Risk Factors of Peritoneal Recurrence and Outcome of Resected Peritoneal Recurrence After Liver Resection in Hepatocellular Carcinoma: Review of 1222 Cases of Hepatectomy in a Tertiary Institution

Background

Reports on the risk factors of peritoneal recurrence (PR) after liver resection for hepatocellular carcinoma are lacking. We examined the risk factors of PR after hepatectomy and the outcome of resected PR at our institution.

Methods

We retrospectively reviewed the data from 1,222 patients who underwent hepatectomies for hepatocellular carcinoma in Samsung Medical Center from January 2006 to August 2010. We identified patients with PR and studied the risk factors and outcomes of resected PR.

Results

The rate of PR was 3.0% (n?=?36). The mean?±?SD age of patients was 54.0?±?10.2?years. Among those with PR, 23 patients (63.9%) had unresectable disease and 13 patients (36.1%) had resectable disease. Multivariate analysis found that tumor size >50?mm, presence of microvascular invasion, bile duct invasion, and positive margins were significant risk factors of PR after liver resection. The median overall survival (OS) for resectable PR was 33.0 (28.0?C61.6) months compared to 14.0 (6.8?C21.2) months for unresectable PR (P?=?0.009). Cox regression analysis demonstrated that resected PR [hazard ratio (HR) 0.042, P?=?0.001] and interval between hepatectomy and PR (>6months) (HR 0.195, P?=?0.016) were positive prognostic factors for OS, while alfa-fetoprotein >200?ng/dl at detection of PR (HR 11.321, P?=?0.015) and serosal involvement of primary hepatocellular carcinoma (HR 25.616, P?=?0.007) were negative prognostic factors for OS.

Conclusions

We found that tumor size >50?mm, presence of microvascular invasion, bile duct invasion, and positive resection margins were significant risk factors of PR after liver resection. Selected patients with resected PR had significantly better OS.     

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.     

Cytokeratin 7 is a Predictive Marker for Survival in Patients with Esophageal Squamous Cell Carcinoma

Background

Patients diagnosed with stage II and III esophageal squamous cell carcinoma (ESCC) have variable prognosis. This group would benefit greatly from the discovery of prognostic markers that are capable of identifying individuals for whom adjuvant treatment would be advantageous. The aim of this study was to investigate the impact of immunohistochemically detected cytokeratin 7 (CK7) expression on disease-free survival, overall survival (OS), or therapeutic outcome in patients with ESCC.

Methods

Immunohistochemical analysis of CK7 was performed on 225 surgically resected specimens of stage 0?CIII ESCC.

Results

In total, 20 (9%) of 225 ESCC cases were positive for CK7. In stage 0?CIII ESCC patients, CK7 expression was statistically significantly associated with OS, independent of clinical covariates, including tumor, node, metastasis system stage. In stage II and III ESCC patients (n?=?124), CK7 expression was significantly associated with poorer OS (P?=?0.0377). Furthermore, in stage II and III ESCC patients who did not receive adjuvant chemotherapy (n?=?73), CK7 expression was significantly associated with poorer OS (P?=?0.0003). CK7 expression was not associated with therapeutic outcome in patients with stage II and III ESCC who received adjuvant chemotherapy. In patients with CK7-positive ESCC (n?=?16), receipt of adjuvant chemotherapy tended to be beneficial for patients with stage II and III ESCC (P?=?0.0654).

Conclusions

Immunohistochemical analysis of CK7 will help to identify high-risk patients.     

Role of Operative Therapy in Non-cirrhotic Patients with Metastatic Hepatocellular Carcinoma

Introduction

We investigated the role of operative therapy in non-cirrhotic patients who developed metastatic hepatocellular carcinoma (HCC).

Methods

This retrospective cohort study included consecutive non-cirrhotic patients with metastatic HCC after a prior hepatectomy treated between 1990 and 2009. Patients were stratified by operative therapy (resection, ablation, transcatheter therapy). Kaplan?CMeier analyses with log-rank comparisons tested effects of operative therapy on overall survival (OS) and progression-free survival (PFS).

