Evolution of Long-Term Outcome of Liver Resection for Colorectal Metastases: Analysis of Actual 5-Year Survival Rates over Two Decades

Background

Liver resection (LR) is the only potentially curative treatment of colorectal liver metastases (CRLM). Its outcome over the past 2 decades was studied using actual 5-year survival rates.

Methods

Data of 393 consecutive patients who underwent LR for CRLM at Mauriziano Umberto I (Turin) until June 2005 were analyzed. Excluding R2 resections (n?=?4) or incomplete 5-year follow-up (n?=?13), 376 patients were divided according to LR date into groups A (before 1995: 90 patients), B (1995?C2000: 94 patients), C (2001?C2005: 192).

Results

Group C presented increased multiple and bilobar metastases compared with combined group A and B (C vs AB: 54.7% vs 40.2%, P?=?0.005; 28.1% vs 19.0%, P?=?0.038, respectively), decreased metastases diameter (C vs AB: 32 vs 40?mm, P?=?0.0001). The 5-year overall survival, calculated excluding 4 operative mortalities (group AB), increased over the years (A, 20.5%; B, 32.6%; C, 46.4%; P?P?=?0.015). Recurrence-free 5-year survival improved (C vs AB: 23.4% vs 13.9%, P?=?0.019) linked to decreased liver recurrences (C vs AB: 26.8% vs 37.4%, P?=?0.023). Resection rate (59% overall for liver recurrence) increased along with 5-year survival after recurrence (A, 4.0%; B, 14.2%; C, 21.4%; P?P?=?0.003) and synchronous metastases (P?=?0.008), N+ tumors (P?=?0.005), and in patients without chemotherapy (P?=?0.001).

Conclusions

Long-term outcome of LR for CRLM improved over 20?years, even in patients with negative prognostic factors, linked to hepatic recurrences reduction and increased survival after recurrence.     

Liver Resection for Multiple Colorectal Liver Metastases with Surgery Up-front Approach: Bi-institutional Analysis of 736 Consecutive Cases

Background

Preoperative chemotherapy has become more common in the management of multiple resectable colorectal liver metastases; however, the benefit is unclear. This study examined clinical outcomes following liver resection for multiple colorectal liver metastases with the surgery up-front approach.

Methods

Data collected prospectively over a 16-year period for 736 patients who underwent hepatic resection at two different centers were reviewed. Patients were divided into three groups depending on the number of tumors as follows: group A, between one and three tumors (n?=?493); group B, between four and seven tumors (n?=?141); and group C, eight or more tumors (n?=?102).

Results

The 5-year overall and recurrence-free survival rates were 51 and 21?%, respectively, for the entire patient cohort, 56 and 29?% in group A, 41 and 12?% in group B, and 33 and 1.7?% in group C. Multivariate analysis showed that decreased survival was associated with positive lymph node metastasis of the primary tumor, the presence of extrahepatic tumors, a maximum liver tumor size >5?cm, and tumor exposure during liver resection.

Conclusions

In patients with multiple liver metastases, the number of liver metastases has less impact on the prognosis than other prognostic factors. Complete resection with repeat metastasectomy offers a chance of cure even in patients with numerous colorectal liver metastases (i.e., those with eight or more nodules). A further prospective study is necessary to clarify the optimal setting of preoperative chemotherapy.     

Selective Reoperation for Locally Recurrent or Metastatic Pancreatic Ductal Adenocarcinoma Following Primary Pancreatic Resection

Background

Resection of certain recurrent malignancies can prolong survival, but resection of recurrent pancreatic ductal adenocarcinoma is typically contraindicated because of poor outcomes.

Methods

All patients from 1992 to 2010 with recurrent pancreatic cancer after intended surgical cure were retrospectively evaluated. Clinicopathologic features were compared from patients who did and did not undergo subsequent reoperation with curative intent to identify factors associated with prolonged survival.

Results

Twenty-one of 426 patients (5?%) with recurrent pancreatic cancer underwent potentially curative reoperation for solitary local-regional (n?=?7) or distant (n?=?14) recurrence. The median disease-free interval after initial resection among reoperative patients was longer for those with lung or local-regional recurrence (52.4 and 41.1?months, respectively) than for those with liver recurrence (7.6?months, p?=?0.006). The median interval between reoperation and second recurrence was longer in patients with lung recurrence (median not reached) than with liver or local-regional recurrence (6 and 9?months, respectively, p?=?0.023). Reoperative patients with an initial disease-free interval >20?months had a longer median survival than those who did not (92.3 versus 31.3?months, respectively; p?=?0.033).

