Off-clamp robot-assisted partial nephrectomy for purely hilar tumors: Technique,perioperative, oncologic and functional outcomes from a single center series

ObjectivesPurely hilar lesions and those abutting the main renal artery or vein may be significantly different in terms of surgical complexity, requiring different resection strategies. To describe surgical technique and to assess its safety, oncologic and functional outcomes of a single centre experience of Off-Clamp Robotic Partial Nephrectomy (Off-C RPN) for purely hilar renal masses.MethodsThe Institutional Review Board renal cancer database was queried for: “robotic”, “partial nephrectomy” and “hilar”. Baseline imaging was reviewed for all cases to strictly select patients with purely hilar tumors, defined as tumors arising into the renal hilum without any exophytic growth. Off-C RPN with straight access to the hilum was performed in all cases. We reported baseline, perioperative, oncologic and functional outcomes of the institutional series of purely hilar masses treated with Off-C RPN.ResultsBetween 2011 and 2019, 680 Off-C RPN were performed. Overall, 20 cases were classified as “hilar” renal tumors. Ten lesions abutting the main renal artery or vein were excluded leaving 10 purely hilar cases for analysis. Median operative time was 85 (range 68–115) minutes. No high-grade complications occurred. One patient (10%) required blood transfusion. At a median follow-up of 27 months, one renal recurrence and one newly onset Chronic Kidney Disease stage 3A was observed.ConclusionsRPN for purely hilar tumors has been poorly addressed and distinguishing purely hilar from tumors abutting the hilar vessels may have significant technical implications. In tertiary referral centers, Off-C RPN for purely hilar tumors provides excellent perioperative, oncologic and functional outcomes.     

Laparoscopic partial nephrectomy for endophytic hilar tumors: feasibility and outcomes

Objective

To analyze feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for endophytic hilar tumors in low-intermediate (ASA I-II) risk patients.

Methods

This is a single centre retrospective study. From May 2009 to September 2011, 208 LPNs were performed at our institution. Overall 11 (5.2%) elective LPNs were for hilar tumors not visible on kidney surface. Hilar tumor was defined as a mass located in the renal hilum and in contact with a major renal vessel on preoperative imaging. Procedures were carried out by a single experienced surgeon (G.G.) via retroperitoneal approach by clamping the only main renal artery.

Results

Mean (range) age of patients was 45.3 years (38.2–64.1), tumor size 1.6 cm (1.2–2.0), warm ischemia time 24 min (19–32), operative time 140 min (110–200) and estimated blood loss 270 ml (100–750). Two collecting system injuries were observed and repaired intraoperatively. No conversion to open surgery was required. Final pathological examination revealed 10 renal cell carcinomas and 1 oncocytoma. A negative surgical margin was obtained in 10/11 (91%) patients. Renal function and serum hemoglobin were nearly unaltered pre and post-surgery. No tumor recurrence was observed at mean (range) follow-up of 34 months (15–43).

Conclusions

In experienced hands, LPN represents a feasible, safe and effective treatment for selected patients diagnosed with endophytic hilar masses. A larger number of patients and longer follow-up are required to draw definitive conclusions.     

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates

BackgroundIn clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making.MethodsPatients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN.ResultsRAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased.ConclusionWhen pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.     

Differing Risk of Cancer Death Among Patients With Pathologic T3a Renal Cell Carcinoma: Identification of Risk Categories According to Fat Infiltration and Renal Vein Thrombosis