Results

Of 195 non-cirrhotic patients treated for HCC during the study period, 98 [median age 65, interquartile range (IQR) 53?C71; 55?% male] subsequently developed metastatic HCC (55 intrahepatic only). Median time to development of metastases after the index operation was 10?months (IQR 5?C20?months); median number of metastases was 3 (IQR 2?C7). Half of these patients (n?=?50) underwent operative treatment of metastases; 20 (40?%) underwent metastasectomy, 18 (36?%) ablation, and 12 (24?%) transcatheter therapy. Operative therapy was associated with improved OS (p?p????0.006). Nine patients (seven resection, two ablation) are disease free at a median of 50?months (IQR 24?C80?months) posttreatment.

Conclusions

Resection and ablation are associated with an improved PFS and long-term OS and should be considered in select patients with metastatic HCC.     

Clinical, Pathological and Surgical Characteristics of Duodenal Gastrointestinal Stromal Tumor and Their Influence on Survival: A Multi-Center Study

Background

The duodenum is a rare site of primary gastrointestinal stromal tumor (GIST). Overall (OS) and disease-free survival (DFS) after limited resection (LR) versus pancreaticoduodenectomy (PD) were studied.

Methods

All patients who underwent surgery for primary, localized duodenal GIST between 2000 and 2011 were identified from four prospective institutional databases. OS and DFS were calculated by Kaplan?CMeier method. Univariate analysis was performed.

Results

Eighty-four patients (median follow-up 42?months) underwent LR (n?=?56, 67?%) or PD (n?=?28, 33?%). Patients in the PD group had a larger median tumor size (7?cm vs. 5?cm, p?=?0.024) and higher mitotic count (39?% vs. 19?% >5/50 high-power fields, p?=?0.05). Complications were observed in five patients (9?%) in the LR group and ten patients (36?%) in the PD group. OS and DFS for the entire cohort were 89?% and 64?% at 5?years, respectively. No difference in outcome between LR and PD were observed. Eleven patients were treated with preoperative IM. A major RECIST response was obtained in nine (80?%), whereas two had stable disease. Twenty-three patients received postoperative Imatinib (IM). A trend toward a better OS in IM-treated patients could be detected only in the high-risk group.

Conclusions

Type of duodenal resection does not impact outcome. The choice should be determined by duodenal site of origin and tumor size. IM may be considered in cases at high risk of recurrence; in neoadjuvant setting, IM might facilitate resection and possibly increase the chance of preserving normal biliary and pancreatic anatomy.     

Cardiac Angiosarcoma Management and Outcomes: 20-Year Single-institution Experience

Purpose

To identify the clinicopathologic characteristics, treatments, and outcomes of a series of patients with primary cardiac angiosarcoma (AS).

Methods

This retrospective case series was set in a tertiary referral center with a multidisciplinary clinic. Consecutive patients with institutionally confirmed pathologic diagnosis of cardiac AS from January 1990 to May 2011 were reviewed. Main outcome measures included patient demographics, tumor characteristics, management strategies, disease response, and survival.

Results

Data from 18 patients (78?% male) were reviewed. Sixteen patients (89?%) had AS originating in the right atrium. At diagnosis, eight patients (44?%) had localized/locally advanced disease and ten patients (56?%) had metastatic disease. Initial treatment strategies included resection (44?%), chemotherapy (39?%), and radiotherapy (11?%). Of the eight patients with localized/locally advanced AS, two underwent macroscopically complete resection with negative microscopic margins, one underwent macroscopically complete resection with positive microscopic margins, one underwent macroscopically incomplete resection, two received chemotherapy followed by surgery and intraoperative radiotherapy, one received chemotherapy alone, and one died before planned radiotherapy. Median follow-up was 12?months. Median overall survival (OS) was 13?months for the entire cohort; median OS was 19.5?months for those presenting with localized/locally advanced AS and 6?months for those with metastatic disease at presentation (p?=?0.08). Patients who underwent primary tumor resection had improved median OS compared with patients whose tumors remained in situ (17 vs. 5?months, p?=?0.01).