Conclusion

Patients with a solitary pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for reoperation, as they are more likely to benefit from resection versus other sites of solitary recurrence.     

Usefulness of Contrast-Enhanced Intraoperative Ultrasonography (CE-IOUS) in Patients with Colorectal Liver Metastases after Preoperative Chemotherapy

Aims

The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques.

Methods

From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography.

Results

Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n?=?9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n?=?4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p?=?0.047), resolution of at least one metastasis (p?=?0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p?=?0.007).

Conclusion

In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.     

Prolonged Portal Triad Clamping Increases Postoperative Sepsis after Major Hepatectomy in Patients with Sinusoidal Obstruction Syndrome and/or Steatohepatitis

Background

Portal triad clamping (PTC) has been widely adopted in an attempt to decrease bleeding during liver parenchymal transection. As a larger proportion of patients are treated with chemotherapy prior to liver resection, the safety of PTC in patients with chemotherapy-associated liver injury remains poorly investigated. This study aims to evaluate the influence of PTC on early postoperative outcomes in patients with chemotherapy-associated liver injury undergoing major hepatectomy for colorectal liver metastases (CLM).

Patients and methods

From January 2000 to October 2010, 53 patients with histologically proven chemotherapy-associated liver injuries [sinusoidal obstruction syndrome (SOS; n?=?41), steatohepatitis (n?=?5), and both SOS and steatohepatitis (n?=?7)] who underwent major hepatectomy for CLM were divided into two groups; patients undergoing intermittent TPC (n?=?20) and those who did not undergo TPC (n?=?33). Perioperative clinicobiological factors, morbidity including septic complications, and mortality were analyzed and compared between the two groups.

Results

Intraoperative blood transfusions and postoperative liver function were comparable between the two groups. Sepsis and biloma occurred more often in patients undergoing PTC longer than 30?min than in those undergoing PTC ≤30?min (66.7?% versus 17.1?%, p?=?0.002, and 33.3 versus 0?%, p?=?0.002, respectively). A multiple logistic regression analysis showed that prolonged PTC (>30?min) and the ratio of future liver remnant volume to total liver volume ≤43?% were independent factors for predicting postoperative sepsis [odds ratio (OR): 32.68; 95?% confidence interval (95?% CI): 2.86–372.82; p?=?0.005—and odds ratio: 9.70; 95?% CI: 1.04–90.86; p?=?0.047, respectively].

Conclusions

Portal triad clamping can be safely used in patients with chemotherapy-associated liver injury who require major liver resection. Prolonged PTC can increase the occurrence of postoperative biliary and septic complications.     

Feasibility and Oncological Outcomes of Limited Duodenal Resection in Patients with Primary Nonmetastatic Duodenal GIST

Introduction

Duodenal gastrointestinal stromal tumors (GISTs) are rare but still represent approximately 30?% of primary duodenal tumors. This study aimed to audit the feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST.

Methods

Twelve patients who underwent surgery at our institution since 2002 were prospectively followed up. The duodenal GISTs were located in the first (n?=?3), second (n?=?1), third (n?=?3), and fourth of duodenum (n?=?1). Involving both D1/D2 (n?=?2), D2/D3 (n?=?1), and D3/D4 (n?=?1). The primary endpoint for this analysis was disease-free survival.

Results

The commonest presentation was melena and anemia (83?%). All the patients underwent limited resection; six wedge resections with primary closures and six segmental resections with end-to-end anastomosis. The median tumor size was 8?cm (range, 5?C16?cm). According to Fletcher scale, two GISTs were low risk, while 10 patients were intermediate and high risk. The latter received adjuvant therapy. All the patients had a complete resection with no postoperative mortality. One patient had three liver metastases 4?months after limited resection and had partial hepatectomy. After median follow-up of 45 (15?C78)?months, all patients are alive and disease free.

Conclusion(s)

When technically feasible, limited resection should be considered a reliable and curative option for duodenal GIST achieving satisfactory disease-free survival. The technical feasibility is guided by the tumor size, possible adjacent organ involvement, and its exact anatomical location.     