ObjectivesThe study objectives were to evaluate the prognostic impact of fat infiltration and renal vein thrombosis in patients with pT3a renal cell carcinoma (RCC) and to identify new prognostic groups.Material and MethodsWe analyzed 122 consecutive patients with pT3a who underwent radical nephrectomy for RCC between 2000 and 2011 at the University of Bologna. Cancer-specific survival (CSS) rates were estimated using Kaplan–Meier survival curves; univariable and multivariable analyses were performed with Cox analysis.ResultsThe mean follow-up was 41.7 ± 35.4 months. Patients with peritumoral/hilar fat infiltration (n = 63) and patients with renal vein thrombosis (n = 18) experienced comparable CSS rates, whereas patients with both fat infiltration plus renal vein thrombosis (n = 41) showed worse survival outcomes than the first group (P = .026). Patients were divided in 2 groups: group A, with fat invasion or renal vein thrombosis, and group B, with concomitant fat invasion and renal vein invasion. Group B showed worse cancer-specific survival than group A (P = .024). At multivariate analysis, this new risk-group stratification was found to be an independent prognostic predictor of CSS (P < .05).ConclusionsPatients with T3a RCC with both fat invasion and renal vein thrombosis experience worse survival rates when compared with those patients with only 1 prognostic factor. The TNM classification should consider the concomitant presence of those parameters as a different prognostic predictor.     

开放性零缺血结合同步切缝技术在复杂性孤立肾肾癌治疗中的应用

  目的  探讨开放性零缺血结合同步切缝的肾部分切除术治疗复杂性孤立肾肾癌的可行性、安全性及优势。  方法  回顾性分析2017年10月至2021年10月5例于哈尔滨医科大学附属肿瘤医院收治的解剖性和功能性孤立肾肾癌患者的临床资料,均采用开放性零缺血肾部分切除术和术中同步切缝技术,手术由同一术者完成,分析手术时间、术中失血量、术中及术后并发症、术后肿瘤学结果及肾功能指标的变化。  结果  5例患者均成功采用开放性零缺血结合同步切缝的肾部分切除术,无中转肾动脉阻断和行挽救性肾切除术。手术时间为135～180 min,术中失血量为300～700 mL,平均失血量为450 mL。5例中1例肾门部肾癌患者术后第1天开始出现尿漏,当日膀胱镜下于输尿管内逆行留置F6双“J”管后,术后第2天尿漏消失。术后随访3～48个月,平均随访时间30.4个月,局部未见肿瘤复发,1例出现肋骨转移。与术前相比,术后各项肾功能指标无明显变化（P>0.05）。  结论  开放性零缺血结合同步切缝的肾部分切除术在治疗复杂性孤立肾肾癌安全可行,特别适合复杂和肿瘤体积较大的肾癌,在保护肾脏功能和肿瘤治疗方面有着独特的优势。      

A systematic review and meta-analysis of caudate lobectomy for treatment of hilar cholangiocarcinoma

BackgroundSurgical resection remains the only potentially curative therapy for hilar cholangiocarcinoma (CCC) patients. This meta-analysis aimed to review the current evidence on perioperative and long-term outcomes of routine caudate lobe resection (CLR) for surgical treatment of hilar CCC.MethodsA systematic literature search using MEDLINE, EMBASE and Cochrane databases was performed for studies providing comparative data on perioperative and long-term outcomes of patients undergoing resection for hilar CCC with and without CLR. The MINORS score was used for quality assessment. For time-to-event outcomes hazard ratios (HRs) and associated 95% CI were extracted from identified studies, whereas risk ratios (RRs) were calculated for overall morbidity, mortality, and resection margin status. Meta-analyses were carried out using random-effects models.ResultsEight studies involving 1350 patients met the inclusion criteria. The quality of the included studies was low to moderate. CLR resulted in significantly improved overall survival (HR 0.49; 95%CI 0.32–0.75, P < 0.01). Postoperative morbidity (RR 0.93; 95% CI 0.77–1.13; P = 0.48) and mortality (RR 1.01; 95% CI 0.42–2.41; P = 0.99) rates were comparable between both groups. Patients without concomitant CLR were at higher risk for residual tumor at the resection margin (RR 1.40; 95% CI 1.09–1.80; P = 0.01).ConclusionCLR is associated with improved long-term survival and negative tumor margins after resection of hilar CCC with no adverse impact on perioperative outcomes. CLR might provide the potential to become a standard-of-care procedure in the surgical management of hilar CCC.     