Conclusions

Cardiac AS is associated with poor prognosis. Resection of primary tumor should be attempted when feasible, as OS may be improved. Nevertheless, most patients die of disease progression.     

Outcome of operation in patients with adrenocortical cancer invading the inferior vena cava—a European Society of Endocrine Surgeons (ESES) survey

Background

Most patients with adrenocortical cancer (ACC) continue to present with advanced disease. Invasion into the inferior vena cava (IVC) defines stage III disease and the management of such patients raises additional difficulties.

Method

A multicentre survey was organized by emailing a standardized proforma to members of the European Society of Endocrine Surgery (ESES). Anonymised retrospective clinical data were collected.

Results

Replies were received from 18 centres in nine countries. ACC with IVC invasion was encountered in 38 patients (18F:20M, age 15?C84?years, median 54?years). There were 16 nonfunctioning tumours and 22 functioning tumours predominantly right-sided (26R:12L) and measuring 18?C255?mm (median 115?mm). Fourteen patients had metastatic disease at presentation. Tumour thrombus extended in the prehepatic IVC (n?=?21), subdiaphragmatic IVC (n?=?6) or into the SVC/right atrium (n?=?3). Open adrenalectomy was associated with resection of surrounding viscera in 24 patients (nephrectomy n?=?16, liver resection n?=?14, splenectomy n?=?3, Whipple procedure n?=?2). IVC was controlled locally (n?=?27), at suprahepatic levels (n?=?6) or necessitated cardiac bypass (n?=?5). Complete resection (R0, n?=?20) was achieved in the majority of patients, with a minority having microscopic persistent disease (R1, n?=?7) or macroscopic residual disease (R2, n?=?4). Perioperative 30-day mortality was 13% (n?=?5). Postoperative Mitotane was used in 23 patients and chemotherapy in eight patients. Twenty-five patients died 2?C61?months after their operation (median 5?months). Currently, 13 patients are alive at 2?C58?months (median 16?months) with known metastatic disease (n?=?7) or with no signs of distant disease (n?=?6).

Conclusion

This dataset is limited by the lack of a denominator as it remains unknown how many other patients with ACC presenting with IVC invasion did not undergo surgery. The relatively low perioperative mortality and the long disease-free survival achieved by some patients should encourage surgeons with adequate experience to offer surgical treatment to patients presenting with advanced adrenocortical cancers.     

The Implications of Positive Peritoneal Lavage Cytology in Potentially Resectable Pancreatic Cancer

Background

The clinical implications of peritoneal lavage cytology (CY) status in patients with potentially resectable pancreatic cancer have not been established.

Method

We retrospectively reviewed clinical data from 254 consecutive patients who underwent macroscopically curative resection for pancreatic cancer from February 2003 to December 2010 in our institution. Correlations between CY status and survival and clinicopathological findings were investigated.

Results

Of the 254 patients, 20 were CY+ (7.9?%). There were no significant differences between CY+ and CY? patients in background data (age, sex, the level of preoperative tumor marker, and adjuvant chemotherapy). Patients with positive serosal invasion were more likely to be CY+ than those with negative serosal invasion (P?P?=?0.302). The median recurrence-free survival of CY+ and CY? patients was 8.1?months (95?% CI?=?0.0–17.9) and 13.5?months (95?% CI?=?11.5–15.5), respectively (P?=?0.089).

Conclusion

CY+ status without other distant metastasis does not necessarily preclude resection in patients with pancreatic cancer.     

Does “Conversion Chemotherapy” Really Improve Survival in Metastatic Colorectal Cancer Patients with Liver-Limited Disease?

Background

The clinical benefits of conversion chemotherapy followed by liver resection for initially unresectable colorectal liver metastases are still controversial. The criteria for unresectability vary from one team to another. To clarify this issue, we retrospectively assessed the survival and characteristics of metastatic colorectal cancer (mCRC) patients with liver-limited disease (LLD) who underwent conversion therapy.

