Preoperative lymphocyte count as a prognostic factor in resected pancreatic ductal adenocarcinoma

Background and aims. Recognized prognostic factors for resected pancreatic ductal adenocarcinoma (PDAC) include tumour size, differentiation, resection margin involvement and lymph node metastases. A further prognostic factor of less certain significance is lymphocyte count. The aim of this study was to investigate whether preoperative lymphocyte count is a prognostic indicator in patients with PDAC. Material and methods. Patients who had undergone a potentially curative pancreaticoduodenectomy (PD) for PDAC between 1998 and 2005 were analysed. Standard prognostic factors, preoperative lymphocyte count, preoperative neutrophil count and survival data were collected. Results. Of the 44 patients studied, univariate analysis identified predictors of a poor survival as lymph node status (node positive (+ve) 10.3 [5.4–20.9] months versus node negative (−ve) 14.2 [10.9–31.4] months; p=0.038), posterior resection margin invasion (margin +ve 7.0 [5.1–15.0] months versus margin −ve 13.1 [10.0–28.3] months; p=0.025) and lymphocyte count below the reference range (<1.5×10⁹/litre 8.8 [7.0–13.1] months versus ≥1.5×10⁹/litre 14.3 [7.0–28.3] months; p=0.029). Low preoperative lymphocyte count (p=0.027) and posterior margin invasion (p=0.023) retained significance on multivariate analysis. Preoperative neutrophil to lymphocyte ratio was not a significant prognostic factor. Conclusion. Preoperative lymphocyte count is a significant prognostic factor in patients with PDAC.     

Surgical outcome after pancreatoduodenectomy: effect of preoperative biliary drainage

BACKGROUND/AIMS: Depth of jaundice has been associated with increased risk of complications following operations. The value of preoperative biliary drainage has already been studied with contradictory results. In the present analysis we tried to determine the association between preoperative biliary drainage and postoperative complications in a nonselected series of patients. METHODOLOGY: Patients, who have undergone duodenopancreatectomy for periampullary adenocarcinoma, were included in the study. Patient data consisted of age, gender, diabetes mellitus, preoperative risk assessment according to ASA, preoperative biliary drainage, preoperative bilirubin level, operative time, type of duodenopancreatectomy, postoperative morbidity and mortality. Mann-Whitney exact test, Fisher's exact test and logistic-regression model were used for statistical analysis. RESULTS: Inclusion criteria for the study met 87 patients operated on from January 1996 till January 2000. Preoperative biliary drainage was not associated with mortality, rate of reoperation or length of hospital stay. Morbidity in these patients was slightly higher comparing to patients, who were not preoperatively drained, but this difference was not statistically important (p=0.3). In multivariate analysis, duration of operation was statistically the most significant predictor for postoperative complications (p=0.03). CONCLUSIONS: In patients with a resectable periampullary mass and obstructive jaundice, preoperative biliary drainage is not warranted. It may even be associated with increased risk of postoperative infectious complications. Biliary drainage should be done only in patients, who are not candidates for resection.     

Preoperative Serum CA125 Levels Predict the Prognosis in Hyperbilirubinemia Patients With Resectable Pancreatic Ductal Adenocarcinoma

Serum carbohydrate antigen 19-9 (CA19-9) is widely used to predict the prognosis for pancreatic ductal adenocarcinoma (PDAC). However, hyperbilirubinemia and the CA19-9 nonsecretor phenotype restrict the usage of serum CA19-9 alone. The goal of this study was to confirm the prognostic role of preoperative serum CA125 in PDAC, especially in patients with jaundice.A total of 211 patients with resected PDAC were eligible for this retrospective study, and were classified into 2 groups based on serum bilirubin levels. The prognostic significance of all clinicopathologic factors was evaluated by univariate and multivariate analyses, and the performance of each factor in predicting overall survival (OS) and recurrence-free survival (RFS) was compared.High preoperative CA125, high TNM stage, and lymph node metastasis were independent risk predictors for OS and RFS in all patients and the 2 subgroups, but high CA19-9 was only significant when considering all patients and those with nonelevated bilirubin. Using time-dependent receiver-operating characteristic analysis, better predictive performance for OS and RFS was observed for serum CA19-9 as compared to serum CA125 in these patients.High serum CA125 can independently predict poor prognosis. Importantly, in PDAC patients with hyperbilirubinemia, preoperative serum CA125 can predict the prognosis, whereas CA19-9 cannot. Preoperative CA19-9 had better predictive performance for survival than CA125, and the performance of CA19-9 did not decline between all patients and those with nonelevated bilirubin, but was significantly affected by hyperbilirubinemia.     