Evaluation of a Retroglandular Oncoplastic Technique as a Standard Level I Oncoplastic Breast-Conserving Surgery: A Retrospective Clinicopathologic Study of 102 Patients With Breast Cancer

BackgroundThis study presents a novel Level I oncoplastic breast-conserving surgery technique for performing tumorectomy by retroglandular exploration through a skin incision made in the inferior mammary fold.Patients and MethodsA retrospective single-center cohort study involving patients with early-stage breast cancer (n = 102) was performed. The patient characteristics were recorded, as well as the quality of life rated by BREAST-Q. Postoperative complications were assessed using the Clavien-Dindo classification system. Esthetic outcomes were evaluated with Breast Cancer Conservative Treatment-cosmetic results (BCCT.core) software and a 5-point Likert scale.ResultsThe median follow-up time was 11 months (range, 7-25 months). The median specimen weight and operative time were 49.8 g (range, 13.4-117.9 g) and 40 minutes (range, 20-80 minutes), respectively. The mean pathologic tumor size was 15 mm (SD, ±7). Owing to positive surgical margins, re-excisions and mastectomies were performed in 13.7% and 2.9% of patients, respectively. The overall complication rate was 24.5% (n = 25), with the most common being seroma formation (13.7%; n = 14). The median Likert scale score was 4.3 (range, 2.1-5), and the median overall esthetic outcome assessed by BCCT.core was 2.1 points (range, 1-4 points). In BREAST-Q domains, the median scores of the “adverse effects of radiation,” “physical well-being,” the “satisfaction with breasts,” and the “psychosocial well-being” were 27, 35, 90, and 93, respectively.ConclusionRetroglandular oncoplastic breast-conserving surgery is a novel, effective Level I oncoplastic technique for radical resection of breast tumors ≤ 3 cm in size. Additional advantages include the preservation of natural breast shape, the safety of the technique, and the lack of a need for contralateral symmetrization.     

Soft tissue sarcoma in children,adolescents and young adults: Outcomes according to compliance with international initial care guidelines

BackgroundOutcomes for adults with soft tissue sarcoma are better when managed at referral centers. Care guidelines advise for 5 main criteria: 1-Imaging before biopsy; 2-Tumor biopsy before surgery; 3-Multidiscipinary team discussion (MTD) before biopsy; 4-Biopsy in “expert centers”; 5-Somatic molecular biology feasible. The aim is to describe and assess the prognostic impact of initial management of STS according to the type of referring centers and the number of optimal criteria.MethodsMonocentric retrospective analysis of the management of 127 youths (0–25 years) with localized STS treated from 2006 to 2015.ResultsMedian age at diagnosis was 9.6 years (range: 025). Overall, only 41% patients had 5/5, 28% 3–4, 31% ≤2. No adequate imaging was performed before surgery/biopsy for 18% patients, no biopsy before treatment for 29%. Patients referred by “expert centers” had higher compliance to guidelines (P = 0.025). Upfront surgery was performed in 59/127 patients. Immediate re-operation was inversely related to the number of criteria (0% when 5 criteria vs. 14% for 3–4, 46% if ≤ 2; P < 0.001). For malignant tumors, outcome was better when 5 criteria were reached: 5 year EFS 90.8% (81.4–100.0%) vs. 71.6 for (60.4–84.9%; ≤4 criteria; p = 0.033), OS 93.6% (85.5–100%) vs. 79.5% (68.9–91.8%; p = 0.11), and LRFFS 90.6% (81.0–100.0) vs. 73.1% (62.0–86.3%; p = 0.047).ConclusionLess than half of the youths with STS are initially managed according to international guidelines, highlighting the need for better information about optimal management. These results plead for immediate management in reference centers to reduce initial burden of therapy.     

