors and dose–volume information concerning oral mucosa (OM), constrictors, masticatory muscles, larynx, esophagus and parotids were available. The 25th/10th percentiles of the duration of PEG dependence were our end-points (respectively 3.3 and 7 months, PEG3/PEG7). Logistic uni and multi-variate (MVA) analyses were performed.

Results

Concerning PEG3, the independent predictors at MVA were: CHT/PEG policy (OR: 6.8, p = 0.001), V9.5G_OM Gy/week (OR: 1.017, p = 0.01), larynx V50 (OR: 1.018, p = 0.01) and superior constrictor (SC) D_mean (OR: 1.002, p = 0.005); the predictive value of the model (AUC) was 0.818 (95% CI: 0.751–0.873). The independent predictors of PEG7 were: larynx V50 (OR: 1.042, p = 0.0005) and SC D_mean (OR: 1.003, p = 0.02), symptoms at diagnosis (yes vs no, OR: 3.6, p = 0.08) and sex (male vs female, OR: 0.25, p = 0.07); AUC was 0.897 (95% CI: 0.841–0.939).

Conclusions

OM V9.5 Gy/week and CHT/PEG_policy modulate the risk of early PEG dependence. For longer PEG dependence, larynx V50 (or D_mean) and SC D_mean are highly predictive, suggesting that the fibrosis of constrictors and larynx is the main cause.     

Lower uterine segment involvement is associated with adverse outcome in patients with stage I endometroid endometrial cancer: Results of a multicenter study

Objective

To quantify the relative risk associated with lower uterine segment involvement (LUSI) on outcome measures in patients with apparent stage I endometroid endometrial cancer.

Methods

A cohort of 769 consecutive patients with endometroid endometrial carcinoma apparent stage I, who underwent surgery in five gynecological oncology centers in Israel; 138 patients with and 631 without LUSI were followed for a median time of 51 months. Local recurrence, recurrence-free and overall survival were compared between the two groups.

Results

LUSI was associated with grade 3 tumor (p = 0.002), deep myometrial invasion (p < 0.001), and the presence of lymphvascular space involvement (p = 0.01). There were 22 cases of local recurrences, 40 cases of distal recurrences and 80 patients died. Univariate survival analysis showed that patients with LUSI had trend toward lower regional recurrence-free survival (p = 0.09), and significant lower distant recurrence-free survival (p = 0.04) and lower overall survival (p = 0.002). The Cox proportional hazards model demonstrated a significantly decreased overall survival (HR = 2.3; 95% CI 1.3, 3.9; p = 0.003) in cases with LUSI.

Conclusions

In patients with apparent stage I endometroid endometrial cancer, the presence of LUSI is a poor prognostic factor, associated with a significantly higher risk of distal recurrence and death. The presence of LUSI warrants consideration when deciding upon surgical staging or postoperative management.     

Robotic vs. open radical cystectomy in bladder cancer: A systematic review and meta-analysis

Aims

To evaluate the safety and efficacy of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in the treatment of bladder cancer.

Methods

A systematic search of Medline, Embase databases and the Cochrane Library was performed to identify studies that compared RARC and ORC and were published up to December 2012. Outcomes of interest included demographic and clinical characteristics, perioperative, pathologic variables and complications.

Results

Although there was a significant difference in the operating time in favor of ORC (WMD: 70.69 min; p < 0.001), patients having RARC might benefit from significantly fewer total complications (OR: 0.54; p < 0.001), less blood loss (WMD: −599.03 ml; p < 0.001), shorter length of hospital stay (WMD: −4.56 d; p < 0.001), lower blood transfusion rate (OR: 0.13; p = 0.002), less transfusion needs (WMD: −2.14 units; p < 0.001), shorter time to regular diet (WMD: −1.57 d; p = 0.002), more lymph node yield (WMD: 2.18 n; p = 0.001) and fewer positive lymph node (OR: 0.64; p = 0.03). There was no significant difference between the RARC and ORC regarding positive surgical margins.

Conclusions

In early experience, our data suggest that RARC appears to be a safe, feasible and minimally invasive alternative to its open counterpart when performed by experienced surgeons in selected patients.     