Histologic grade of metastatic lymph node and prognosis of rectal cancer

PURPOSE: It is important to identify cases with a high risk of recurrence to improve the prognosis of colorectal cancer. In this study the difference between the histology of the primary lesion and that of the metastatic lymph node was investigated in an attempt to identify the cases with a high risk of recurrence. METHODS: One-hundred eighty-five patients with Dukes C rectal cancer who had undergone curative resection were investigated. The histologic grade of the metastatic lymph node was determined and compared with other clinicopathologic factors to determine its significance as a prognostic factor. RESULTS: The histologic grade was the same between the primary lesion and the metastatic lymph node in 46.2 percent of all cases, although in the group with well-differentiated adenocarcinoma at the primary lesion the concordance was only 29.5 percent. In the group with well-differentiated adenocarcinoma at the primary lesion, the five-year survival rate was 75.3, 64, and 25 percent in the groups with well-differentiated, moderately differentiated, and poorly differentiated adenocarcinoma at the metastatic lymph node, respectively. The differences between the survival rates of well-differentiated and poorly differentiated adenocarcinoma at the metastatic lymph node were statistically significant (P<0.05). According to multivariate analysis the histologic grade of primary lesion was the most significant prognostic factor (hazard ratio: 2.2801,P=0.0008). However, in well-differentiated adenocarcinoma of patients with Dukes C rectal cancer at the primary lesion, the histology of metastatic lymph node was also an important prognostic factor. CONCLUSIONS: It is clear that the histologic grade between the primary lesion and metastatic lymph node was frequently different, especially in the group with well-differentiated adenocarcinoma at the primary lesion. The analysis of the metastatic lymph node was considered to have additional importance for the prediction of prognosis.     

Predictive factors of recurrence for patients with intrahepatic cholangiocarcinoma after hepatectomy

Background/Aims: To identify risk factors related to postoperative recurrence for intrahepatic cholangiocarcinoma (ICC) patients with negative resection margin. Methodology: A total of 64 ICC patients who underwent resection with negative margin at our center from 2002 to 2010 were recruited in the present study. All clinicopathological characteristics were assessed using univariate analyses. Independent risk factors were identified by Cox regression. Factors significant at a p<0.10 in the univariate analyses were involved in the multivariate analyses. The diagnostic accuracy of the identified risk factors was evaluated using receiver operating curve (ROC). Results: The overall 1-, 3- and 5-year recurrence-free survival rates for patients with ICC were 63%, 32% and 27%, respectively. The most common site of postoperative recurrence was the liver. Lymph node metastasis, perineural invasion and total tumor size greater than 5cm showed prognostic power in multivariate analysis. The recurrence-free survival rates reduced with the increasing of the number of risk factor for patients with ICC. Conclusions: This study suggested liver was the most common recurrence site and confirmed lymph node metastasis, perineural invasion and total tumor size greater than 5cm may be associated with poor outcome for ICC patients with negative resection margin.     

Impact of staging transesophageal EUS on treatment and survival in patients with non-small-cell lung cancer

BACKGROUND: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. OBJECTIVE: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary university-based referral center. PATIENTS: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. MAIN OUTCOMES MEASUREMENTS: Impact of EUS-FNA on therapy and survival in patients with NSCLC. RESULTS: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). LIMITATIONS: Lack of surgical reference standard in all patients and referral to a tertiary center. CONCLUSIONS: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.     

Prognostic value of the preoperative fibrinogen-to-albumin ratio in pancreatic ductal adenocarcinoma patients undergoing R0 resection