Articular degeneration after subchondral cementation for giant cell tumors at the knee

PurposeTo quantify joint degeneration and the clinical outcome after curettage and cementation in subchondral giant cell tumors of the bone (GCTB) at the knee.MethodsWe conducted a retrospective analysis of 14 consecutive patients (seven female, seven male) with a mean age of 34 years (range 19–51) who underwent curettage and subchondral cementation for a biopsy-confirmed GCTB at the distal femur or the proximal tibia between August 2001 and August 2017, with a mean follow-up period of 54.6 months (range 16.1–156 months). The Whole-Organ Magnetic Resonance Imaging Score (WORMS), Kellgren-Lawrence (KL) classification, and Musculo-Skeletal Tumor Society (MSTS) score were assessed.ResultsRadiological degeneration progressed from preoperative to the latest follow-up, with a median WORMS from 2.0 to 4.0 (p = 0.006); meanwhile, the median KL score remained at 0 (p = 0.102). Progressive degeneration (WORMS) tended to be associated with the proximity of the tumor to the articular cartilage (mean 1.57 mm; range 0–12 mm) (p = 0.085). The most common degenerative findings were cartilage lesions (n = 11), synovitis (n = 5), and osteophytes (n = 4). Mean MSTS score increased from 23.1 (preoperatively) to 28.3 at the latest follow-up (p < 0.01).Seven patients (50%) were treated for a local recurrence, with six revision surgeries performed. Removal of the cement spacer and filling of the cavity with a cancellous autograft was performed in seven patients. Conversion to a total knee arthroplasty was performed in one patient for local tumor control.ConclusionsCementation following the curettage of GCTB around the knee is associated with slight degeneration at medium-term follow-up and leads to a significant reduction in pain. Removal of the cement and reconstruction with an autograft may be beneficial in the long term.     

Should the splenic hilar lymph node be dissected for the management of adenocarcinoma of the esophagogastric junction?

BackgroundSplenic hilar lymphadenectomy is not recommended for advanced proximal gastric cancer that does not invade the greater curvature according to the results of the previous studies. The efficacy of splenic hilar lymphadenectomy for type II and type III adenocarcinomas of the esophagogastric junction and easy spread to the greater curvature of the stomach remains unclear. This study aimed to investigate the efficacy of splenic hilar lymphadenectomy and identify the risk factors for metastasis to splenic hilar nodes.MethodsWe examined patients who underwent R0/1 gastrectomy for Siewert types II and III at a single high–volume center in Japan. We analyzed the metastatic incidence, therapeutic value index, and risk factors for splenic hilar lymph node metastasis.ResultsWe examined 126 patients (74, type II; 52, type III). Splenectomy was performed in 76 patients. Metastatic incidence and the therapeutic value index of splenic hilar lymph nodes in patients with type II and type III tumors were 4.5% and 0, and 21.9% and 9.4, respectively. In the patients who underwent splenectomy, we identified Siewert type III tumors (odds ratio: 6.93, 95% confidence interval: 1.24–38.8, p = 0.027) and tumor location other than the lesser curvature (odds ratio: 7.36, 95% confidence interval: 1.32–41.1, p = 0.023) to be independent risk factors. The metastatic incidence (46.2%) and therapeutic value index (15.4) were high in patients with both risk factors.ConclusionsSplenic hilar lymphadenectomy may contribute to the survival of patients with Siewert type III tumors, especially when the predominant location is not the lesser curvature.     

Survival of patients with metastatic melanoma and brain metastases in the era of MAP-kinase inhibitors and immunologic checkpoint blockade antibodies: A systematic review

BackgroundThe incidence of brain metastases (BM) in melanoma patients is common and associated with poor prognosis. MAP-kinase inhibitors and immunologic checkpoint blockade antibodies led to improved survival of metastatic melanoma patients; however, patients with BM are under-represented or excluded from the majority of clinical trials and the impact of new drugs on their survival is less clear. With the present systematic review, we aimed to analyze outcomes of patients with melanoma BM treated with the new drugs, both in the setting of phase I–II–III clinical trials and in the “real world”.MethodsAn electronic search was performed to identify studies reporting survival outcomes of patients with melanoma BM treated with MAP-kinase inhibitors and/or immunologic checkpoint blockade antibodies, regardless of study design.ResultsTwenty-two studies were included for a total of 2153 patients. Median OS was 7.9 months in phase I–II–III trials and 7.7 months in “real world” studies. In clinical trials, median OS was 7.0 months for patients treated with immunotherapy and 7.9 months for patients treated with BRAF inhibitors. In “real world” studies, median OS was 4.3 months and 7.7 months for patients treated with immunotherapy and BRAF inhibitors, respectively. Evidence of clinical activity exists for both immunotherapy and MAP-kinase inhibitors.ConclusionsMAP-kinase inhibitors and immunologic checkpoint blockade antibodies have clinical activity and may achieve improved OS in patients with metastatic melanoma and BM. These results support the inclusion of patients with BM in investigations of new agents and new treatment regimens for metastatic melanoma.     