Prognostic factors and assessment of staging systems for head and neck soft tissue sarcomas in adults

Objectives

The primary objectives of this study were to analyse the outcome of patients diagnosed with head and neck soft tissue sarcomas (HNSTS) and to identify relevant prognostic factors. As well as this, we compared the prognostic value of two staging systems proposed by the American Joint Committee on Cancer (AJCC) and the Memorial Sloan-Kettering Cancer Center (MSKCC).

Methods

From 07/1988 to 01/2008, the charts of 42 adult patients were retrospectively reviewed. Potential prognostic factors were analysed according to overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS).

Results

At 5 years, OS was 57%, DFS 47% and DSS 72%. On univariate analysis, statistically significant prognostic factors were for OS, distant or lymph node metastasis at diagnosis (p = 0.032), for DFS, margins after surgery (p = 0.007), for DSS, regional or distant metastasis at diagnosis (p = 0.002), initial AJCC and MSKCC stage (p = 0.018 and p = 0.048) and margins after surgery (p = 0.042). On multivariate analysis, margins remained statistically significant for DFS (p = 0.039) when there was a trend with the initial AJCC stage (p = 0.054) for OS. The AJCC staging system was of more prognostic value than the MSKCC staging system.

Conclusions

Achieving clear margins after surgery is vital for improved local control and the best chance of survival. Adjuvant chemotherapy and radiotherapy were not shown to provide additional benefit. To better identify prognostic factors, it seems essential to set up national and international databases allowing multicenter registration for those patients.     

Patterns of lymph node spread and its influence on outcome in resectable parotid cancer

Aim

To assess the metastatic topography of intraparotideal and neck lymph nodes in parotid cancer and its influence on tumour recurrence and survival.

Methods

The lymph node spread of 142 patients with primary parotid carcinoma treated from 1986 to 2006 was analysed. Disease-free survival (DFS) and overall survival (OS) were calculated. The role of the metastatic pattern as prognostic factors were univariately and multivariately analysed.

Results

A lateral, total or radical parotidectomy was performed in 19, 80 and 43 patients, respectively. A radical/radical-modified or selective neck dissection was performed in 68 and 74 patients, respectively. Eighty-seven neck dissection specimens were negative (pN0). Twelve patients had intraparotideal and cervical lymph node involvement (pPar+/pN+). In 24 patients only intraparotideal metastases were detected (pPar+/pN0). 19 patients only had cervical nodal involvement (pPar−/pN+). Twenty-five patients had occult locoregional lymph metastases (cN0/pN+). The median follow-up was 24.4 months. The disease-free survival rate was 81% at 5 years, and 62% at 10 years. By univariate analysis, R+ (p = 0.001), pT (p = 0.019), lymphangiosis carcinomatosa (p = 0.019), pN+ (p = 0.042), and extracapsular spread (p = 0.046) were prognostic for disease-free survival. Multivariate analysis revealed R+ as independent risk factor (p = 0.046). In pN+ patients, involvement of parotid lymph nodes (p = 0.013), nodes in neck level I (p < 0.0001) and IV (p = 0.005) were univariate risk factors. Multivariate analysis showed lymph node metastases in level I as independent risk factor (p = 0.022).

Conclusion

Total parotidectomy and radical-modified neck dissection is recommended as surgical treatment of parotid cancer and should be analysed in a prospective trial.     

A case-control study comparing percutaneous radiofrequency ablation alone or combined with transcatheter arterial chemoembolization for hepatocellular carcinoma

Aims

To assess whether combining percutaneous radiofrequency ablation (PRFA) with transcatheter arterial chemoembolization (TACE) was better than PRFA alone for hepatocellular carcinoma (HCC).

Materials and methods

One hundered twenty patients (with a solitary HCC ≤ 7.0 cm in diameter or multiple HCC (≤3), each ≤3.0 cm in diameter) treated with PRFA combined with TACE were compared with 120 well-matched controls selected from a pool of 652 patients who received PRFA alone during the study period.