Indeterminate Pulmonary Nodules Represent Lung Metastases in a Significant Portion of Patients Undergoing Liver Resection for Malignancy

Introduction

Despite detection on imaging before resection of hepatic malignancies, the natural history of indeterminate pulmonary nodules (IPN) is unknown. The objective of this study is to determine how often IPN detected on imaging before surgery for hepatic malignancies represent lung metastases.

Methods

Demographics, comorbidities, tumor characteristics, and surgical treatments of patients with pre-operative IPN who underwent liver resection and/or radiofrequency ablation for malignant diagnoses were reviewed.

Results

From 2000 to 2010, 90 patients with at least one IPN underwent liver resection or radiofrequency ablation for malignancy. Of these, 44 (48.9?%), 32 (35.6?%), and 14 (15.6?%) patients had colorectal cancer liver metastases (CRCLM), primary hepatobiliary malignancies (HB), and other cancers, respectively. The median number of IPN was 1. The median size was 4?mm. Twenty (22?%) patients had isolated lung recurrence after hepatic surgical therapy. Eighty percent occurred in the exact location of the pre-operative IPN. Isolated lung recurrence was more common among patients with CRCLM compared to those with HB and other cancers (42.9 vs. 9.4 vs. 14.3?%, p?=?0.004).

Conclusion

Pre-operatively detected IPN represent lung metastases in a substantial portion of patients undergoing surgery for hepatic malignancy. IPN are more likely to represent lung metastases in patients with CRCLM compared to those with primary HB and other cancers.     

Abdominoperineal Resection for Squamous Cell Anal Carcinoma: Survival and Risk Factors for Recurrence

Background

Despite the results of combined chemoradiation therapy for anal canal squamous cell carcinoma (SCC), up to 30?% of patients will undergo abdominoperineal resection (APR). The aim of this study was to evaluate oncologic outcomes, survival, and recurrence, following APR for anal canal SCC performed in a single center over a 13-year period.

Methods

All patients who underwent APR for anal canal SCC between 1996 and 2009 were retrospectively included. Demographic data, details on treatments, pathological report, and follow-up were noted. Survival curves were plotted using the Kaplan?CMeier method and potential prognostic factors were evaluated using Cox proportional hazards models.

Results

A total of 105 patients (77 women) were included. Indications for APR included tumor persistence (n?=?42; 40?%), recurrence (n?=?55; 52.4?%), or a contraindication to radiotherapy (n?=?8; 7.6?%). Median follow-up was 33.3?months (range, 1.5?C174.3?months). Overall survival and disease-free survival were, respectively, 61 and 48?% at 5?years. In multivariate analysis, tumor stage (T3 or T4), positive margin on pathologic examination and existence of distant metastases at the time of the surgery were associated with a poor prognosis. The indication for APR (persistent vs recurrent disease), gender, concurrent HIV infection, or performance of a VRAM flap did not influence OS or DFS. Overall recurrence rate was 42.6?% (n?=?43 of 101). The type of recurrence did not exert a significant effect on survival (p?=?.4571).

Conclusion

This study describes the largest single series of APR for anal carcinoma. Major prognostic factors for survival and recurrence were T status and involved margin. The 5-year overall survival was 60?%.     

Surveillance of Small Rectal Carcinoid Tumors in the Absence of Metastatic Disease

Background

The incidence of rectal carcinoids is rapidly increasing, typically presenting as small (<1.0?cm), localized tumors. Although the evaluation of rectal carcinoids on presentation is well standardized, surveillance after resection has not been well established.

Methods

A prospective database documented patients with rectal carcinoids at our institution between January 1995 and September 2011. Information collected included patient and tumor characteristics, treatment method, surveillance schedule, recurrence, and survival.

Results

Twenty-eight patients with rectal carcinoid were identified. Ten patients were excluded for tumors >1?cm, known metastases at presentation, <6?months follow-up, or previous resections. The mean age of the remaining patients was 56?±?3?years, and 61?% of the patients were female. All patients were diagnosed at endoscopy, with 50?% diagnosed incidentally on screening endoscopy. Treatment methods included endoscopic therapy (n?=?13, 72?%), transanal excision (n?=?3, 17?%), and transanal endoscopic microsurgery (n?=?1, 5.5?%). One patient (5.5?%) received no additional invasive therapy after diagnostic endoscopy. The mean tumor diameter was 4.6?±?0.5?mm. The average length of follow-up was 5.4?±?0.9?years, with a median number of 2 follow-up endoscopies (range 0?C6). Two patients (11?%) died within the follow-up period from noncarcinoid causes. Importantly, no surviving patients developed local or distant recurrence with up to 12.3?years of follow-up.

