Prognostic significance of CA-125 re-elevation after interval debulking surgery in patients with advanced-stage ovarian cancer undergoing neoadjuvant chemotherapy

AimsWe evaluated the prognostic significance of postoperative re-elevation of cancer antigen-125 (CA-125) levels in patients with ovarian cancer and preoperative normalization of CA-125 levels after neoadjuvant chemotherapy (NAC).MethodsThe data of 103 patients with preoperative CA-125 normalization after NAC at the Yonsei Cancer Hospital (2006–2017) were analyzed. We compared the clinical characteristics and survival outcomes among patients with normal postoperative CA-125 levels and those with re-elevated CA-125 levels after interval debulking surgery (IDS). CA-125 elevation was defined as levels >35 U/mL.ResultsAmong 103 patients, 52 (50.5%) and 51 (49.5%) had normal and re-elevated CA-125 levels after IDS, respectively. Patients with CA-125 re-elevation underwent more radical surgeries during IDS than those with normal CA-125 levels (p = 0.018). We found no significant differences in progression-free survival (PFS; p = 0.726) or overall survival (OS; p = 0.293) between the two groups. Moreover, patients with persistent CA-125 elevation (3 weeks after IDS) did not have inferior PFS (p = 0.171 and p = 0.208, respectively) or OS (p = 0.128 and p = 0.095, respectively) compared to patients with early normalization (within 3 weeks of IDS) or normal CA-125 levels. Multivariate regression showed that CA-125 re-elevation had no effect on recurrence (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.43–1.30) or death (HR, 0.99; 95% CI, 0.33–2.98).ConclusionAmong patients with preoperative CA-125 normalization after NAC, postoperative CA-125 re-elevation had no prognostic value. Novel and reliable biomarkers reflecting the tumor response after IDS should be identified.     

Delayed genital necrosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with Mitomycin-C

IntroductionGenital necrosis (GN) is a rare complication of cytoreductive surgery with hyperthermic intraoperative chemotherapy (CRS/HIPEC) which can be confused with necrotizing fasciitis. We present an analysis of GN after CRS/HIPEC to define its natural history.MethodsWe identified patients with GN after CRS/HIPEC at two peritoneal surface malignancy institutions. Patient demographic, surgical, and postoperative data were extracted from prospective databases.ResultsOf 1597 CRS/HIPECs performed, 13 patients (0.8%) had GN. The median age was 57 years (IQR: 49–64) and 77% (n = 10) were male. Mitomycin-C was the perfusion agent in all cases of GN (100%). The median time to GN onset after CRS/HIPEC was 64 days (IQR: 60–108) and 2 (15%) patients were receiving systemic chemotherapy at the time of GN onset. Symptoms included severe pain (100%), edema (100%), labial or scrotal skin ulceration (92%), signs of infection (39%), and fever (15%). Seven (54%) patients had thrombocytosis >400 110⁹/L, whereas coagulation tests were within normal reference range in 100% cases. All patients initially underwent conservative treatment, with antibiotic therapy administered in 62% (n = 8). Surgical debridement was performed in 9 (70%) cases with median time after GN onset of 57 (IQR: 8–180).ConclusionGN is a debilitating complication after CRS/HIPEC with delayed onset and a protracted clinical course. Optimal treatment results could be achieved with initial conservative management until complete lesion demarcation followed by surgical debridement. The pathophysiology of GN is unclear, and we call for other researchers attention to better understand the complication and prevention.     

Readmission with venous thromboembolism after surgical treatment by primary cancer site

BackgroundVenous thromboembolism (VTE) is a common, high-mortality condition among surgical cancer patients. Comprehensive analyses of VTE among postoperative cancer patients are lacking. We sought to determine the association between readmission with VTE and primary cancer diagnosis in a nationwide database at 90- and 180-days after initial admission for cancer surgery.MethodsRetrospective analyses of post-surgical cancer patients readmitted with VTE were conducted using data from the Nationwide Readmissions Database (NRD) (2010–2014). Multivariate logistic regression models adjusting for patient and hospital factors were used to determine 90- and 180-day readmission rates for VTE by cancer type. Patient factors associated with readmission were also examined.ResultsAmong a sample of 535,992 cancer patients undergoing tumor resection, readmission with VTE occurred in 1.7% within 90-days and 2.3% within 180-days. Patients readmitted for VTE experienced a 7% mortality rate. Highest rates of VTE readmission at 180 days occurred in brain (6.7%), pancreatic (5.6%), and respiratory and intrathoracic cancers (4.4%). Using pancreatic cancer as reference, brain cancer had the highest odds of readmission at 180-days (OR 2.23, 95% CI [1.95–2.55]).ConclusionReadmission with VTE among surgical cancer patients occurred in 2.3% of patients within 180 days. Among cancer types, primary brain cancer was independently associated with readmission with VTE.     