Results

The 1-, 2-, 3-, 5-year overall survival rates for the TACE-PRFA and PRFA groups were 93%, 83%, 75%, 50%, and 89%, 76%, 64%, 42%, respectively (p = .045). Subgroup analyses showed the survival for the TACE-PRFA group was better than the PRFA group for tumors >5.0 cm (p = .031) and for multiple tumors (p = .032), but not for tumors ≤5.0 cm (p = .319) and for solitary tumor (p = .128). The 1-, 2-, 3-, 5-year progression free survival (PFS) for the TACE-PRFA and PRFA groups was 90%, 76%, 63%, 42%, and 76%, 60%, 47%, 30%, respectively (p = .002). Child-pugh class, Diameter of tumor and hepatitis B surface antigen (HBsAg) were significant prognostic factors.

Conclusion

Patients treated with TACE-PRFA had better overall survivals than PRFA alone, but only in a subgroup of patients with tumor >5 cm or multiple tumors.     

Important prognostic factors for lung cancer in tobacco predominant Eastern North Carolina: Study based on a single cancer registry

Background

It is known that lung cancer incidence and mortality rate are higher in African Americans (AA) than whites. In Eastern North Carolina, there is a higher percentage of AA population than the national average (30.2% vs. 12.4%) and a higher incidence of lung cancer in this region. We investigated demography and survival of lung cancer patients diagnosed and treated in a single institution.

Methods

The study includes 2351 patients diagnosed with lung cancer between 2001 and 2010 at East Carolina University. AA and whites were compared by age, sex, race, stage, histology, smoking history and insurance information using chi-square analyses. Patient survival was modeled using Cox proportional hazards regression (SAS version 9.2).

Results

The distribution of lung cancer was 70% in whites and 30% in AA. The proportion of AA and whites differed significantly for age, sex, histology, stage, and insurance. Patients aged >70 (p < 0.0001) and 51–70 (p = 0.0064) died sooner than those ≤50 years old. Compared with squamous cell, SCLC had inferior survival (HR = 2.0, 95%CI = 1.7–2.3). Privately insured patients survived longer than those with medicare (p < 0.0001), medicaid (p = 0.0009), or no insurance (p < 0.0001). The survival disadvantage for medicaid (p = 0.0076) and no insurance (p = 0.0033) persisted on multivariable analysis. Race was not a significant predictor of survival on multivariable analysis (p = 0.66).

Conclusion

This is one of the largest lung cancer patient populations from a single institution showing demographic differences between the two races with similar survival outcome. Age, histology and type of insurance were strong predictors of survival outcome. Older age, small cell histology and medicaid and no insurance had significantly shorter overall survival.     

Metachronous hepatic metastases from gastric carcinoma: A multicentric survey

Background

The treatment of hepatic metastases from gastric cancer is controversial, due to biologic aggressiveness of the disease.

Objective

To survey the clinical approach to the subset of patients presenting with metachronous hepatic metastases as sole site of recurrence after curative resection of gastric cancer, focusing on the results achieved by different therapies and to investigate the prognostic factors of major clinical relevance.

Methods

Retrospective multi-center chart review evaluating 73 patients, previously submitted to D ≥ 2 gastrectomy for gastric cancer, who developed exclusive hepatic recurrence. Prognostic factors related to the patient, to the gastric malignancy and its treatment, and to the metastatic disease and its therapy were evaluated.

Results

Forty-five patients received supportive care, 17 were submitted to chemotherapy, and 11 to hepatic resection. Survival was independently influenced by the variables T (p = 0.019), N (p = 0.05) and G (p = 0.018) of the gastric primary and by the therapeutic approach to the metastases (p < 0.005). In particular, T4 gastric cancer, presence of lymph-node metastases and G3 tumor displayed a negative prognostic value. Therapeutic approach to the metastases was the principal prognostic variable: 1, 2, and 3 years survival rates were 22.2%, 4.4% and 2.2%, respectively, for patients without specific treatment; 44.9%, 12.8% and 6.4% after chemotherapy (p = 0.08) and 80.8%, 30.3% and 20.2% after surgical resection (p < 0.001).

Conclusions

Our data suggest some clinical criteria that may facilitate selection of therapy for patients with hepatic recurrence after primary gastric cancer resection. The best survival rates are associated with surgical treatment, which should be chosen whenever possible.     