BACKGROUNDInflammation plays an important role in tumor progression, and growing evidence has confirmed that the fibrinogen-to-albumin ratio (FAR) is an important prognostic factor for overall survival in malignant tumors.AIMTo investigate the prognostic significance of FAR in patients undergoing radical R0 resection of pancreatic ductal adenocarcinoma (PDAC).METHODSWe retrospectively analyzed the data of 282 patients with PDAC who underwent radical R0 resection at The Cancer Hospital of the Chinese Academy of Medical Sciences from January 2010 to December 2019. The surv_cutpoint function of the R package survminer via RStudio software (version 1.3.1073, http://www.rstudio.org) was used to determine the optimal cut-off values of biological markers, such as preoperative FAR. The Kaplan-Meier method and log-rank tests were used for univariate survival analysis, and a Cox regression model was used for multivariate survival analysis for PDAC patients who underwent radical R0 resection.RESULTSThe optimal cut-off value of FAR was 0.08 by the surv_cutpoint function. Higher preoperative FAR was significantly correlated with clinical symptoms (P = 0.001), tumor location (P < 0.001), surgical approaches (P < 0.001), preoperative plasma fibrinogen concentration (P < 0.001), and preoperative plasma albumin level (P < 0.001). Multivariate analysis showed that degree of tumor differentiation (P < 0.001), number of metastatic lymph nodes [hazard ratio (HR): 0.678, 95% confidence interval (CI): 0.509-0.904, P = 0.008], adjuvant therapy (HR: 1.604, 95%CI: 1.214-2.118, P = 0.001), preoperative cancer antigen 19-9 level (HR: 1.740, 95%CI: 1.288-2.352, P < 0.001), and preoperative FAR (HR: 2.258, 95%CI: 1.720-2.963, P < 0.001) were independent risk factors for poor prognosis in patients with PDAC who underwent radical R0 resection.CONCLUSIONThe increase in preoperative FAR was significantly related to poor prognosis in patients undergoing radical R0 resection for PDAC. Preoperative FAR can be used clinically to predict the prognosis of PDAC patients undergoing radical R0 resection.     

Risk factors for in-hospital mortality of patients with high model for end-stage liver disease scores following living donor liver transplantation

Background. Living donor liver transplantation (LDLT) for patients with high model for end-stage liver disease (MELD) scores is controversial due to its poor outcome. However, there is little information regarding which factor would negatively impact the outcome of patients with high MELD scores. The aim of this study was to identify factors associated with the in-hospital mortality of patients with high MELD scores after LDLT.Material and methods. All patients with an MELD scores ≥ 20 who received LDLT from 2005 to 2011 were recruited for the present study. Pre-and intra-operative variables were retrospectively and statistically analyzed. Results. A total of 61 patients were included in the current study. The overall 3-month survival rate was 82% for patients with high MELD scores. Preoperative renal dysfunction, hyponatremia, starting albumin level < 2.8 g/dL, preoperative renal replacement for severe renal failure, anhepatic period > 100 minutes and intraoperative red blood cell (RBC) transfusion ≥ 10 units were identified as potential risk factors by univariate analysis. However, only hyponatremia, preoperative dialysis and massive RBC transfusion were independent risk factors in a multivariate analysis. The 3-month survival rates of patients with two or more independent risk factors and patients with none or one risk factor were 91 and 25%, respectively. A significant difference was observed (P < 0.001).Conclusion. Hyponatremia, preoperative dialysis and massive RBC transfusion were related to poor outcome for sicker patients. Patients with two or more of the above-mentioned risk factors and high MELD scores may exhibit extremely poor short-term survival.     

Prognosis of malignant intraductal papillary mucinous tumours of the pancreas after surgical resection. Comparison with pancreatic ductal adenocarcinoma

BACKGROUND: Although the prognosis in malignant resectable intraductal papillary mucinous tumours of the pancreas (IPMT) is often considered more favourable than for ordinary pancreatic ductal adenocarcinoma, the long term outcome remains ill defined. AIMS: To assess prognostic factors in patients with malignant IPMT after surgical resection, and to compare long term survival rates with those of patients surgically treated for ductal adenocarcinoma. METHODS: Seventy three patients underwent surgery for malignant IPMT in four French centres. Clinical, biochemical, and pathological features and follow up after resection were recorded. Patients with invasive malignant IPMT were matched with patients with pancreatic ductal adenocarcinoma, according to age and TNM stages; survival rates after resection were compared. RESULTS: Surgical treatment for IPMT were pancreaticoduodenectomy (n=46), distal (n=14), total (n=11), or segmentary (n=2) pancreatectomy. The operative mortality rate was 4%. IPMT corresponded to in situ (n=22) or invasive carcinoma (n=51). In the latter group, 17 had lymph node metastases. Overall median survival was 47 months. Five year survival rates in patients with in situ and invasive carcinoma were 88% and 36%, respectively. On univariate analysis, abdominal pain, preoperative high serum carbohydrate antigen 19.9 concentrations, caudal localisation, invasive carcinoma, lymph node metastases, peripancreatic extension, and malignant relapse were associated with a fatal outcome. Using multivariate analysis, lymph node metastases were the only prognostic factor (OR 7.5; 95% CI: 3.4 to 16.4). Overall five year survival rate was higher in patients with malignant invasive IPMT compared with those with pancreatic ductal carcinoma (36 v 21%, p=0.03), but was similar in the subset of stage II/III tumours. CONCLUSIONS: The prognosis of patients with resected in situ/invasive stage I malignant IPMT is excellent. In contrast, prognosis of locally advanced forms is as poor as in patients with pancreatic ductal adenocarcinoma.     