Method

Our criteria for resectability depended on the size of the remnant liver volume (>30 %) and expected function after removal of all metastases. Between December 2007 and September 2011, a total of 115 patients were diagnosed as having mCRC with LLD and received chemotherapy. Among them, 47 had tumors that were initially diagnosed as resectable. They underwent hepatic resection after chemotherapy (resected group). Of the 67 tumors were initially diagnosed as unresectable, 12 became resectable after chemotherapy (conversion group), leaving 55 tumors that remained unresectable after chemotherapy (unresected group).

Results

The median follow-up was 25.2 months. Hepatic resection was more invasive in the conversion group than in the resected group. Median disease-free survival was significantly higher in the resected group than in the conversion group (p = 0.013). Overall survival (OS) was also higher in the resected group, but the difference was not significant (p = 0.36). However, OS was significantly higher in the conversion group than in the unresected group (p = 0.034). Multivariate analysis of the resected and conversion groups showed that OS was significantly negatively influenced by abnormal carcinoembryonic antigen levels at surgery (p = 0.037) and a hospital stay >30 days (p = 0.009).

Conclusions

Our results showed that conversion chemotherapy could contribute to longer OS in mCRC patients with LLD.     

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?%.     

Defined Clinical Classifications Are Associated with Outcome of Patients with Anatomically Resectable Pancreatic Adenocarcinoma Treated with Neoadjuvant Therapy

Background

We previously introduced a classification system for patients with localized pancreatic adenocarcinoma that integrates assessments of tumor anatomy, cancer biology, and patient physiology. By means of this system, we sought to analyze outcomes of patients with resectable anatomy but heterogeneous biology and physiology who were treated with neoadjuvant therapy.

Methods

We evaluated consecutive patients (2002?C2007) with anatomically potentially resectable cancers treated with chemotherapy or chemoradiation before potential pancreatectomy. We compared clinical factors and outcomes of patients classified as having disease that was clinically resectable (CR; no extrapancreatic disease, preserved performance status); suspicion for extrapancreatic disease (BR-B); or marginal performance status or significant comorbidity (BR-C). Patients with borderline resectable anatomy (BR-A) were excluded.

Results

Resection rates for 138 CR, 41 BR-B, and 38 BR-C patients were 75, 46, and 37%, respectively (P?P?P?>?0.22).

Conclusions

This system describes discrete clinical subgroups of patients with pancreatic cancer who have similar, potentially resectable tumor anatomy but heterogeneous physiology and cancer biology. It may be used with neoadjuvant therapy to predict outcomes, individualize treatment algorithms, and optimize survival.     

Surgical Resection after Downsizing Chemotherapy for Initially Unresectable Locally Advanced Biliary Tract Cancer: A Retrospective Single-center Study

Background

Surgical resection is the only method for curative treatment of biliary tract cancer (BTC). Recently, an improved efficacy has been revealed in patients with initially unresectable locally advanced BTC to improve the prognosis by the advent of useful cancer chemotherapy. The aim of this study was to evaluate the effect of downsizing chemotherapy in patients with initially unresectable locally advanced BTC.

Methods

Initially unresectable locally advanced cases were defined as those in which therapeutic resection could not be achieved even by proactive surgical resection. Gemcitabine was administered intravenously once a week for 3 weeks followed by 1 week’s respite. Patients whose disease responded to chemotherapy were reevaluated to determine whether their tumor was resectable.

Results

Chemotherapy with gemcitabine was provided to 22 patients with initially unresectable locally advanced BTC. Tumor was significantly downsized in nine patients, and surgical resection was performed in 8 (36.4%) of 22 patients. Surgical resection resulted in R0 resection in four patients and R1 resection in four patients. Patients who underwent surgical resection had a significantly longer survival compared with those unable to undergo surgery.

Conclusions

Preoperative chemotherapy enables the downsizing of initially unresectable locally advanced BTC, with radical resection made possible in a certain proportion of patients. Downsizing chemotherapy should be proactively carried out as a multidisciplinary treatment strategy for patients with initially unresectable locally advanced BTC with the aim of expanding the surgical indication.     

Topically Applied 2-Octyl Cyanoacrylate (Dermabond) for Prevention of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Objective

We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF).