Latent TB infection in newly diagnosed lung cancer patients – A multicenter prospective observational study

Objectives

Lung cancer and tuberculosis (TB) share common risk factors and are associated with high morbidity and mortality. Coexistence of lung cancer and TB were reported in previous studies, with uncertain pathogenesis. The association between lung cancer and latent TB infection (LTBI) remains to be explored.

Methods

Newly diagnosed, treatment-naïve lung cancer patients were prospectively enrolled from four referral medical centers in Taiwan. The presence of LTBI was determined by QuantiFERON-TB Gold In-Tube (QFT-GIT). Demographic characteristics and cancer-related factors associated with LTBI were investigated. The survival status was also analyzed according to the status of LTBI.

Results

A total of 340 lung cancer patients were enrolled, including 96 (28.2%) LTBI, 214 (62.9%) non-LTBI, and 30 (8.8%) QFT-GIT results-indeterminate cases. Non-adenocarcinoma cases had higher proportion of LTBI than those of adenocarcinoma, especially in patients with younger age. In multivariate analysis, COPD (OR 2.41, 95% CI 1.25–4.64), fibrocalcified lesions on chest radiogram (OR 2.73, 95% CI 1.45–5.11), and main tumor located in typical TB areas (OR 2.02, 95% CI 1.15–3.55) were independent clinical predictors for LTBI. Kaplan–Meier survival analysis demonstrated patients with indeterminate QFT-GIT results had significantly higher 1-year all-cause mortality than those with LTBI (p < 0.001) and non-LTBI (p = 0.003). In multivariate analysis, independent predictors for 1-year all-cause mortality included BMI < 18.5 (HR 2.09, 95% CI 1.06–4.14, p = 0.033), advanced stage of lung cancer (RR 7.76, 95% CI 1.90–31.78, p = 0.004), and indeterminate QFT-GIT results (RR 2.40, 95% CI 1.27–4.54, p = 0.007).

Conclusions

More than one-quarter of newly diagnosed lung cancer patients in Taiwan have LTBI. The independent predictors for LTBI include COPD, fibrocalcified lesions on chest radiogram, and main tumor located in typical TB areas. The survival rate is comparable between LTBI and non-LTBI cases. However, indeterminate QFT-GIT result was an independent predictor for all-cause mortality in lung cancer patients.     

The clinical significance of cytology versus histology-based diagnosis in small cell lung cancer: A retrospective study

Objectives

The aim of this study was to investigate the clinical significance of cytology versus histology-based diagnosis among patients diagnosed with small cell lung cancer (SCLC).

Materials and methods

Retrospective analysis of medical records of 443 patients with histologically or cytologically confirmed small cell lung carcinoma (SCLC) was performed. All patients received platinum-based chemotherapy regimens. Survival data (overall survival) were compared between patients with histology or cytology-based diagnosis in the overall study population as well as after stratification of patients according to disease stage (limited or extensive) at the time of diagnosis.

Results

Distribution of demographics and clinicopathological characteristics among the two groups (“histology” and “cytology”) was similar. No statistically significant differences in the survival curves between the “histology” and “cytology” groups were found in the overall study population (log rank test, p = 0.237), as well as in the subgroup of patients with limited disease (log rank test, p = 0.474). In contrast, patients with histology-based diagnosis had a statistically significant longer survival as compared to those with cytology-based diagnosis in the extensive disease subgroup (log rank test, p = 0.031), but this association was not retained after adjusting the analysis for demographics and clinical characteristics via a Cox regression model (HR = 1.18, 95% CI: 0.96–1.44, p = 0.110).

Conclusion

The results of our study suggest that the type of diagnostic modality employed (histology or cytology-based) for the establishment of a diagnosis of SCLC may not have a significant effect on the overall survival of patients. Further studies are warranted to further investigate this important, yet rather unexplored, issue.     

Positive prognostic impact of miR-210 in non-small cell lung cancer

Objectives

miR-210 is an important regulator of the cellular response to hypoxia. Therefore, we aimed to explore the prognostic significance of miR-210 in non-small cell lung cancer (NSCLC) patients with stage I-IIIA disease.