Conclusions

On the basis of this experience, patients presenting with small (??1.0?cm), nonmetastatic rectal carcinoids are unlikely to develop local or distant recurrence after resection. Aggressive surveillance with repeat endoscopies or other imaging studies after resection may be unnecessary in this patient population.     

Risk for local recurrence of early gastric cancer treated with piecemeal endoscopic mucosal resection during a 10-year follow-up period

Background

Endoscopic mucosal resection (EMR) is a therapy for early gastric cancer (EGC) that can be provided relatively easily and safely in any institution. Identification of the resection margin is a problem in EMR, especially in cases of piecemeal EMR. Despite the long-standing widespread use of piecemeal EMR for EGC, its limitation and long-term outcomes in clinical practice have not been fully evaluated. This study aimed to determine the risk factors of piecemeal EMR, the local recurrence rates, and the mortality rate.

Methods

A cross-sectional, retrospective cohort study was performed to investigate the risks of piecemeal EMR for patients with the diagnosis of differentiated adenocarcinoma localized to the mucosa. Local recurrence of EGC was investigated by annual follow-up esophagogastroduodenoscopy (EGD) for 10?years. EMR was performed with snare electrocautery using a two-channel scope. When a resection margin was clearly positive for cancer, additional surgery was performed soon after the initial EMR.

Results

For the 149 EGC patients (mean age, 68.8?±?9.8; male, 77%) who underwent EMR between 1995 and 2001, EMR was performed en bloc in 66 cases and piecemeal in 83 cases. The comorbid conditions existing in 34 of the 149 patients included other malignancies (n?=?12), heart failure (n?=?5), pulmonary disease (n?=?7), liver cirrhosis (n?=?4), and other illness (n?=?6). However, EMR was completed without complication. The mean area (length?×?width) of the lesions was 404?±?289?mm² in the piecemeal group and 250?±?138?mm² in the en bloc groups. The en bloc and piecemeal EMR groups differed significantly in terms of unclear horizontal margins but not in terms of unclear vertical margins. Multiple logistic regression suggested that the adjusted odds ratio for maximum diameters exceeding 20?mm for piecemeal EMR was 2.71 (95% confidence interval [CI], 1.30?C5.64). According to Kaplan?CMeier estimates, the local recurrence rate was 30% (95% CI, 20?C40%) at both 5 and 10?years. No recurrence was observed in the en bloc group. The adjusted hazard ratio of unclear horizontal margins for local recurrence was 1.63 (95% CI, 1.12?C2.36). A total of 24 patients died after EMR because of comorbid conditions, including other malignancies (n?=?11), cardiovascular disease (n?=?6), pulmonary disease (n?=?4), liver cirrhosis (n?=?2), and traffic accident (n?=?1). However, no patient died of gastric cancer during the 10-year follow-up period.

Conclusions

An evaluation of horizontal margins in terms of local recurrence after piecemeal EMR is important, and en bloc resection is recommended. Close follow-up assessment is warranted, especially within 5?years in cases of unclear margin resection after piecemeal EMR. The use of EMR is safe even for patients with severe comorbid conditions.     

The surgical management of angiosarcoma of the breast—a single institution experience

Background

Angiosarcoma of the breast is a rare and aggressive tumour of the vascular endothelium. It may arise spontaneously or secondary to radiation. We present our experience of managing breast angiosarcoma, the largest single institution case series from the UK to date along with a summary of the relevant literature.

Methods

Data on all patients with breast angiosarcoma treated in our unit were prospectively recorded (2002–2014). Demographics, surgical details and outcomes were analysed.