Groin recurrence in patients with early vulvar cancer following superficial inguinal node dissection

ObjectiveTo investigate the causes of groin recurrence in patients with vulval cancer who previously had negative nodes following superficial inguinal node dissection (SIND).Material and methodsForty-one patients with squamous cell carcinoma of the vulva (stage I or II) were operated upon. The primary treatment was wide local excision with 2 cm safety margin and superficial inguinal lymphadenectomy. Six patients had ipsilateral and one patient had bilateral groin recurrence. Those patients were subjected to deep inguinal node dissection (one patient required bilateral node dissection).ResultsThe mean age at time of diagnosis was 59 years (range 51–68). The median follow-up period for all patients was 63 months (range 24–71) and that of the recurrent cases was 20 months (range 12–38). The mean depth of invasion of the recurrent cases was 5.5 mm (range 5–5.9 mm) and the mean diameter of the primary tumor in recurrent cases was 3.8 cm (range 3–4.5 cm). All recurrent cases had a high grade of the primary tumor. The median interval to recurrence was 21 months (range 12–57). The groin recurrence rate after negative SIND was 17% (7/41 patients).The mean number of nodes resected per groin was eight (range 1–17). The nodes ranged in size from 0.2 to 4.0 cm.ConclusionCarcinoma of the vulva with the following criteria (size of tumor is greater than 3 cm, depth of invasion greater than 5 mm, and high grade tumors) is at high risk of recurrence.     

Establishing and validating predictive nomograms for lateral pelvic lymph node metastasis in patients with rectal cancer based on radiologic factors and clinicopathologic characteristics

IntroductionIt is critical to accurately predict the occurrence of lateral pelvic lymph node (LPN) metastasis. Currently, verified predictive tools are unavailable. This study aims to establish nomograms for predicting LPN metastasis in patients with rectal cancer who received or did not receive neoadjuvant chemoradiotherapy (nCRT).Materials and methodsWe carried out a retrospective study of patients with rectal cancer and clinical LPN metastasis who underwent total mesorectal excision (TME) and LPN dissection (LPND) from January 2012 to December 2019 at 3 institutions. We collected and evaluated their clinicopathologic and radiologic features, and constructed nomograms based on the multivariable logistic regression models.ResultsA total of 472 eligible patients were enrolled into the non-nCRT cohort (n = 312) and the nCRT cohort (n = 160). We established nomograms using variables from the multivariable logistic regression models in both cohorts. In the non-nCRT cohort, the variables included LPN short diameter, cT stage, cN stage, histologic grade, and malignant features, and the C-index was 0.930 in the training cohort and 0.913 in the validation cohort. In the nCRT cohort, the variables included post-nCRT LPN short diameter, ycT stage, ycN stage, histologic grade, and post-nCRT malignant features, and the C-index was 0.836 in the training dataset and 0.827 in the validation dataset. The nomograms in both cohorts were moderately calibrated and well-validated.ConclusionsWe established nomograms for patients with rectal cancer that accurately predict LPN metastasis. The performance of the nomograms in both cohorts was high and well-validated.     