Materials and methods

In addition to clinicopathological and demograpic information, tumor tissues were collected and tissue micro arrays (TMAs) were constructed from 335 patients with stage I-IIIA NSCLC. Expression of miR-210 in cancer cells and stromal cells of the tumor was assessed by in situ hybridization.

Results

In univariate analyses, high cancer cell (p = 0.039) and high stromal cell expression (p = 0.008) of miR-210 were both significantly associated with an improved disease-spesific survival (DSS). High co-expression of miR-210 in cancer and stromal cells was also a positive prognostic factor for DSS (p = 0.010). In multivariate analysis, miR-210 in stromal cells (p = 0.011), and miR-210 co-expressed in cancer and stromal cells was an independent prognosticator for DSS (p = 0.011).

Conclusions

We show that miR-210 in stromal cells, and co-expressed in cancer cells and stromal cells mediates an independent prognostic impact. It is a candidate marker for prognostic stratification in NSCLC.     

Blood biomarkers are helpful in the prediction of response to chemoradiation in rectal cancer: A prospective,hypothesis driven study on patients with locally advanced rectal cancer

Purpose/objective

Chemoradiation (CRT) has been shown to lead to downsizing of an important portion of rectal cancers. In order to tailor treatment at an earlier stage during treatment, predictive models are being developed. Adding blood biomarkers may be attractive for prediction, as they can be collected very easily and determined with excellent reproducibility in clinical practice. The hypothesis of this study was that blood biomarkers related to tumor load, hypoxia and inflammation can help to predict response to CRT in rectal cancer.

Material/methods

295 patients with locally advanced rectal cancer who were planned to undergo CRT were prospectively entered into a biobank protocol (NCT01067872). Blood samples were drawn before start of CRT. Nine biomarkers were selected, based on a previously defined hypothesis, and measured in a standardized way by a certified lab: CEA, CA19-9, LDH, CRP, IL-6, IL-8, CA IX, osteopontin and 25-OH-vitamin D. Outcome was analyzed in two ways: pCR vs. non-pCR and responders (defined as ypT0-2N0) vs. non-responders (all other ypTN stages).

Results

276 patients could be analyzed. 20.7% developed a pCR and 47.1% were classified as responders. In univariate analysis CEA (p = 0.001) and osteopontin (p = 0.012) were significant predictors for pCR. Taking response as outcome CEA (p < 0.001), IL-8 (p < 0.001) and osteopontin (p = 0.004) were significant predictors. In multivariate analysis CEA was the strongest predictor for pCR (OR 0.92, p = 0.019) and CEA and IL-8 predicted for response (OR 0.97, p = 0.029 and OR 0.94, p = 0.036). The model based on biomarkers only had an AUC of 0.65 for pCR and 0.68 for response; the strongest model included clinical data, PET-data and biomarkers and had an AUC of 0.81 for pCR and 0.78 for response.

Conclusion

CEA and IL-8 were identified as predictive biomarkers for tumor response and PCR after CRT in rectal cancer. Incorporation of these blood biomarkers leads to an additional accuracy of earlier developed prediction models using clinical variables and PET-information. The new model could help to an early adaptation of treatment in rectal cancer patients.     

Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: A case matched study

Background

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

Methods

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

Results

Operative blood losses were: synchronous group, median 475 mL (range 150–850 mL) vs median 425 mL (range 50–1700 mL), (p > 0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p = 0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8–21] vs 20 [range 7–51], p = 0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8–13.7) versus 14 (95% CI 12.2–16.3; p = 0.487) and 21% versus 24% at 5 years (p = 0.838).

Conclusion

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.     

Long-term outcomes after hepatectomy for recurrences after prior local ablation for hepatocellular carcinoma

Aims

Intrahepatic recurrence is the most common manifestation of failure after local ablation therapy for hepatocellular carcinoma. The present study evaluates the safety and efficacy of partial hepatectomy for intrahepatic recurrence after prior local ablation.

Methods

A retrospective analysis was conducted of 188 consecutive patients with hepatocellular carcinoma who underwent either partial hepatectomy for recurrence after prior local ablation (n = 13) or partial hepatectomy as initial local treatment (n = 175). The 13 patients with recurrence after prior local ablation were referred to our division after the resectable recurrences were considered to be resistant to non-surgical treatment modalities.