Results

Eighteen female patients presented with breast angiosarcoma. Sixteen patients previously underwent adjuvant radiotherapy following surgery for breast carcinoma; the mean duration between radiotherapy and angiosarcoma development was 8.4 years (range 3–21). Resections were as follows: radical mastectomy (n?=?14), simple mastectomy (n?=?1) and wide local excision (n?=?3). Reconstruction was undertaken as follows: pedicled lattisimus dorsi (LD) musculocutaneous flap (n?=?5), pedicled LD muscle flap and split skin graft (n?=?7), free deep inferior epigastric perforator (DIEP) flap (n?=?1), pedicled vertical rectus abdominus muscle (VRAM) flap and split skin graft (n?=?1), pedicled LD muscle and pedicled VRAM muscle flaps and split skin graft (n?=?1), pedicled LD muscle and pedicled (contralateral) pectoralis major muscle flaps and split skin graft (n?=?1) and direct closure (n?=?2). Three patients developed local recurrence; mean duration from resection to recurrence was 12 months (range 9–19). Three patients developed metastasis. Seven patients (38.8 %) died; median survival from presentation was 19 months (range 2–55 months). The remaining eleven patients remain well with no disease recurrence; mean follow-up was 38 months (range 4–125). The estimated 5-year survival (Kaplan-Meier equation) in our cohort was 49 %.

Conclusions

Breast angiosarcomas are rare and challenging to manage. Successful outcomes can be achieved by early, aggressive resection and appropriate reconstruction. Level of Evidence: Level IV, therapeutic study.     

Is laparoscopic surgery for recurrent Crohn’s disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

Background

Patients undergoing abdominal surgery for Crohn??s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn??s through midline laparotomy is controversial.

Methods

Patients with previous open resection for intestinal Crohn??s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5?years), gender, body mass index (±2?kg/m²), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3?years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

Results

26 patients undergoing laparoscopic ileocolectomy (n?=?14), proctocolectomy (n?=?5), small bowel resection (n?=?4), abdominoperineal resection (n?=?1), extended right colectomy (n?=?1), and strictureplasty (n?=?1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12?%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158?min, p?=?0.94), estimated blood loss (222 versus 427?ml, p?=?0.32), overall morbidity (39 versus 69?%, p?=?0.051), reoperation rates (8 versus 0?%, p?=?0.5), postoperative return of bowel function (3.5?±?1.4 versus 3.9?±?1.7?days, p?=?0.3), mean length of hospital stay (6.4?±?6.2 versus 6.9?±?3.5?days, p?=?0.12), and readmission rates (8 versus 12?%, p?=?0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27?%, p?=?0.01).

Conclusions

Surgery for recurrent Crohn??s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.     

FDG-PET SUVmax Combined with IASLC/ATS/ERS Histologic Classification Improves the Prognostic Stratification of Patients with Stage I Lung Adenocarcinoma

Background

We investigated the association between the newly proposed International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification and ¹⁸F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET), and whether the combination of these radiologic and pathologic factors can further prognostically stratify patients with stage I lung adenocarcinoma.

Methods

We retrospectively evaluated 222 patients with pathologic stage I lung adenocarcinoma who underwent FDG-PET scanning before undergoing surgical resection between 1999 and 2005. Patients were classified by histologic grade according to the IASLC/ATS/ERS classification (low, intermediate, or high grade) and by maximum standard uptake value (SUVmax) (low?<3.0, high???3.0). The cumulative incidence of recurrence (CIR) was used to estimate recurrence probabilities.

Results

Patients with high-grade histology had higher risk of recurrence (5-year CIR, 29?% [n?=?25]) than those with intermediate-grade (13?% [n?=?181]) or low-grade (11?% [n?=?16]) histology (p?=?0.046). High SUVmax was associated with high-grade histology (p?n?=?113] vs. 8?% [n?=?109]; p?=?0.013). Among patients with intermediate-grade histology, those with high SUVmax had higher risk of recurrence than those with low SUVmax (5-year CIR, 19?% [n?=?87] vs. 7?% [n?=?94]; p?=?0.033). SUVmax was associated with recurrence even after adjusting for pathologic stage (p?=?0.037).

Conclusions

SUVmax on FDG-PET correlates with the IASLC/ATS/ERS classification and can be used to stratify patients with intermediate-grade histology, the predominant histologic subtype, into two prognostic subsets.     