Impact of body mass index on the difficulty and outcomes of laparoscopic left lateral sectionectomy

IntroductionCurrently, the impact of body mass index (BMI) on the outcomes of laparoscopic liver resections (LLR) is poorly defined. This study attempts to evaluate the impact of BMI on the peri-operative outcomes following laparoscopic left lateral sectionectomy (L-LLS).MethodsA retrospective analysis of 2183 patients who underwent pure L-LLS at 59 international centers between 2004 and 2021 was performed. Associations between BMI and selected peri-operative outcomes were analyzed using restricted cubic splines.ResultsA BMI of >27kg/m2 was associated with increased in blood loss (Mean difference (MD) 21 mls, 95% CI 5–36), open conversions (Relative risk (RR) 1.13, 95% CI 1.03–1.25), operative time (MD 11 min, 95% CI 6–16), use of Pringles maneuver (RR 1.15, 95% CI 1.06–1.26) and reductions in length of stay (MD -0.2 days, 95% CI -0.3 to −0.1). The magnitude of these differences increased with each unit increase in BMI. However, there was a “U” shaped association between BMI and morbidity with the highest complication rates observed in underweight and obese patients.ConclusionIncreasing BMI resulted in increasing difficulty of L-LLS. Consideration should be given to its incorporation in future difficulty scoring systems in laparoscopic liver resections.     

Percutaneous thermal ablation for cT1 renal mass in solitary kidney: A multicenter trifecta comparative analysis versus robot-assisted partial nephrectomy

IntroductionRenal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation (PTA) in SK patients with renal tumors cT1.Materials and methodsWe performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite “trifecta” to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of “trifecta” achievement.ResultsWe included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement.ConclusionPTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.     

The natural history of epithelioid sarcoma. A retrospective multicentre case-series within the Italian Sarcoma Group

IntroductionThis case-series is aimed to describe the natural history of epithelioid sarcoma (ES) and to provide insights into the differential clinical behaviour of its two variants (“classic-type” and “proximal-type”). The value of a subtype-adapted grading system based on pathological features is explored.MethodsData from consecutive, primary, localised, INI1-deleted ES operated at three Italian sarcoma reference centres (1995–2015) were included. Centralised pathological review was performed. Classic-type ES was broken down into “high-grade” and “low-grade”, according to number of mitoses, evidence of necrosis and nuclear atypia. Five- and 10-year overall survival (OS) and crude cumulative incidence (CCI) of local recurrence (LR) and distant metastasis (DM) were estimated.ResultsFifty-two patients were included. 5- and 10-year OS estimates were 70% and 47% in the whole series, 57% and 37% in patients with proximal-type ES, 77% and 54% in patients with classic-type ES (P = 0.02). In classic-type ES, 5- and 10-year OS was higher for low-grade (95% and 72%, respectively) than high-grade tumours (P = 0.002). 5- and 10-year CCI estimates for LR were 21% and 33% in the whole series. 5- and 10-year CCI estimates for DM were 35% and 39% in the whole series, both 28% in classic-type ES, 47% and 59% in proximal-type ES (P = 0.03).ConclusionsSuffering from a proximal- or a classic-type is the stronger predictor of outcome in patients with localised ES, with proximal-type ES patients having lower survival due to a higher tendency toward metastatic spreading. However, the “high-grade” classic-type ES was associated with outcomes close to proximal-type ES.     

Patient reported outcome and cosmetic evaluation following implant-based breast-reconstruction with a titanized polypropylene mesh (TiLOOP® Bra): A prospective clinical study in 269 patients