Methods

Patients who underwent PD with duct-to-mucosa PJ were evaluated (n?=?124). Outcome was compared between patients who received Dermabond (n?=?75) after PD and historic patients who did not (n?=?49). Risk factors for POPF were identified.

Results

Overall and clinically relevant rates of POPF were significantly lower in patients who received Dermabond than in patients who did not (2.6?% and 1.3?% vs. 22?% and 12?%, respectively; p?=?0.001). In univariate analysis, pancreatic duct diameter ??3?mm, low serum albumin level, and no Dermabond were independent risk factors for POPF; in multivariate analysis, no Dermabond was an independent risk factor for POPF. In patients with pancreatic duct diameter ??3?mm, the rate of POPF was significantly lower in patients who received Dermabond than in patients who did not (3.5?% versus 36?%, respectively; p?=?0.0001). Patients who received Dermabond had significantly shorter hospital stays and lower re-operation and re-admission rates.

Conclusions

Topical application of Dermabond to the PJ anastomotic site after PD significantly reduced the rate of POPF, particularly in patients at risk.     

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

Background and Purpose

There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3?years.

Methods

The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n?=?164) or laparoscopic surgery (LS group; n?=?126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0?months after OS and LS, respectively.

Results

There were 10 (6.1?%) versus 9 (7.1?%) deaths unrelated to cancer, 15 (9.1?%) versus 5 (4?%) cases of local recurrence, 7 (4.2?%) versus 5 (4?%) cases of peritoneal carcinosis, and 37 (22.5?%) versus 14 (11.1?%) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8?%). The OS group had a significantly higher probability of local recurrence and metastases (p?<?0.001) with a significant higher probability of cancer-related death (p?=?0.001) than the LS group.

Conclusions

These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.     

Distal Pancreatectomy with En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Adenocarcinoma Following Neoadjuvant Therapy

Background

Celiac trunk encasement by adenocarcinoma of the pancreatic body is generally regarded as a contraindication for surgical resection. Recent studies have suggested that a subset of stage III patients will succumb to their disease in the absence of distant metastases. We hypothesized that patients with stage III tumors invading the celiac trunk, who are free of distant disease following neoadjuvant therapy, may derive prolonged survival benefit from aggressive surgical resection.

Methods

We performed a retrospective review of distal pancreatectomies with en bloc celiac axis resection for pancreatic adenocarcinoma.

Results

Eleven patients underwent a distal pancreatectomy with en bloc celiac axis resection after completing neoadjuvant chemoradiation therapy. Median operative time was 8?h, 14?min, and median estimated blood loss was 700?ml. Median length of stay was 9?days. Five patients (45%) had postoperative complications; three were Clavien grade I. Four patients (35%) had pancreatic leaks; two were ISGPF grade B, and two were grade A. There were two 90-day perioperative deaths. Ten patients had R0 resections (91%). After a median follow-up of 41?weeks, six patients recurred. Four of the five patients with SMAD4 loss recurred, and two of the five patients with intact SMAD4 recurred. Median disease-free and overall survival were 21?weeks and 26?months, respectively.

Conclusions

Resection of pancreatic body adenocarcinoma with celiac axis resection is technically feasible with acceptable perioperative morbidity and mortality.     

Preoperative Cholangitis and Metastatic Lymph Node Have a Negative Impact on Survival After Resection of Extrahepatic Bile Duct Cancer

Background

The significance of the presence of preoperative inflammation for the prognosis of patients with extrahepatic bile duct cancer (BDCA) was evaluated.

Methods

The clinical data of 84 patients who underwent surgery for BDCA from August 2003 to May 2009 were reviewed, and survival analysis was performed. The patients were classified into two groups according to the presence of preoperative cholangitis: Group A had no cholangitis (n?=?59), and group B had cholangitis (n?=?25).