Perioperative Complications After Neoadjuvant Chemotherapy With and Without Bevacizumab for Colorectal Liver Metastases

Purpose

Bevacizumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Neoadjuvant bevacizumab is commonly used in patients undergoing liver resection. Our purpose was to evaluate whether bevacizumab is associated with increased rate of perioperative complications in patients undergoing hepatic resection for colorectal liver metastases (CRLM).

Methods

Retrospective analysis of patients undergoing hepatic resection for CRLM who received chemotherapy and bevacizumab (group 1, n?=?134), or chemotherapy alone (group 2, n?=?57). We compared demographics, surgical characteristics, and perioperative course.

Results

Perioperative complications developed in 35 % of patients in group 1, and 47 % in group 2 (p?=?0.11). Of those complications, 15 (11.2 %) in group 1, and 5 (8.8 %) in group 2 were considered major (p?=?0.617). Four patients, all of whom received preoperative bevacizumab, developed enteric leaks following combined liver and bowel resection. The rate of anastomotic leak in group 1 was 10 %, compared with 0 in group 2, p?=?0.56.

Conclusion

Neoadjuvant chemotherapy along with bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection. Possible association of increased morbidity with simultaneous bowel and liver resections following bevacizumab administration was found and we recommend avoiding such treatment combination.     

Factors predicting prognosis and recurrence in patients with esophago-gastric adenocarcinoma and histopathological response with less than 10 % residual tumor

Purpose

Neoadjuvant treatment is an accepted standard approach for treating locally advanced esophago-gastric adenocarcinomas. Despite a response of the primary tumor, a significant percentage dies from tumor recurrence. The aim of this retrospective exploratory study from two academic centers was to identify predictors of survival and recurrence in histopathologically responding patients.

Methods

Two hundred thirty one patients with adenocarcinomas (esophagus: n?=?185, stomach: n?=?46, cT3/4, cN0/+, cM0) treated with preoperative chemotherapy (n?=?212) or chemoradiotherapy (n?=?19) followed by resection achieved a histopathological response (regression 1a: no residual tumor (n?=?58), and regression 1b?<?10 % residual tumor (n?=?173)).

Results

The estimated median overall survival was 92.4 months (5-year survival, 56.6 %) for all patients. For patients with regression 1a, median survival is not reached (5-year survival, 71.6 %) compared to patients with regression 1b with 75.3 months median (5-year survival, 52.2 %) (p?=?0.031). Patients with a regression 1a had lymph node metastases in 19.0 versus 33.7 % in regression 1b. The ypT-category (p?<?0.001), the M-category (p?=?0.005), and the type of treatment (p?=?0.04) were found to be independent prognostic factors in R0-resected patients. The recurrence rate was 31.7 % (n?=?66) (local, 39.4 %; peritoneal carcinomatosis, 25.7 %; distant metastases, 50 %). Recurrence was predicted by female gender (p?=?0.013), ypT-category (p?=?0.007), and M-category (p?=?0.003) in multivariate analysis.

Conclusion

Response of the primary tumor does not guarantee recurrence-free long-term survival, but histopathological complete responders have better prognosis compared to partial responders. Established prognostic factors strongly influence the outcome, which could, in the future, be used for stratification of adjuvant treatment approaches. Increasing the rate of histopathological complete responders is a valid endpoint for future clinical trials investigating new drugs.     

Peri-Operative Bowel Perforation in Early Stage Colon Cancer is Associated with an Adverse Oncological Outcome

Background

The presence of an inflammatory response resulting from bowel perforation or anastomotic leakage has been suggested to enhance recurrence rates in colorectal cancer patients. Currently, it is unknown if bowel perforation or anastomotic leakage has prognostic significance in early stage colon cancer patients. In this study, the impact of peri-operative bowel perforation including anastomotic leakage on disease-free survival of stage I/II colon cancer patients was investigated.

Methods

Prospective follow up data of 448 patients with stages I/II colon cancer that underwent resection were included. Patients who died within 3?months after initial surgery were excluded.

Results

Median follow up was 56.0?months. Patients with peri-operative bowel perforation (n?=?25) had a higher recurrence rate compared to patients without perforation (n?=?423), 36.0?% vs. 16.1?% (p?=?0.01). Disease-free survival was significantly worse for the perforation group compared to patients without perforation (p?=?0.004). Multivariate analysis including T-stage, histological grade, and adjuvant chemotherapy showed peri-operative bowel perforation to be an independent factor significantly associated with disease recurrence (odds ratio, 2.7; 95?% CI, 1.1?C6.7).