Postoperative recovery of accelerometer-based physical activity in older cancer patients

IntroductionRecovery of physical activity is an important functional outcome measure after cancer surgery. However, objective data on physical activity for older cancer patients is scarce. The aims of this study were to quantify perioperative physical activity levels, assess recovery of physical activity three months after surgery, and characterise patients who achieved recovery.Materials and methodsThis observational cohort study analysed physical activity data collected from patients aged >65 who were scheduled for cancer surgery between May 2018 and July 2019. Perioperative daily step count was measured using a Fitbit device. The primary outcome measure was the percentage of patients who returned to (≥90% of) their preoperative (baseline) physical activity levels three months after surgery.ResultsFifty patients (mean age 73) were recruited, and available Fitbit data was analysed. Median daily step counts at baseline (n = 40), before hospital discharge (n = 40), and three months postoperative (n = 37) were 5,974 (IQR 4,250–7,922), 1,619 (IQR 920–2,839), and 4,674 (IQR 3,047–7,592), respectively. The 15/37 (41%) patients who had reached baseline levels three months after surgery seemed to have more preoperative self-reported physical activity, better anaesthesiologists’ physical status classification, and fewer in-hospital complications compared to patients who had not, although the differences were statistically non-significant.ConclusionPerioperative physical activity was quantified for older cancer patients, and 41% returned to baseline levels within three months. Accelerometer-based physical activity provided a valuable outcome measure for postoperative physical recovery. Future studies using objective physical activity measures are needed to evaluate effects of interventional studies aimed at improving physical activity.     

Association of frailty with 90-day postoperative mortality & geriatric comanagement among older adults with cancer

IntroductionGeriatric medical comanagement of older surgical patients with cancer is associated with lower 90-day postoperative mortality. Here, we investigate the hypothesis that this association varies on the basis of the degree of a patient's frailty.MethodsFrailty was assessed using the Memorial Sloan Kettering Frailty Index. Our hypothesis was evaluated using two approaches, both adjusted for age, sex, American Society of Anesthesiologists Physical Status, preoperative albumin, operating room duration, and estimated blood loss. A logistic regression was performed with 90-day mortality as the outcome and geriatric comanagement, continuous Memorial Sloan Kettering Frailty Index, and an interaction term between these two variables as the primary predictors. We then categorized frailty into four levels and, within each level, performed logistic regression with geriatric comanagement as the primary predictor and 90-day mortality as the outcome. Finally, we extracted the effect size and used a meta-analytic approach to test for heterogeneity.ResultsOf 1687 patients aged ≥75 years who underwent elective cancer surgery with a length of stay of ≥1 day, 931 (55%) received comanagement; 31 patients (3.3%) who received comanagement died within 90 days, compared with 72 (9.5%) who did not. Ninety-day mortality was not statistically significantly different by degree of frailty in either analysis (interaction P = 0.4; test of heterogeneity P = 0.8).ConclusionGeriatric comanagement is valuable for all older surgical patients, not just the frail, and should be provided to as large a portion of the older surgical population as possible. Further research should examine predictors of response to geriatric comanagement.     