IntroductionImplant-based or expander-supported breast reconstruction is an established surgical method after mastectomies due to cancer or to prophylactic reasons. Patient reported outcome (PRO) and cosmetic outcome after breast reconstruction with a synthetic surgical mesh was investigated in a prospective, single-arm, multi-center study.Material and methodsPrimary or secondary implant-based breast reconstruction with support of TiLOOP® Bra was performed in 269 patients during the PRO-BRA study. PRO 12 months after breast reconstruction was evaluated using Breast-Q questionnaire. Cosmetic outcome was evaluated by two independent experts by means of pictures taken preoperatively and at the follow-up visits.ResultsBreast-Q and 12 months FU were completed by 210 women. Patients without adverse event had a significantly higher Breast-Q score for “sexual well-being” (p = 0.001); “psychosocial well-being” was negatively influenced by prior therapies (p < 0.01), and older patients had significantly lower scores at 12 months FU compared to pre-OP for “satisfaction with breasts” (p < 0.01) while the opposite was true for younger patients. Unilateral surgery resulted in reduced “satisfaction with breast” at 12 months FU (p < 0.01). Radiotherapy negatively influenced “satisfaction with breast”, “sexual well-being” and “physical well-being chest”. The cosmetic evaluation showed a significant difference (p < 0.001) in the evaluation by the patients and experts with the patients' assessment being worse compared to experts' assessment.ConclusionOur study showed that two years after implant-based breast reconstruction with support of TiLOOP® Bra PRO is influenced by different factors. This information can be used to improve the decision-making process for women who chose implant-based breast reconstruction.     

Chemotherapy for advanced non-pancreatic well-differentiated neuroendocrine tumours of the gastrointestinal tract,a systematic review and meta-analysis: A lost cause?

BackgroundChemotherapy is well-established in the treatment of patients with well-differentiated neuroendocrine tumours (NETs) arising from the pancreas (pNETs); however, its role in patients with gastrointestinal non-pancreatic NETs (non-pNETs) is uncertain. This systematic review assesses the evidence for the role of chemotherapy in well-differentiated non-pNET patients.MethodsEligible studies (identified using MEDLINE) were those reporting response and/or survival data for patients with well-differentiated non-pNETs receiving systemic chemotherapy. The primary end-point was overall-response (OR) rate; secondary end-points were progression-free survival (PFS), overall survival (OS), disease-stabilization (DS) and disease-control (DC) rates.ResultsOf 6434 studies screened, 20 were eligible: one randomised phase III trial, 2 randomised phase II studies, 10 single-arm phase II trials and 7 retrospective analyses including a total of 264 patients (median of 11 patients per study, range 6–49); and employing multiple chemotherapy schedules. The mean “median PFS” and “median OS” were 16.9 months (95%-confidence interval (CI) 3.8–30.04) and 32.2 months (95%-CI 10.4–54.2), respectively. The non-weighted mean OR, DS and DC rates were 11.5% (95%-CI 5.8–17.2), 56.5% (95%-CI 38.1–74.9) and 70.7% (95%-CI 54.9–86.5), respectively. In studies including both pNETs and non-pNET patients, meta-analysis showed a lower OR-rate in the non-pNET patients when compared to pNETs [odds ratio (OR) 0.35 (95% CI 0.18–0.66)]; however significance was lost when high-risk bias studies were excluded in a sensitivity analysis [OR 0.45 (95% CI 0.19–1.07); p-value 0.07].ConclusionStudies were of evidence level-C with heterogeneous populations and treatments; and small patient numbers. Well-designed, prospective studies are needed to adequately evaluate the role of chemotherapy in this setting.     

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BackgroundRobotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study.MethodsFrom July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments.ResultsTwenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days.ConclusionsThe results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.     

Renal involvement in cancer and renal paraneoplastic syndromes

BackgroundRenal alterations in the context of neoplastic disease are relatively frequent manifestations but are overall poorly reported.Material and methodsA search in the English and French literature was performed using the following key words: “cancer”, “renal”, “paraneoplastic syndrome”, “glomerulopathy” and “kidney failure”.ResultsThe various renal manifestations can be divided into specific and paraneoplastic. They include paraneoplastic glomerulopathies (membranous glomerulonephristis being the most frequent), direct involvement of the renal parenchyma, hydroelectrolytic abnormalities (hypercalcemia, inappropriate antidiuretic hormone secretion…), retroperitoneal fibrosis, micro-angiothrombotic disease and tumor lysis syndrome. Anticancer and symptomatic treatments do not guaranty complete recovery in all cases.ConclusionThe frequency and the severity of some renal manifestations associated with malignant hemopathies and carcinomas indicates a need for initial renal-oriented work-up and follow-up.