Conclusion

Peri-operative bowel perforation is associated with increased recurrence rates and impaired disease-free survival in early-stage colon cancer patients.     

Reoperations for esophageal achalasia

Purpose

To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia.

Methods

We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5?±?11.0?years), who underwent reoperations for achalasia between August 1994 and August 2010.

Results

The primary surgical procedures were Heller–Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n?=?2), recurrent adhesion after myotomy (n?=?2), reflux esophagitis (n?=?2), difficulty in passage caused by tortuosity of the esophagus (n?=?2), difficulty in passage through the thoracic esophagus (n?=?1), and severe chest pain (n?=?1). The reoperations included repeated HD procedures (n?=?4), repair of an esophageal hiatal hernia (n?=?2), thoracic esophageal myotomy (n?=?2), straightening of the lower esophagus with gastropexy (n?=?1), and subtotal esophagectomy (n?=?1). The success rate of the reoperations for resolving symptoms was 90?% (9 patients).

Conclusion

Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.     

Role of Portal Vein Embolization in Hepatocellular Carcinoma Management and Its Effect on Recurrence: A Case-control Study

Background

Liver regeneration that occurs after portal vein embolization (PVE) may have adverse effects on the microscopic tumor foci in the residual liver mass in patients with hepatocellular carcinoma (HCC).

Methods

Fifty-four HCC patients with inadequate functional residual liver volume were offered PVE during a seven-year period. Among them, 34 (63%) patients underwent curative resection. They were compared with a matched control group (n?=?102) who underwent surgery without PVE. Postoperative complications, pattern of recurrence, and survival were compared between groups.

Results

In the PVE group, a pre-embolization functional residual liver volume of 23% (12–33.5%) improved to 34% (20–54%) (p?=?0.005) at the time of surgery. When the two groups were compared, minor (PVE, 24%; control, 29%; p?=?0.651) and major (PVE, 18%; control, 15%; p?=?0.784) complications were similar. After a follow-up period of 35?months (standard deviation 25?months), extrahepatic recurrences were detected in 10 PVE patients (29%) and 41 control patients (40%) (p?=?0.310). Intrahepatic recurrences were seen in 10 (29%) and 47 (46%) cases (p?=?0.109) in the PVE and control groups, respectively. In the PVE group, 41% (n?=?14) of the recurrences were detected before one year, compared with 42% (n?=?43) in the control group (p?=?1). Disease-free survival rates at 1, 3, and 5?years were 57, 29, and 26% in the control group and 60, 42, and 42% in the PVE group (log-rank, p?=?0.335). On multivariate analysis, PVE was not a factor affecting survival (p?=?0.821).

Conclusions

Portal vein embolization increases the resectability of initially unresectable HCC due to inadequate functional residual liver volume, and it has no deleterious oncological effect after major resection of HCC.     

Strong YB-1 Expression Predicts Liver Recurrence Following Resection for Colorectal Metastases

Introduction

The Y-box binding protein-1 (YB-1) is a multifunctional oncoprotein involved in the proliferation and aggressiveness of cancer cells. The aim of this study was to determine whether strong YB-1 expression in neoplastic cells of colorectal liver metastases (CRLM) may have an impact on liver disease-free survival following liver resection.

Materials and Methods

Immunohistochemistry was performed to evaluate YB-1 in 66 patients who underwent liver resection for CRLM. YB-1 expression was classified as weak (low-staining intensity) and strong (high-staining intensity).

Results

YB-1 expression was observed in the cytoplasm of all CRLM. YB-1 expression was weak in 17 patients (25.8 %) and strong in 49 patients (74.2 %). Liver recurrence rate was significantly higher in the strong than in the weak expression group: 55.1 vs. 23.5 % (p?=?0.023). Multivariable logistic regression analysis showed that YB-1 strong expression was the only independent risk factor for liver recurrence. The 5-year specific liver disease-free survival rate was 76.0 % in the weak expression group and 41.5 % in the strong expression group (p?=?0.034). These results were not influenced by clinical prognostic factors of tumor recurrence.

Conclusions

This is the first study showing that the degree of YB-1 expression in tissue specimens of CRLM predicts liver recurrence following liver resection.