Survival of surgical and non-surgical older patients with non-metastatic colorectal cancer: A population-based study in the Netherlands

BackgroundSurgery is the primary treatment for non-metastatic colorectal cancer (CRC) but is omitted in a proportion of older patients. Characteristics and prognosis of non-surgical patients are largely unknown.ObjectiveTo examine the characteristics and survival of surgical and non-surgical older patients with non-metastatic CRC in the Netherlands.MethodsAll patients aged ≥70 years and diagnosed with non-metastatic CRC between 2014 and 2018 were identified in the Netherlands Cancer Registry. Patients were divided based on whether they underwent surgery or not. Three-year overall survival (OS) and relative survival (RS) were calculated for both groups separately. Relative survival and relative excess risks (RER) of death were used as measures for cancer-related survival.ResultsIn total, 987/20.423 (5%) colon cancer patients and 1.459/7.335 (20%) rectal cancer patients did not undergo surgery. Non-surgical treatment increased over time from 3.7% in 2014 to 4.8% in 2018 in colon cancer patients (P = 0.01) and from 17.1% to 20.2% in rectal cancer patients (P = 0.03). 3 year RS was 91% and 9% for surgical and non-surgical patients with colon cancer, respectively. For rectal cancer patients this was 93% and 37%, respectively. In surgical patients, advanced age (≥80 years) did not decrease RS (colon; RER 0.9 (0.7–1.0), rectum; RER 0.9 (0.7–1.1)). In non-surgical rectal cancer patients, higher survival rates were observed in patients treated with chemoradiotherapy (OS 56%, RS 65%), or radiotherapy (OS 19%, RS 27%), compared to no treatment (OS 9%, RS 10%).ConclusionNon-surgical treatment in older Dutch CRC patients has increased over time. Because survival of patients with colon cancer is very poor in the absence of surgery, this treatment decision must be carefully weighed. (Chemo-)radiotherapy may be a good alternative for rectal cancer surgery in older frail patients.     

Assessment of peritoneal metastases with DW-MRI,CT, and FDG PET/CT before cytoreductive surgery for advanced stage epithelial ovarian cancer

BackgroundPreoperative assessment of peritoneal metastases is an important factor for treatment planning and selection of candidates for cytoreductive surgery (CRS) in primary advanced stage (FIGO stages III–IV) epithelial ovarian cancer (EOC). The primary aim was to evaluate the efficacy of DW-MRI, CT, and FDG PET/CT used for preoperative assessment of peritoneal cancer index (PCI).Material and methodsIn this prospective observational cohort study, 50 advanced stage EOC patients were examined with DW-MRI and FDG PET/CT with contrast enhanced CT as part of the diagnostic program. All patients were deemed amenable for upfront CRS. Imaging PCI was determined for DW-MRI, CT, and FDG PET/CT by separate readers blinded to the surgical findings. The primary outcome was agreement between the imaging PCI and PCI determined at surgical exploration (the reference standard) evaluated with Bland-Altman statistics.ResultsThe median surgical PCI was 18 (range: 3–32). For all three imaging modalities, the imaging PCI most often underestimated the surgical PCI. The mean differences between the surgical PCI and the imaging PCI were 4.2 (95% CI: 2.6–5.8) for CT, 4.4 (95% CI: 2.9–5.8) for DW-MRI, and 5.3 (95% CI: 3.6–7.0) for FDG PET/CT, and no overall statistically significant differences were found between the imaging modalities (DW-MRI – CT, p = 0.83; DW-MRI – FDG PET/CT, p = 0.24; CT – FDG PET/CT, p = 0.06).ConclusionNeither DW-MRI nor CT nor FDG PET/CT was superior in preoperative assessment of the surgical PCI in patients scheduled for upfront CRS for advanced stage EOC.     

间歇性肿瘤细胞减灭术与初始肿瘤细胞减灭术对晚期上皮性卵巢癌的疗效评价

目的探讨间歇性肿瘤细胞减灭术(IDS)与初始肿瘤细胞减灭术(PDS)对晚期上皮性卵巢癌(EOC)的疗效。方法根据手术方法的不同将132例晚期EOC患者分为PDS组(n=87例)和IDS组(n=45)。PDS组患者行PDS手术后接受6~8个疗程的化疗。IDS组患者行PDS手术后接受3个疗程的化疗,然后再行IDS手术后化疗3~5个疗程。观察两组患者的PDS切除范围,比较两组患者的减瘤满意率、疗效、血清CA125水平和不良反应发生情况。结果IDS组患者的PDS切除范围明显小于PDS组(P﹤0.01)。IDS组患者的减瘤满意率高于PDS组(P﹤0.05)。IDS组患者的临床疗效明显优于PDS组(P﹤0.01)。术前和第3次化疗后,两组患者的血清CA125水平比较,差异均无统计学意义(P﹥0.05)。IDS组患者PDS后的血清CA125水平高于PDS组,完成化疗后的血清CA125水平低于PDS组(P﹤0.05)。IDS组患者的不良反应总发生率低于PDS组(P﹤0.05)。结论IDS有助于提高晚期EOC患者的手术减瘤满意率和近期疗效,且不会显著增加不良反应。     

