Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

Background and aimsThe role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.MethodsMedline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.ResultsSeven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78–1.06, p = 0.241) and 0.86 (95% CI:0.73–1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54–0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55–0.99, p = 0.041).ConclusionsThis meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.     

Clinical utility of lymphocyte to C-reactive protein ratio in predicting survival and postoperative complication for esophago-gastric junction cancer

BackgroundThere are still no useful predictive biomarkers for esophago-gastric junction (EGJ) cancer. We compared 15 candidate inflammation-based markers and investigated the clinical impact of the selected biomarker.MethodsOne hundred three patients with EGJ cancer between 2002 and 2020 were enrolled, and associations between clinicopathological data and inflammatory biomarkers were retrospectively analyzed. Area under the curve (AUC) values of 15 candidate biomarkers were compared in receiver operating characteristic (ROC) curves regarding overall survival (OS). Clinical impacts of the selected marker were further investigated regarding long-term prognosis, postoperative complications, and preoperative chemotherapy effects.ResultsLymphocyte/CRP ratio (LCR) demonstrated the highest AUC (0.68552) and was chosen as a candidate biomarker. The high LCR group (LCR >4610) demonstrated significantly better OS (p < 0.0001) and relapse-free survival (RFS) (p < 0.0001) compared with the low LCR group (LCR ≤4610), and preoperative LCR was an independent prognostic factor for both OS (HR 4.97, 95% CI:2.24–11.58; p < 0.0001) and RFS (HR 2.84, 95% CI:1.33–6.14, p = 0.007) in EGJ cancer patients. Another cut-off value was established for postoperative complications, and the incidence rates were significantly higher in the low LCR group (LCR ≤12000) than in the high LCR group (LCR >12000) for all postoperative complications, infectious complications, and surgical site infection (p = 0.013, p = 0.016, and p = 0.030, respectively). Furthermore, patients with decreased LCR after preoperative chemotherapy demonstrated significantly worse RFS compared with patients with increased LCR (p = 0.043).ConclusionsLCR is a potential biomarker to predict long-term prognosis as well as occurrence of postoperative complications in patients with EGJ cancer.     

Long-term oncological safety of minimally invasive surgery in high-risk endometrial cancer

BackgroundSeveral studies showed that women with low-risk endometrial cancers staged by minimally invasive surgery (MIS) experience fewer postoperative complications compared to those staged by laparotomy with similar disease-free survival (DFS) and overall survival (OS). However, high-risk patients were poorly represented. In this study, we compared DFS and OS in high-risk endometrial cancer patients who underwent surgical staging via MIS versus laparotomy.MethodsUsing a multicentric database, we compared DFS and OS between 114 patients with high-risk histology who underwent surgical staging via MIS and 114 patients who underwent laparotomy. Patients were matched for age, tumour type, FIGO stage and management criteria.ResultsAmong the 114 patients who underwent MIS, 93 underwent laparoscopy and 21 robotic surgery. Groups were comparable for stage, body mass index, histology and adjuvant therapies. However, patients in the MIS group underwent paraaortic lymphadenectomy less frequently (13% versus 29%; p = 0.01), had less lymph nodes removed (19.0 versus 28.6; p < 0.01) and had lower mean tumour size (30 versus 40 mm; p < 0.01). With a median follow-up time of 49 months, DFS and OS were not significantly different between the surgical cohorts. In multivariable analysis, both higher stage (hazard ratio [HR] = 2.2) and histology (HR = 4.9) were associated with DFS in contrast to surgical procedure (HR = 0.9).ConclusionsBeyond the benefit of MIS on immediate surgical outcome, our results show that fear for a poor long-term outcome should not be the reason to refrain from MIS in patients with high-risk endometrial cancer.     