Results

There were no differences in sex, mean age, TNM stage, biliary drainage, type of resection, or radicality between the two groups (p?>?0.05). The 3-year disease-specific survival (DSS) and disease-free survival (DFS) rates for the group B patients (21.5 and 11.9?%, respectively) were significantly lower than those for the group A patients (66.1 and 57.3?%, respectively; p?=?0.013 and 0.001, respectively). The multivariate analysis showed that preoperative inflammation and lymph node metastasis were the independent prognostic factors for both overall survival (OS) [p?=?0.021, relative risk (RR)?=?2.224 and p?=?0.015, RR?=?2.367, respectively] and DFS (p?=?0.014; RR?=?2.192 and p?=?0.013; RR?=?2.240, respectively). The rates of angiolymphatic and perineural invasion were higher for group B than those for group A (p?=?0.016 and 0.030, respectively).

Conclusions

The presence of preoperative inflammation is an independent poor prognostic factor for OS and DFS for patients with BDCA.     

Influence of Young Age on Outcome After Esophagectomy for Cancer

Background

The incidence of esophageal cancer has risen among all age groups. Controversy exists about the clinical presentation and prognosis of young patients. The aim of this study was to compare the clinicopathologic characteristics and outcomes after surgery between patients with esophageal cancer who were <50?years of age and those ≥50?years of age.

Methods

Patients diagnosed with esophageal carcinoma who underwent esophagectomy between January 1990 and December 2010 in a single institution were selected from a prospective database. Patients aged <50?years at diagnosis (n?=?163) were compared with those ≥50?years (n?=?1151) with respect to clinicopathologic stage and oncologic outcome.

Results

Younger patients had less co-morbidity (p?<?0.001). There were no significantly differences in tumor localization, histology, differentiation, or TNM stage in the two groups. In both groups, 37?% of the patients underwent neoadjuvant chemo(radio)therapy. One or more nonsurgical complications developed in 53?% of the older group versus 42?% in the younger group (p?=?0.012). In-hospital mortality was 6.3?% for patients ≥50?years compared to 1.8?% for younger patients (p?=?0.021). The 5?year overall survival was significantly better for the younger patients than for those ≥50?years (41 vs. 31?%, p?<?0.001), but median disease-specific and disease-free survival did not differ between the groups (37 vs. 30?months, p?=?0.140 and 49 vs. 28?months, p?=?0.079, respectively). Multivariate analysis identified moderate, poorly, and undifferentiated tumors; tumor-positive resection margins (pR1–2); and TNM stage IIB–IV as independent predictors of disease-specific survival.

Conclusions

A considerable proportion (12?%) of patients diagnosed with resectable esophageal carcinoma were <50?years. Phenotypic tumor characteristics and disease-specific survival were comparable for the two age groups.     

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.     

Neither Neoadjuvant nor Adjuvant Therapy Increases Survival After Biliary Tract Cancer Resection with Wide Negative Margins

Background

We investigated the role of neoadjuvant/adjuvant therapies on survival for resectable biliary tract cancer. We hypothesized that neoadjuvant and adjuvant therapy should improve the survival probability in these patients.

Methods

This was a retrospective review of a prospective database of patients resected for gallbladder cancer (GBC) and cholangiocarcinoma (CC). One hundred fifty-seven patients underwent resection for primary GBC (n?=?63) and CC (n?=?94). Fisher??s exact test, Student??s t test, the log-rank test, and a Cox proportional hazard model determined significant differences.

Results

The 5-year overall survival rate after resection of GBC and CC was 50.6 % and 30.4?%, respectively. Of the patients, 17.8?% received neoadjuvant chemotherapy, 48.7?% received adjuvant chemotherapy, while 15.8?% received adjuvant chemoradiotherapy. Patients with negative margins of at least 1?cm had a 5-year survival rate of 52.4?% (p?<?0.01). Adjuvant therapy did not significantly prolong survival. Neoadjuvant therapy delayed surgical resection on average for 6.8?months (p?<?0.0001). Immediate resection increased median survival from 42.3 to 53.5?months (p?=?0.01).

Conclusions

Early surgical resection of biliary tract malignancies with 1?cm tumor-free margins provides the best probability for long-term survival. Currently available neoadjuvant or adjuvant therapy does not improve survival.     

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.