Impact of surgery and chemotherapy timing on outcomes in older versus younger epithelial ovarian cancer patients: A nationwide Danish cohort study

IntroductionTo explore differences in surgical complexity, chemotherapy administration, and treatment delays between younger and older Danish patients with epithelial ovarian cancer (EOC).Materials and MethodsWe included a nationwide cohort diagnosed with EOC from 2013 to 2018. We described surgical complexity and outcomes, the extent of chemotherapy and treatment delays stratified by age (<70 and ≥ 70 years), and surgical modality (primary, interval, or no debulking surgery).ResultsIn total, we included 2946 patients. For patients with advanced-stage disease, 52% of the older patients versus 25% of the younger patients did not undergo primary debulking surgery (PDS) or interval debulking surgery (IDS). For patients undergoing PDS or IDS, older patients underwent less extensive surgery and more often had residual disease after surgery >0 cm compared to younger patients. Furthermore, older patients were less often treated with chemotherapy. Older patients had PDS later than younger. We did not find any differences between age groups concerning treatment delays. Two-year cancer-specific survival differed significantly between age groups regardless of curatively intended treatment.DiscussionThis study demonstrates that older patients are treated less actively concerning surgical and oncological treatment than younger patients, leading to worse cancer-specific survival. Older patients do not experience more treatment delays than younger ones.     

Surgical and non-surgical complications after colorectal cancer surgery in older patients; time-trends and age-specific differences

BackgroundTrends of surgical and non-surgical complications among the old, older and oldest patients after colorectal cancer (CRC) surgery could help to identify the best target outcome to further improve postoperative outcome.Materials and methodsAll consecutive patients ≥70 years receiving curative elective CRC resection between 2011 and 2019 in The Netherlands were included. Baseline variables and postoperative complications were prospectively collected by the Dutch ColoRectal audit (DCRA). We assessed surgical and non-surgical complications over time and within age categories (70–74, 75–79 and ≥ 80 years) and determined the impact of age on the risk of both types of complications by using multivariate logistic regression analyses.ResultsOverall, 38648 patients with a median age of 76 years were included. Between 2011 and 2019 the proportion of ASA score ≥3 and laparoscopic surgery increased. Non-surgical complications significantly improved between 2011 (21.8%) and 2019 (17.1%) and surgical complications remained constant (from 17.6% to 16.8%). Surgical complications were stable over time for each age group. Non-surgical complications improved in the oldest two age groups. Increasing age was only associated with non-surgical complications (75–79 years; OR 1.17 (95% CI 1.10–1.25), ≥80 years; OR 1.46 (95% CI 1.37–1.55) compared to 70–74 years), not with surgical complications.ConclusionThe reduction of postoperative complications in the older CRC population was predominantly driven by a decrease in non-surgical complications. Moreover, increasing age was only associated with non-surgical complications and not with surgical complications. Future care developments should focus on non-surgical complications, especially in patients ≥75 years.     

Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis

AimWe aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer.MethodWe searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes.ResultsThis meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] −110.02, 95% confidence interval [CI]: 143.98, −76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, −214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS.ConclusionTEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.     

Do older patients with stage IB non-small-cell lung cancer obtain survival benefits from surgery? A propensity score matching study using SEER data