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.     

Inducible nitric oxide synthase, nitrotyrosine and apoptosis in gastric adenocarcinomas and their correlation with a poor survival

AIM: To detect the presence of inducible nitric oxide synthase (iNOS), nitrotyrosine (NT) and apoptosis in gastric adenocarcinomas and their possible correlations with the clinicopathological characteristics and prognosis of gastric adenocarcinoma. METHODS: Sixty-six specimens of gastric adenocarcinoma and corresponding adjacent normal gastric tissues were studied. Immunohistochemistry was employed to localize iNOS and NT protein and an immunohistochemical scoring system was used. The occurrence of apoptotic cell death (apoptotic index [AI]) was analyzed by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick-end labeling (TUNEL) method. RESULTS: Results showed that iNOS expression was detected at an intermediate or high level in 41 of 66 (62%) specimens of gastric adenocarcinoma. NT expression was 58%. Neither of them was found in the normal gastric tissues; there were significant positive correlations among iNOS expression, NT expression and AI. Many clinicopathologic characteristics of gastric adenocarcinoma, such as tumor size, depth of invasion, lymph node metastasis and TNM staging, were related to iNOS and NT expressions (P<0.05). In 66 surviving patients, the 5-year survival rate of 41 patients who had tumors with intermediate or high iNOS expressions and high AIs (4.09%; 19.96%) was significantly lower than that of 25 patients who had tumors with negative or low iNOS expressions and low AIs (0.79%; 47.14%) (P= 0.001). COX's multivariate analysis revealed that the iNOS expression was identified as one of the significant independent prognostic factors predictive of a poor survival (relative risk [RR] = 2.69). CONCLUSION: NO produced by iNOS may play a stronger role in promoting gastric adenocarcinoma growth than in suppressing its growth. iNOS and NT expressions by gastric adenocarcinoma may correlate with a poor survival.     

Prognostic significance of the fibrinogen-to-albumin ratio in gallbladder cancer patients

AIM To investigate the prognostic role of fibrinogen-toalbumin ratio(FAR) on patients with gallbladder cancer(Gbc) in this study.METHODS One hundred and fifty-four Gbc patients were retro-spectively analyzed, who received potentially curative cholecystectomy in our institute from March 2005 to December 2017. Receiver operating characteristic curve(ROc curve) was used to determine the optimal cut-offs for these biomarkers. In addition, Kaplan-Meier survival analysis as well as multivariate analysis were applied for prognostic analyses.RESULTS ROc curve revealed that the optimal cut-off value for FAR was 0.08. FAR was significantly correlated with age(P = 0.045), jaundice(P 0.001), differentiation(P = 0.002), resection margin status(P 0.001), T stage(P 0.001), TNM stage(P 0.001), and c A199(P 0.001) as well as albumin levels(P 0.001). Multivariate analysis indicated that the resection margin status [hazard ratio(HR): 2.343, 95% confidence interval(c I): 1.532-3.581, P 0.001], TNM stage(P = 0.035), albumin level(HR = 0.595, 95%c I: 0.385-0.921, P = 0.020) and FAR(HR: 2.813, 95%c I: 1.765-4.484, P 0.001) were independent prognostic factors in Gbc patients.CONCLUSION An elevated preoperative FAR was significantly correlated with unfavorable overall survival in Gbc patients, while an elevated preoperative albumin level was a protective prognostic factor for patients with Gbc. The preoperative FAR could be used to predict the prognosis of Gbc patients, which was easily accessible, costeffective and noninvasive.     