Comparative study on the oncological prognosis of laparoscopy and laparotomy for stage IIA1 cervical squamous cell carcinoma

ObjectiveTo compare the 5-year overall survival (OS) and disease-free survival (DFS) rate of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IIA1 cervical squamous cell carcinoma.MethodsBased on a large database containing information on the clinical diagnosis and treatment of cervical cancer in China, the oncological outcomes of the two surgical approaches for stage IIA1 cervical squamous cell carcinoma were compared after 1:2 propensity score matching (PSM).ResultsAfter 1:2 propensity score matching (PSM), 510 patients were included in the LRH group, and 999 patients were included in the ARH group. LRH showed a similar 5-year OS but a lower DFS rate (81.3% vs. 87.4%, P = 0.018) than ARH. In the multivariate analysis, LRH was identified as an independent risk factor for worse 5-year DFS (HR = 1.569, 95% CI: 1.131–2.176, P = 0.007). Among patients with a tumour size <2 cm, the LRH and ARH groups showed similar OS and DFS rates after 1:2 PSM, and multivariate analysis showed that the surgical approach was not an independent risk factor affecting the OS or DFS rate. Among patients with a tumour size ≥2 cm and <4 cm, there was no difference in OS between the LRH and ARH groups after matching, but the DFS in the LRH group was significantly lower than that in the ARH group (81.1% vs 86.2%, P = 0.034). In the multivariate analysis, the laparoscopic approach was not associated with OS but was independently associated with worse DFS (HR = 1.546, 95% CI: 1.094–2.185, P = 0.014).ConclusionsLRH was associated with poorer 5-year DFS than ARH in patients with stage IIA1 cervical squamous cell carcinoma. However, LRH showed 5-year OS and DFS rates similar to those of ARH among patients with a tumour size <2 cm. For patients with a tumour size ≥2 cm and <4 cm, LRH showed a lower DFS rate than ARH.     

Capecitabine in early breast cancer: A meta-analysis of randomised controlled trials

PurposeCapecitabine is an effective therapy for metastatic breast cancer. Its role in early breast cancer is uncertain due to conflicting data from randomised controlled trials (RCTs).MethodsPubMed and major conference proceedings were searched to identify RCTs comparing standard chemotherapy with or without capecitabine in the neoadjuvant or adjuvant setting. Hazard ratios (HRs) for disease-free survival (DFS) and overall survival (OS), as well as odds ratios (ORs) for toxicities were extracted or calculated and pooled in a meta-analysis. Subgroup analysis compared triple-negative breast cancer (TNBC) to non-TNBC and whether capecitabine was given in addition to or in place of standard chemotherapy. Meta-regression was used to explore the influence of TNBC on OS.ResultsEight studies comprising 9302 patients were included. In unselected patients, capecitabine did not influence DFS (hazard ratio [HR] 0.99, p = 0.93) or OS (HR 0.90, p = 0.36). There was a significant difference in DFS when capecitabine was given in addition to standard treatment compared with in place of standard treatment (HR 0.92 versus 1.62, interaction p = 0.002). Addition of capecitabine to standard chemotherapy was associated with significantly improved DFS in TNBC versus non-TNBC (HR 0.72 versus 1.01, interaction p = 0.02). Meta-regression showed that adding capecitabine to standard chemotherapy was associated with improved OS in studies with higher proportions of patients with TNBC (R = −0.967, p = 0.007). Capecitabine increased grade 3/4 diarrhoea (odds ratio [OR] 2.33, p < 0.001) and hand-foot syndrome (OR 8.08, p < 0.001), and resulted in more frequent treatment discontinuation (OR 3.80, p < 0.001).ConclusionAdding capecitabine to standard chemotherapy appears to improve DFS and OS in TNBC, but increases adverse events in keeping with its known toxicity profile.     

Laparoscopic liver resection versus open liver resection for intrahepatic cholangiocarcinoma: 3-year outcomes of a cohort study with propensity score matching