BackgroundSurgical resection is the preferred treatment for Stage IB non-small cell lung cancer (NSCLC), but one-third of patients still do not receive surgery, which might be due to the lack of robust and dedicated studies on the outcomes of surgical treatment in older patients with stage IB NSCLC. This study aims to investigate whether older patients with stage IB NSCLC benefit from surgery.MethodsData of patients with NSCLC were downloaded from the SEER (Surveillance, Epidemiology, and End Results) database classifications were converted from the 7th edition staging system to the 8th edition staging system, and older patients (aged ≥65 years at diagnosis) with stage IB NSCLC were included. The propensity score matching (PSM) method was used to balance the distribution proportions of clinical characteristics between the surgery and no surgery groups.ResultsAfter 1:1 propensity score matching, the distribution proportions of clinical characteristics were balanced between the surgery and no surgery groups (all P > 0.05). The overall and disease-specific survival rates of patients in the surgery group were significantly higher than those of patients in the no-surgery group (both P < 0.001). Furthermore, subgroup analysis showed that receiving surgery was a protective factor for overall survival and disease-specific survival of patients in all clinical character-related subgroups. Ultimately, univariate and multivariate Cox regression analyses showed that sex, tumor size, tumor grade, and tumor classification were independent prognostic factors for overall and disease-specific survival in patients undergoing surgery.ConclusionsOlder patients with Stage IB NSCLC can benefit significantly from surgical treatment after eliminating confounding factors, which is expected to provide strong medical evidence for surgical treatment.     

Complications and risk factors in vulvar cancer surgery – A population-based study

IntroductionPrimary surgery for vulvar cancer has become less radical in past decades. This study investigates risk factors and prevalence of short-and long-term complications after up-to-date vulvar cancer surgery.MethodsPopulation-based cohort study of surgically treated primary vulvar cancer at a national center of vulvar cancer, assessing surgical outcome. The Swedish Quality Registry for Gynecological Cancer was used for identification, journals reviewed and surgical outcome including complications within 30 days and one year registered. Multivariable logistic regression analysis comprising risk factors of short-term complications; age>80 years, BMI, smoking, diabetes, lichen sclerosus and FIGO stage was performed.Results182 patients were identified, whereas 55 had vulvar surgery only, 53 surgery including sentinel lymph node biopsy (SLNB) and 72 surgery including inguinofemoral lymphadenectomy (IFL), with short-term complication rates of 21.8%, 39.6% and 54.2% respectively. Vulvar wound dehiscence was reported in 6.0% and infection in 13.7%. Complication rates were lower after SLNB than IFL (wound dehiscence 0% vs 8.3%; p = 0.04, infection 15.1% vs 36.1%; p = 0.01 and lymphocele 5.7% vs 9.7%; p = 0.52). Severe complications were rare. Persisting lymphedema evolved in 3.8% after SLNB and in 38.6% after IFL (p = 0.001), ubiquitous after adjuvant radiotherapy. In multivariable regression analysis, no associations between included risk factors and complications were found.ConclusionSurgical complications are still common in vulvar cancer surgery and increase with the extent of groin surgery. To thrive for early diagnosis and to avoid IFL seem to be the most important factors in minimizing short-and long-term complications.     

Self-assessed preoperative level of habitual physical activity predicted postoperative complications after colorectal cancer surgery: A prospective observational cohort study

IntroductionThere is a growing interest in physical activity in relation to recovery after surgery. One important aspect of measuring recovery after surgical procedures is postoperative complications. The aim of this study was to determine if there is an association between the preoperative level of habitual physical activity and postoperative complications in patients undergoing elective surgery for colorectal cancer.Materials and methods115 patients scheduled for elective surgery due to colorectal cancer between February 2014 and September 2015 answered a questionnaire regarding physical activity and other baseline variables. Physical activity was assessed using the Saltin-Grimby physical activity level scale. Complications within 30 days after surgery were classified according to Clavien-Dindo, and the Comprehensive Complications Index (CCI) was calculated. Primary outcome was difference in CCI and key secondary outcome was risk for CCI ≥20.ResultsPhysically inactive individuals had a CCI that was 12 points higher than individuals with light activity (p = 0.002) and 17 points higher than regularly active individuals (p = 0.0004). Inactive individuals had a relative risk for a CCI ≥20 that was 65% higher than for individuals reporting light activity (95% confidence interval (CI) for relative risk (RR) = 1.1–2.5) and 338% higher than for regularly active individuals (95% CI for RR = 2.1–9.4).ConclusionSelf-assessed level of habitual physical activity before colorectal cancer surgery was associated with fewer postoperative complications measured with CCI, in a dose-response relationship.     