Haemoglobin,albumin,lymphocyte and platelet predicts postoperative survival in pancreatic cancer

BACKGROUND Systemic inflammation and nutrition status play an important role in cancer metastasis.The combined index of hemoglobin,albumin,lymphocyte,and platelet(HALP),consisting of haemoglobin,albumin,lymphocytes,and platelets,is considered as a novel marker to reflect both systemic inflammation and nutrition status.However,no studies have investigated the relationship between HALP and survival of patients with pancreatic cancer following radical resection.AIM To evaluate the prognostic value of preoperative HALP in pancreatic cancer patients.METHODS The preoperative serum levels of hemoglobin,albumin,lymphocyte counts,and platelet counts were routinely detected in 582 pancreatic adenocarcinoma patients who underwent radical resection.The relationship between postoperative survival and the preoperative level of HALP was investigated.RESULTS Low levels of HALP were significantly associated with lymph node metastasis(P=0.002),poor tumor differentiation(P=0.032),high TNM stage(P=0.008),female patients(P=0.005)and tumor location in the head of the pancreas(P<0.001).Low levels of HALP were associated with early recurrence[7.3 mo vs 16.3 mo,P<0.001 for recurrence-free survival(RFS)]and short survival[11.5 mo vs 23.6 mo,P<0.001 for overall survival(OS)]in patients with resected pancreatic adenocarcinoma.A low level of HALP was an independent risk factor for early recurrence and short survival irrespective of sex and tumor location.CONCLUSION Low levels of HALP may be a significant risk factor for RFS and OS in patients with resected pancreatic cancer.     

Adenocarcinoma of the esophagogastric junction in Japan

BACKGROUND/AIMS: The prognosis of adenocarcinoma of the esophagogastric junction is worse than that in adenocarcinoma of other parts of the stomach. In particular, the clinical features and prognosis of adenocarcinoma of the esophagogastric junction and the differences between Siewert's type II and III tumors in Japan were evaluated. METHODOLOGY: We analyzed one hundred and forty patients with adenocarcinoma of the esophagogastric junction including one patient with a type I tumor, sixty-seven patients with type II tumors, and seventy-two patients with type III tumors. RESULTS: The prognosis of patients with type III tumors was poorer in comparison to that of type II tumors in adenocarcinoma of the esophagogastric junction (p<0.05). A significant difference was observed in the survival of patients with type III tumors between those with positive and negative lymph nodes (p<0.001). However, there was no such difference in patients with type II tumors. In a multivariate analysis, lymph node metastasis, age and the depth of tumor invasion were all found to be independent prognostic factors. CONCLUSIONS: The prognosis of patients with lymph node metastasis of type III adenocarcinoma of the esophagogastric junction was found to be extremely poor. An aggressive treatment after surgery may therefore be necessary to improve the survival of this population.     

Survival After Curative Resection for Mucinous Adenocarcinoma of the Colorectum

PURPOSE: Previous reports have suggested that mucinous colorectal adenocarcinomas are more advanced at diagnosis and have a poorer prognosis than nonmucinous colorectal adenocarcinomas. The purpose of this study was to clarify whether the mucin-producing histologic type of carcinoma is associated with a worse prognosis than nonmucinous, differentiated colorectal adenocarcinoma for patients who undergo curative surgery. METHODS: Using a database of 2,678 surgical patients with colorectal cancers operated on at Aichi Cancer Center between 1965 and 1994, we investigated 97 cases of mucinous adenocarcinoma and 2,197 cases of nonmucinous adenocarcinoma. We also evaluated the outcomes of patients who underwent surgery with curative intent. To determine whether the mucinous adenocarcinoma itself was an independent prognostic factor in the curative resected patients, a multivariate analysis was performed. RESULTS: The mucinous adenocarcinoma patients were found to be younger (P = 0.0003), have more lymph node involvement (48.5 vs. 40.3 percent; P = 0.0564), more peritoneal dissemination (19.6 vs. 5.6 percent; P < 0.0001), greater frequency of advanced stage disease (P = 0.0006), a lower rate of curative resection (76.3 vs. 84.4 percent; P = 0.0450), and lower overall 5-year survival rates (41 vs. 62.4 percent; P = 0.0002) than nonmucinous adenocarcinoma patients. In the subjects who underwent curative resection, the 5-year survival rate for those with mucinous adenocarcinoma was significantly worse than for those with nonmucinous adenocarcinoma (54 vs. 73.3 percent; P = 0.0020). Multivariate analysis using the Cox proportional hazards model showed that the clinically significant predictive factors were stage at diagnosis, mucinous histology, tumor location, gender and age. The mucinous histologic type itself was an independent factor for poor prognosis for patients who underwent curative surgery. CONCLUSIONS: In patients with colorectal carcinomas who underwent surgery with curative intent and who had colorectal carcinomas of the mucinous histologic type, there was significant correlation with prognosis as measured by overall survival rate after adjustment had been made for major confounders.     