Results

The incidences of postoperative morbidity and mortality were similar for patients with prior local ablation and patients without prior local ablation (p = 0.75 and p = 0.52, respectively). The overall survival rates after hepatectomy were comparable between patients with prior local ablation (median survival time of 86 months; cumulative 5-year survival rate of 63%) and patients without prior local ablation (median survival time of 76 months; cumulative 5-year survival rate of 54%; p = 0.60). The disease-free survival rates after hepatectomy were significantly worse for patients with prior local ablation based on both univariate (p = 0.01) and multivariate (relative risk, 2.73; p < 0.01) analyses.

Conclusions

Hepatectomy can be performed safely and may be efficacious, in terms of overall survival, for selected patients with intrahepatic recurrence after prior local ablation for hepatocellular carcinoma. On the other hand, prior local ablation appears to increase the probability of failure after hepatectomy.     

Oncological outcome of patients with deeply located soft tissue sarcoma of the pelvis: A follow up study at minimum 5 years after diagnosis

Aims

The treatment of pelvic soft tissue sarcomas (STS) presents one of the most challenging problems in musculoskeletal oncology because of the complex anatomy of the pelvis, late diagnosis and large tumor size. Our study was designed to determine the outcome and prognostic factors for survival and local recurrence in patients with pelvic STS located deep to the fascia and deemed suitable for curative surgical treatment.

Patients and methods

Ninety consecutive pelvic STS patients with at least 5-year possible follow-up from diagnosis were studied. Mean age at diagnosis was 54 years. Mean follow-up and tumor size were 69 months and 13 cm, respectively. Histological grades were grade 3 in 51, grade 2 in 22 and grade 1 in 17 patients. Tumor locations were extra-pelvic or outside pelvic brim (n = 67), intra-pelvic or within pelvic brim (n = 10), and combined or involving both outside and within pelvic brim (n = 13).

Result

Surgical treatment was excision in 84 patients and hindquarter amputation in 6 patients. In 84 patients who underwent excision, surgical margin was wide in 21 patients, marginal in 33, and intralesional in 30. Radiotherapy was used for all high grade tumors. Disease-specific survival was 53.3% at 5 years. Local recurrence occurred in 23%. Development of local recurrence was related to surgical margin (p = 0.03). Local recurrence, tumor histological grade and metastasis at diagnosis independently influenced disease-specific survival (p = 0.0008, p < 0.0001, p = 0.02, respectively).

Conclusion

The patients with high grade tumors and positive surgical margins represent a particular group with high risk of local recurrence even with radiotherapy.     

Influence of neoadjuvant radio-chemotherapy on tumor-infiltrating lymphocytes in squamous esophageal cancer

Introduction

Data on influence of radio-chemotherapy (RCT) on tumor-infiltrating lymphocytes (TILs) is scarce and no study addressed this issue in esophageal squamous cell cancer (SCC) so far.

Methods

Tumor specimens of 49 patients with SCC were re-evaluated with immunohistochemical staining with anti-CD3, anti-CD4, anti-CD8, anti-CD25 and anti-FOXP3 antibodies. Lymphocytes were counted in one high power field (0.189 mm²) at the periphery and in the centre of tumors.

Results

21 patients received preoperative RCT, 28 proceeded directly to surgery. There was no significant difference in survival between the two groups (median survival 23.2 months vs. 22.1 months, log rank test p = n.s.). Cox regression analysis showed that no variable had a significant effect on survival. The infiltrating pattern of TILs revealed higher numbers peripherally independent of the administration of RCT. There was a significant decrease in all cell numbers except CD4⁺ cells in the centre of the tumors after RCT (CD3⁺p = 0.005; CD8⁺p = 0.02; CD25⁺p = 0.01; FoxP3⁺p = 0.01). There were fewer TILs in the periphery after RCT; however, this difference only reached significance in FoxP3⁺ cells (p = 0.01).

Conclusion

Neoadjuvant RCT reduced the number of TILs in esophageal SCC. This was primarily seen in the centre of tumors and suggests that the effect of RCT on immunological response is located in the centre of tumors.