Predictors of lung recurrence and disease-specific mortality after pulmonary metastasectomy for soft tissue sarcoma

BackgroundWe identified prognostic factors in a 30-year series of STS treated at a single Institution, using an advanced statistical approach.MethodsFrom June 1988 to July 2019, 164 patients were referred to Rizzoli Orthopedic Hospital, Bologna, Italy) for STS lung metastasectomy (LMTS). The endpoints were lung metastasis recurrence (LMR) and lung metastasis-specific mortality (LMSM).The analysis included directed acyclic graphs, cubic splines, and a competing risk model in order to minimize bias.ResultsThe 10- and 15- year LMR cumulative incidence were 0.77 (0.76–0.78) whereas 10- and 15- year freedom from LMSM were 0.60 [0.51–0.70] and 0.56 [0.47–0.67], respectively. The malignant peripheral nerve sheath tumor (MPNST) histotype (SHR 4.12 [2.05–8.27]), a disease-free interval (DFI) up to 68 months (HR from 2 [1.7–2.2] to 1.5 [1.1–1.9]) and a LM size ≥4 mm (3.1 [2.1–4.4]) predicted LMR.Myxofibrosarcoma (HR 2.52[1.64–3.86]), synovial sarcoma (2.53[1.22–5.23]), adjuvant chemotherapy (2.01[1.11–3.61]), DFI between 2 months and 20 months (HR from 1.5 [1.1–2.3] to 1.3 [1.1–1.7] and primary tumor size a primary tumor size comprised between 3.6 cm and 10 cm predicted LMSM. A sharp increase in LMSM was observed with a tumor size from ≥20 cm.ConclusionsOur analysis corrected by potential confounders allowed us to identify specific histotypes and DFI intervals as predictors of both LMR and LMSM. Tumor size adjuvant chemotherapy adversely affected LM-related survival. Our findings need to be confirmed by larger randomized studies.     

Does laparoscopy increase the risk of peritoneal recurrence after resection for pT4 colon cancer? Results of a propensity score-matched analysis from an international cohort

BackgroundPeritoneal metastases (PM) occur in 15–20% of surgically resected pT4 colon cancer (CC) and strongly affect prognosis. Since no standard treatment has been established, efforts should be addressed toward its prevention. Some literature suggests a detrimental effect of laparoscopy in pT4 CC, hence we aimed to determine its impact on the development of PM after potentially curative resection.MethodsInternational multicenter retrospective cohort study including consecutive patients undergoing surgery for pT4a and pT4b CC (2014–2018) at 5 referral centers. The inclusion criteria were absence of distant metastasis, elective surgery, curative-intent resection (R0-1), and a minimum follow-up of 24 months (median, IQR: 35, 25.8–50.5 months).Results276 patients fulfilled the inclusion criteria and were selected for analysis. After 1:1 propensity score matching (PSM), 63 patients in the laparoscopic group (LapGroup) were compared with 63 patients in the open surgery group (OpenGroup). The two groups were comparable in terms of demographic and clinical parameters, operative data, and specimen characteristics. The OpenGroup presented a higher estimated intraoperative blood loss (P < .001) and postoperative length of stay (P < .001). Overall survival, cancer-specific survival, and disease-free survival resulted comparable. The 5-year probability of developing PM was 16.2% after laparoscopy and 19.5% after open surgery (P = .686). Multivariate analysis confirmed laparoscopy not to be an independent risk factor for PM.ConclusionsElective laparoscopic surgery for pT4 CC does not seem to increase the risk of metachronous PM after potentially curative surgery. Long-term outcomes after laparoscopy are not inferior to conventional open resections.     

Myosteatosis predicts higher complications and reduced overall survival following radical oesophageal and gastric cancer surgery

IntroductionLow muscle attenuation, as governed by increased intramuscular fat infiltration (myosteatosis), may associate with adverse surgical outcomes. We aimed to determine whether myosteatosis is associated with an increased risk of postoperative complications and reduced long-term survival after oesophago-gastric (OG) cancer surgery.MethodsPatients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Myosteatosis was evaluated using previously defined cut-points for low skeletal muscle attenuation measured by CT. Oncological, surgical, complications, and outcome data were obtained from a prospective database.ResultsOf 108 patients, 56% (n = 61) had myosteatosis. Patients with myosteatosis were older (69.1 ± 9.1 vs. 62.8 ± 9.8 years, p = 0.001) and had a similar body mass index (BMI) (23.4 ± 5.3 vs. 25.9 ± 6.7 kg/m², p = 0.766) compared to patients with normal muscle attenuation. Patients with myosteatosis had a higher rate of anastomotic leaks (15% vs. 2%, p = 0.041). On multivariate analysis, myosteatosis was an independent predictor of overall (OR 3.03, 95% CI 1.31–6.99, p = 0.009) and severe complications (OR 4.33, 95% CI 1.26–14.9, p = 0.020). Patients with myosteatosis had reduced 5 year overall (54.1% vs. 83%, p = 0.004) and disease-free (55.2% vs. 87.2%, p = 0.007) survival.ConclusionMyosteatosis is associated with a significantly increased risk of overall and severe complications as well as substantially reduced long-term survival. Assessment of muscle attenuation provides analysis beyond standard anthropometrics and may form part of preoperative physiological staging tools used to improve surgical outcomes.     