IntroductionLaparoscopic liver resection(LLR) for intrahepatic cholangiocarcinoma is debatable due to technical challenges associated with major hepatectomy and lymph node dissection. This study aims to analyze the long-term outcomes with propensity score matching.MethodsPatients who underwent liver resection for intrahepatic cholangiocarcinoma from August 2004 to October 2015 were enrolled. Those who had combined hepatocellular-cholangiocarcinoma and palliative surgery were excluded. Medical records were reviewed for postoperative outcome, recurrence, and survival. The 3-year disease-free survival(DFS) and 3-year overall survival(OS) were set as the primary endpoint, and 3-year disease-specific survival, 1-year OS, 1-year DFS, operative outcome, and postoperative complications were secondary endpoints.ResultsA total of 91 patients were enrolled with 61 in the open group and 30 in the laparoscopic group. Propensity score matching included 24 patients in both groups. In total, the 3-year OS was 81.2% in the open group and 76.7% in the laparoscopic group(p = 0.621). For 3-year DFS, open was 42.5% and laparoscopic was 65.6%(p = 0.122). Mean operation time for the open group was 343.2 ± 106.0 min and laparoscopic group was 375.2 ± 204.0 min(p = 0.426). Hospital stay was significantly shorter in the laparoscopic group(9.8 ± 5.1 days) than the open group(18.3 ± 14.7, p=<0.001). There was no difference in complication rate and 30-day readmission rate. Tumor size, nodularity, and presence of perineural invasion showed an independent association with the 3-year DFS in multivariate analysis.ConclusionLaparoscopic liver resection for intrahepatic cholangiocarcinoma is technically feasible and safe, providing short-term benefits without increasing complications or affecting long-term survival.     

Multicenter study of surgical and oncologic outcomes of extra-levator versus conventional abdominoperineal excision for lower rectal cancer

BackgroundThe surgical and oncological outcome of extra-levator abdominoperineal excision (ELAPE) procedure remains unclear in low rectal cancer.MethodsA total of 194 cases of rectal cancer patients underwent ELAPE or conventional abdominoperineal excision (APE) procedure were analyzed in four hospitals’ databases from January 2010 to December 2015. Clinicopathological data, overall survival (OS), disease free survival (DFS) and local recurrence free survival (LRFS) of patients were compared between two groups.ResultsThe operation time spent in perineal phase was significantly shorter in the ELAPE group than that in conventional APE procedure (P < 0.001). There were more specimens with excellent or good quality in ELAPE group compared to conventional APE group (P = 0.033). Patients whom underwent ELAPE procedures showed significantly better OS, DFS and LRFS than those underwent conventional APE procedures. Patients with preoperative stage cT3∼T4 (P = 0.033, P = 0.008, P = 0,033), cN+ (P = 0.002, P < 0.001, P = 0.006) and pathological stage III-IV (P = 0.023, P = 0.008, P = 0.016) were associated with significant benefits from ELAPE procedure in terms of OS, DFS and LRFS. DFS differed significantly between two groups of patients whom got preoperative chemoradiation therapy (P = 0.009) or postoperative chemotherapy (P = 0.029). For patients of pathological stage IIII-IV without preoperative chemoradiation, ELAPE procedures resulted in statistically better OS (P = 0.018) and DFS (P = 0.030). ELAPE procedure was an independent risk factor of OS, DFS and LRFS in multivariate analysis.ConclusionLow rectal cancer patients might benefit from ELAPE procedure on both surgical and oncological outcomes, especially in patients with relatively advanced tumors, inspite of the effects of pre-operative radio- and chemotherapy.     

Optimal cytoreduction: is a CT's picture worth a surgeon's word?

IntroductionThe presence of residual disease after cytoreductive surgery is subjectively determined by the surgeon at the end of the operation. Nevertheless, in up to 21–49% of CT scans, residual disease can be found. The aim of this study was to establish the relationship between post-surgical CT findings after optimal cytoreduction in patients with advanced ovarian cancer and oncological outcome.Material and methodsPatients with advanced ovarian cancer (FIGO II and IV), diagnosed between 2007 and 2019 in Hospital La Fe Valencia, in whom cytoreductive surgery was performed, achieving R0 or R1, were assessed for eligibility (n = 440). A total of 323 patients were excluded because a post-operative CT scan was not performed between the third and eighth post-surgery week and prior to the start of chemotherapy.Results117 patients were finally included. The CT findings were classified into three categories: no evidence, suspicious or conclusive of residual tumour/progressive disease. 29.9% of CT scans were “conclusive of residual tumour/progressive disease”. No differences were found when the DFS (p = 0.158) and OS (p = 0.215) of the three groups were compared (p = 0.158).ConclusionAfter cytoreduction in ovarian cancer with no macroscopic disease or residual tumour < 1 cm result, up to 29.9% of post-operative CT scans before chemotherapy found measurable residual or progressive disease. Notwithstanding, a worse DFS or OS was not associated with this group of patients.     