Should jaundice preclude resection in patients with gallbladder cancer? Results from a nation-wide cohort study

BackgroundIt is controversial whether patients with gallbladder cancer (GBC) presenting with jaundice benefit from resection. This study re-evaluates the impact of jaundice on resectability and survival.MethodsData was collected on surgically explored GBC patients in all Dutch academic hospitals from 2000 to 2018. Survival and prognostic factors were assessed.ResultsIn total 202 patients underwent exploration and 148 were resected; 124 non-jaundiced patients (104 resected) and 75 jaundiced patients (44 resected). Jaundiced patients had significantly (P < 0.05) more pT3/T4 tumors, extended (≥3 segments) liver- and organ resections, major post-operative complications and margin-positive resection. 90-day mortality was higher in jaundiced patients (14% vs. 0%, P < 0.001). Median overall survival (OS) was 7.7 months in jaundiced patients (2-year survival 17%) vs. 26.1 months in non-jaundiced patients (2-year survival 39%, P < 0.001). In multivariate analysis, jaundice (HR1.89) was a poor prognostic factor for OS in surgically explored but not in resected patients. Six jaundiced patients did not develop a recurrence; none had liver- or common bile duct (CBD) invasion on imaging.ConclusionJaundice is associated with poor survival. However, jaundice is not an independent adverse prognostic factor in resected patients. Surgery should be considered in patients with limited disease and no CBD invasion on imaging.     

The impact of tumor extent (T stage) and lymph node involvement (N stage) on survival after surgical resection for gallbladder adenocarcinoma

Introduction. Tumor extent (T stage) and lymph node involvement (N stage) have a known combined negative effect on survival in patients with gallbladder adenocarcinoma, but the independent effects of these factors have been less well described. We investigated whether T stage and N stage independently predict survival after surgery for gallbladder adenocarcinoma. Methods. We queried the Surveillance, Epidemiology and End Results database for patients treated with surgical resection for gallbladder adenocarcinoma between 1988 and 2004. Cases were stratified by disease severity based on tumor extent and nodal involvement. Kaplan–Meier and Cox regression methods were used to test the effect of disease severity and to develop multivariate models of the effects of demographic and clinical covariates on survival. Univariate and multivariate models were tested in the entire cohort and in a subsample with pathologically confirmed lymph node status. Results. Four thousand and forty-eight patients who survived the immediate perioperative period comprised the full cohort. The subsample with pathologically confirmed lymph node status included 1298 patients. Age, gender, radiation treatment, tumor grade, tumor extent and lymph node status had statistically significant independent effects on survival in both models (all p<0.03). After accounting for T by N stage interactions, both tumor extent (1.21≤HR≤3.81, all p≤0.005) and lymph node involvement (1.80≤HR≤2.84, p<0.001) had independent effects on survival. Conclusions. Tumor extent and lymph node metastases are independent predictors of survival after surgical resection for gallbladder adenocarcinoma. Tumor penetration of the gallbladder wall and pathologically confirmed lymph node involvement each carry poor prognosis.     

Blood neutrophil-lymphocyte ratio predicts survival after hepatectomy for hepatocellular carcinoma: A propensity score-based analysis

AIM: To investigate whether an elevated preoperative neutrophil-to-lymphocyte ratio(NLR) can predict poor survival in patients with hepatocellular carcinoma(HCC).METHODS: We retrospectively reviewed 526 patients with HCC who underwent surgery between 2004 and 2011.RESULTS: Preoperative NLR ≥ 2.81 was an independent predictor of poor disease-free survival(DFS, P 0.001) and overall survival(OS, P = 0.044). Compared with patients who showed a preoperative NLR 2.81 and postoperative increase, patients who showed preoperative NLR ≥ 2.81 and postoperative decrease had worse survival(DFS, P 0.001; OS, P 0.001). Among patients with preoperative NLR ≥ 2.81, survival was significantly higher among those showing a postoperative decrease in NLR than among those showing an increase(DFS, P 0.001; OS, P 0.001). When elevated, alpha-fetoprotein(AFP) provided no prognostic information, and so preoperative NLR ≥ 2.81 may be a good complementary indicator of poor OS whenever AFP levels are low or high.CONCLUSION: Preoperative NLR ≥ 2.81 may be an indicator of poor DFS and OS in patients with HCC undergoing surgery. Preoperative NLR ≥ 2.81 may be a good complementary indicator of poor OS when elevated AFP levels provide no prognostic information.     