Laparoscopic approach for T4 colon cancer can be associated with poor prognosis in right-sided T4b tumours

IntroductionAlthough recent studies have demonstrated the safety of laparoscopic surgery in T4 colon cancer, some patients could have poor prognosis. In this study, we aimed to analyse the risk factors affecting oncologic outcome of laparoscopic surgery.Materials and methodsAmong the 1033 T4 colon cancer patients collected from a multicentre database (2004–2017), 584 patients (458 T4a and 126 T4b) underwent laparoscopic approach for radical surgery. Risk factors associated with 3-year disease-free survival (DFS) and overall survival (OS) were evaluated through multivariate analysis. In addition, subgroups were classified using a combination of risk factors, and the survival rate was evaluated.ResultsDuring this period, 188 (32.2%) had recurrence, and 151 (25.9%) died. In the multivariate analysis for oncologic outcome, elevated carcinoembryonic antigen level (hazard ratio [HR] 1.37) and absence of adjuvant chemotherapy (HR 1.60) were associated with poor DFS. T4b (HR 1.56, 1.46), right-sided location (HR 1.52, 1.42), and open conversion (HR 2.70, 2.12) were independently associated with both poor DFS and OS. When four subgroups were analysed through the combination of tumour location and T stage, the DFS and OS rates were significantly lower in patients with right-sided T4b cancer than in other groups (log-rank p < 0.001).ConclusionRight-sided T4b colon cancer for laparoscopic surgery may lead to poor oncologic outcome. This approach could be a caution in suspected cases preoperatively.     

Laparoscopic versus open transhiatal approach for adenocarcinoma of the esophagogastric junction: A systematic review and meta-analysis

BackgroundThe incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide. Laparoscopic transhiatal approach (LTH) has gained growing popularity in the treatment of AEG. However, its safety and efficacy need to be evaluated.MethodsOriginal studies comparing LTH with open transhiatal approach (OTH) were searched. Meta-analysis was performed using RevMan 5.3.ResultsNine studies involving 2149 patients were eligible. Compared with OTH, LTH was associated with longer operation time (mean difference [MD] = 31min, 95%CI [20,41], P < 0.001) while less blood loss (MD = −103ml [-135, −72], P < 0.001), and harvested similar number of lymph nodes (MD = 0.1 [-1.2, 1.4], P = 0.89). There were no differences in time to ambulation (MD = −0.79 days [-1.77, 0.20], P = 0.12) or time to first flatus (MD = −0.82 days [-1.76, 0.11], P = 0.08); however, LTH was associated with shorter postoperative hospital stay (MD = −1.70 days [-2.34, −1.05], P < 0.001). The mortality after surgery was comparable for LTH and OTH (risk difference [RD] = -0.00 [-0.01, 0.01], P = 0.55). The incidence of total major complications was similar in LTH (6.1%) and OTH (8.4%) (RD = −0.02 [-0.05, 0.01], P = 0.12); there were no significant differences in the incidence of each complication. Furthermore, LTH achieved similar 2-year overall survival (OS) rate (risk ratio [RR] = 1.17 [0.86, 1.60], P = 0.31) while higher 5-year OS rate (RR = 1.43 [1.18, 1.73], P = 0.0003) and significant improvement of OS (univariable hazard ratio = 0.65 [0.50, 0.84], P = 0.0009; multivariable hazard ratio = 0.59 [0.44, 0.80], P = 0.0006).ConclusionsLTH is feasible and safe for AEG, and may provide more favorable short-term outcomes and potential long-term survival benefit, which needs to be confirmed by randomized trials.