Long-term outcome of the REMAGUS 02 trial,a multicenter randomised phase II trial in locally advanced breast cancer patients treated with neoadjuvant chemotherapy with or without celecoxib or trastuzumab according to HER2 status

BackgroundThe REMAGUS-02 multicenter randomised phase II trial showed that the addition to neoadjuvant chemotherapy (NAC) of trastuzumab in patients with localised HER2-positive breast cancer (BC) increased the pathological complete response (pCR) rate and that the addition of celecoxib in HER2-negative cases did not increase the pCR rate. We report here the long-term follow-up results for disease-free survival (DFS) and overall survival (OS).Patients and methodsFrom 2004 to 2007, 340 stage II–III BC patients were randomly assigned to receive neoadjuvant EC-T (four cycles of epirubicin–cyclophosphamide followed by four cycles of docetaxel) +/− celecoxib in HER2-negative cases (n = 220) and ± trastuzumab in HER2-positive cases (n = 120). From September 2005, all patients with HER2-positive BC received adjuvant T (n = 106).ResultsMedian follow-up was nearly 8 years (94.4 months, 20–127 m). In the HER2-negative subgroup, addition of celecoxib was not associated with a DFS benefit. Favourable factors were smaller tumour size, expression of progesterone receptor status (PgR) and pCR. In the HER2-positive population, neoadjuvant trastuzumab was not associated with a DFS benefit. Axillary pCR was the only prognostic factor associated with DFS in this group [HR = 0.44, 95% CI = 0.2–0.97], p = 0.035]. To note, DFS and OS were significantly higher in the HER2-positive than in HER2-negative BC patients (HR = 0.58 [0.36–0.92], p = 0.021).ConclusionCelecoxib combined with NAC provided neither pCR nor survival benefit in patients with HER2-negative BC. Absence of PgR is a major prognostic factor. Neoadjuvant trastuzumab increased pCR rates without translation into a DFS or OS benefit compared with adjuvant trastuzumab only. Axillary pCR could be a more relevant surrogate of survival than in the breast in HER2-positive population. A retrospective comparison shows that patients with HER2-positive tumours have a better outcome than HER2-negative BC patients showing the impact of trastuzumab on the natural history of BC.     

Risk of metachronous peritoneal metastases in patients with pT4a versus pT4b colon cancer: An international multicentre cohort study

IntroductionWith evolving treatment strategies aiming at prevention or early detection of metachronous peritoneal metastases (PM), identification of high-risk colon cancer patients becomes increasingly important. This study aimed to evaluate differences between pT4a (peritoneal penetration) and pT4b (invasion of other organs/structures) subcategories regarding risk of PM and other oncological outcomes.Materials and methodsFrom eight databases deriving from four countries, patients who underwent curative intent treatment for pT4N0-2M0 primary colon cancer were included. Primary outcome was the 5-year metachronous PM rate assessed by Kaplan-Meier analysis. Independent predictors for metachronous PM were identified by Cox regression analysis. Secondary endpoints included 5-year local and distant recurrence rates, and 5-year disease free and overall survival (DFS, OS).ResultsIn total, 665 patients with pT4a and 187 patients with pT4b colon cancer were included. Median follow-up was 38 months (IQR 23–60). Five-year PM rate was 24.7% and 12.2% for pT4a and pT4b categories, respectively (p = 0.005). Independent predictors for metachronous PM were female sex, right-sided colon cancer, peritumoral abscess, pT4a, pN2, R1 resection, signet ring cell histology and postoperative surgical site infections. Five-year local recurrence rate was 14% in both pT4a and pT4b cancer (p = 0.138). Corresponding five-year distant metastases rates were 35% and 28% (p = 0.138). Five-year DFS and OS were 54% vs. 62% (p = 0.095) and 63% vs. 68% (p = 0.148) for pT4a vs. pT4b categories, respectively.ConclusionPatients with pT4a colon cancer have a higher risk of metachronous PM than pT4b patients. This observation has important implications for early detection and future adjuvant treatment strategies.     

Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts

BackgroundThe extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach.MethodsSixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I–V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3–4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS).ResultsClinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92).ConclusionThis study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.     

Prediction scores for complication and recurrence after multivisceral resection in gastric cancer

BackgroundMultivisceral resection (MVR) is indicated in T4b gastric cancer (GC) when R0 can be achieved. Patient's selection for MVR is imperative, since it carries an increased risk for postoperative complications (POC) and disease recurrence. This study aims to elaborate prediction scores for POC and recurrence after MVR for cT4b GC.MethodsPatients who underwent MVR with curative intent due to cT4b gastric adenocarcinoma were selected from our prospective database. Scoring models were based on the variables identified as risk factors for the studied outcome. Through binary regression the model that best predicted the outcome was created.ResultsFrom 237 MVRs, 58 fulfilled the inclusion criteria. Males were 70.7%, mean age was 61.8 years. A pT4b was confirmed in 34 patients, 29 had 2 or more adjacent organs removed. Major POC occurred in 25.9%, mortality was 8.6%. Overall survival (OS) and disease-free survival (DFS) were similar for pT4b and non-pT4b. DFS was worse for pN+ and when >2 adjacent organs were removed. Scoring models included 5 and 6 parameters for POC and recurrence, respectively, and their accuracy was 80.6% (95%CI = 0.69–0.92) and 78% (95%CI = 0.66–0.90). The POC and recurrence rates in low- and high-score groups were statistically different (p < 0.001 and p = 0.004, respectively). Patients with high-risk for POC had lower OS (p = 0.036) and DFS was worse in the high-recurrence risk group (p = 0.008).ConclusionThe proposed scoring systems accurately predict POC and recurrence in GC patients undergoing MVR. These models are easy to use and can assist in the adoption of an individualized approach.     

Transhiatal distal esophagectomy for Siewert type II cardia cancer can be a treatment option in selected patients

BackgroundWhile surgical treatment of Siewert I and III (S1,S3) Esophagogastric Junction (EGJ) cancer is codified, the efficay of transhiatal procedure with anastomosis in the lower mediastinum for Siewert II (S2) still remains a dibated topic.MethodsThis is a large multicenter retrospective study. The results of 598 consecutive patients submitted to resection with curative intent from January 2000 to January 2017 were reported. Clinical and oncological outcomes of different procedures performed in S2 tumor were analyzed to investigate the efficacy of transhiatal approach.ResultsThe 5-year overall survival rate (OS) was poor (32%) for all Siewert types. The most performed operations in S2 cancer were proximal gastrectomy + transthoracic esophagectomy (TTE or Ivor-Lewis procedure, 60%), total gastrectomy + transhiatal distal esophagectomy with anastomosis in the chest (THE, 24%) and total gastrectomy + transthoracic esophagectomy (TGTTE, 15%). Cardiovascular and pulmonary complications were higher after TTE. On the contrary, surgical complications were significantly higher after THE. Postoperative mortality was similar. The distribution of TNM stages was different in the 3 types of procedures: patients submitted to THE had an earlier stage disease. With this bias, OS after THE was higher than after TTE but the difference was not significant (49.85% vs 28.42%, p = 0.0587).ConclusionsDespite a higher rate of postoperative surgical complications, OS after total gastrectomy and transhiatal distal esophagectomy was at least comparable to that of transthoracic approach in less advanced S2 tumors. Therefore, THE with anastomosis in the chest could be a treatmen option in earlier S2 tumors.     