Value of rectal ultrasound in predicting staging and outcome in patients with rectal adenocarcinoma

PURPOSE: Transrectal ultrasonography is considered the best method to stage rectal cancer, and thus the need for preoperative radiotherapy. This retrospective study was designed to determine the prognostic value of uTN classification on survival of patients treated by preoperative radiotherapy and surgery.METHODS: A total of 218 patients with proven rectal adenocarcinoma were staged by transrectal ultrasonography before treatment. Transrectal ultrasonography reports were reviewed for TN classification, quality of examinations, and downstaging (pT < uT).RESULTS: Transrectal ultrasonography stages were as follows: uT1, n = 2; uT2, n = 61; uT3, n = 145; uT4, n = 10; uN0, n = 94; uN+, n = 124. After radiotherapy, based on operative specimen, lesions were staged as pT0, n = 27; pT1, n = 20; pT2, n = 60; pT3/4, n = 111; pN0, n = 160; pN+, n = 58; pM+, n = 10. Downstaging (measured as a reduction in TN level determined by transrectal ultrasonography and pathology of resected specimen) occurred in 42.6 percent for T and 38.1 percent for N. Five-year overall and disease-free survivals were 71.3 and 62.7 percent, respectively (median follow-up, 62 months). In univariate or multivariate analysis including parameters available before treatment, uT and age but not uN were statistically significant prognosis factor for overall survival. Patients with TN downstaging had significantly better overall survival. In multivariate analysis, including all parameters, only age, gender, pT, and pN+ status predicted poor outcome.CONCLUSIONS: In patients with rectal adenocarcinoma treated by preoperative radiotherapy, uT classification determined by transrectal ultrasonography before radiotherapy, pT and pN classification determined after radiotherapy, and tumor downstaging were predictors of survival contrary to uN. Only pTN classification, age, and gender were independent predictors in multivariate analysis.Presented at the meeting of the American Society for Gastrointestinal Endoscopy, Atlanta, Georgia, May 20 to 23, 2001.     

Long term survival after pancreatic resection for pancreatic adenocarcinoma

OBJECTIVE: The aim of this study was to determine the long term survival of patients with pancreatic adenocarcinoma who underwent surgical resection and to assess the association of clinical, pathological, and treatment features with survival. METHODS: Between January, 1990, and December, 1998, 125 patients underwent a pancreaticoduodenal or partial pancreatic resection for pancreatic ductal adenocarcinoma at our institution. The records of these patients were reviewed for demographics, tumor characteristics including size, histological grade, margin status, lymph node status, surgical TNM staging, and postoperative adjuvant therapy. The primary outcome variable analyzed was survival. RESULTS: A total of 116 patients had complete follow-up and were included in the final analysis. The median survival after surgery was 16 months. The 1-, 3-, 5-, and 7-yr survival rates for all 116 patients were 60%, 23%, 19%, and 11%, respectively. The 1-, 3-, 5-, and 7-yr survival rates for patients who received adjuvant therapy were 69%, 28%, 23%, and 18% compared with 20% and 0% in patients who did not receive adjuvant therapy (p < 0.0001). The 1-, 3-, 5-, and 7-yr survival rates for patients with negative lymph nodes were 73%, 38%, 26%, and 22% compared with survival rates of 52%, 14%, 14%, and 9% in patients with positive lymph nodes (p = 0.01). In multivariate analyses, adjuvant therapy was the only feature found to be strongly associated with survival (hazards ratio = 0.26, 95% CI = 0.15-0.44). CONCLUSIONS: The overall 5- and 7-yr survival rates of 19% and 11% in our study further validate that surgical resection in patients with pancreatic adenocarcinoma can result in long term survival, particularly when performed in association with adjuvant chemoradiation.