Association of TIMP3 expression with vessel density,macrophage infiltration and prognosis in human malignant melanoma

AimsSeveral anti-tumour properties have been ascribed to the tissue inhibitor of matrix metalloproteinases-3 (TIMP3) gene, including inhibition of neovascularisation in tumour xenografts. Reduced protein expression has been linked to promoter hypermethylation and allelic loss of heterozygosity in various human malignancies. In melanoma-positive lymph nodes from patients, we evaluated the association between TIMP3 expression, vessel density, macrophage infiltration and potential correlations with disease-free survival (DFS) and overall survival (OS).Patients and methodsTIMP3 expression was analysed by immunohistochemistry (IHC) in melanoma lymph node biopsies of stage III melanoma patients (n = 43). Blood vessel density and macrophage infiltration were quantitatively assessed and correlation with TIMP3 expression was investigated. Methylation status of the gene promoter was determined using methylation-specific polymerase chain reaction (MSP). Protein expression and promoter methylation status were investigated for associations with DFS and OS.ResultsReduced expression of TIMP3, as determined by IHC, was observed in 74% of the cases (32 in 43). A significant inverse correlation was observed between TIMP3 expression and vessel density (p = 0.031). Correlation between TIMP3 expression and macrophage infiltration was not statistically significant (p = 0.369). MSP analysis revealed methylation of the gene promoter in 18% (7 in 38) of the analysed cases. No differences in OS and DFS were observed between cases with high and low TIMP3 expression. Gene promoter methylation was significantly associated with both poor 5-year DFS (p = 0.024) and OS (p = 0.034).ConclusionsOur data indicate that TIMP3 is a dominant negative regulator of angiogenesis in cutaneous melanoma and gene silencing by promoter methylation is associated with poor outcome.     

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma – A meta-analysis

BackgroundHepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR.AimTo compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC.Materials and methodsA systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM).ResultsEight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62–0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58–0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05–5.86, p = 0.04) compared to SR but IDR and DM rates were not significant.Discussion and conclusionTACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.     

The impact of postoperative radiological surveillance intensity on disease free and overall survival from primary retroperitoneal,abdominal and pelvic soft-tissue sarcoma

AimThis observational study aimed to evaluate the impact of intensity of radiological surveillance on survival following resection of retroperitoneal sarcoma.MethodRetrospective cohort study of patients undergoing primary resection of soft tissue sarcoma arising in the retroperitoneum, abdomen or pelvis at a single, high-volume sarcoma centre. Intensity of follow-up regimes up to 5 postoperative years were categorized as ‘European Society for Medical Oncology (ESMO) compliant’ (intense), or ‘non-ESMO compliant’ (less-intense). The primary outcome measure was overall survival (OS). The secondary outcome measures were disease-free survival (DFS) and reoperation rate. Analyses were stratified by high (grade 2 or 3) or low (grade 1) tumour grade.ResultsOf 168 patients, 67.1% had high-grade and 32.9% had low-grade disease. Overall, 40.0% of patients had ESMO-compliant radiological follow-up (high-grade:25.7%, low-grade:66.7%). 41.7% of patients died and 48.2% suffered local or distant recurrence by cessation of follow up. Upon univariable analysis for high-grade tumours, ESMO compliance reduced DFS (p = 0.066) but had no impact on OS. There was no significant difference in the reoperation rate in patients with ESMO-compliant and non-compliant follow-up (p = 0.097). In low-grade tumours, ESMO compliance significantly reduced DFS (p < 0.001), but without effecting OS. In risk-adjusted models for high-grade tumours, ESMO compliant follow-up was associated with reduced OS (HR:3.47, 1.40–8.61, p = 0.007) and no difference in DFS. In low-grade tumours, there was no association between overall ESMO compliance and OS or DFS.ConclusionThis study did not find a benefit for high-intensity radiological surveillance and overall survival in patients undergoing primary resection for high or low-grade retroperitoneal sarcoma.     

Local resection versus radical surgery for parathyroid carcinoma: A National Cancer Database analysis

IntroductionParathyroid carcinoma (PC) is rare and often diagnosed incidentally after local resection (LR) for other indications. Although recommended treatment has traditionally been radical surgery (RS), more recent guidelines suggest that LR alone may be adequate. We sought to further investigate outcomes of RS versus LR for localized PC.Materials and methodsPC patients from 2004 to 2015 with localized disease were identified from the National Cancer Database, then stratified by surgical therapy: LR or RS. Demographic and clinicopathologic data were compared. Cox proportional hazard models were constructed to estimate associations of variables with overall survival (OS). OS was estimated from time of diagnosis using Kaplan-Meier curves.ResultsA total of 555 patients were included (LR = 522, RS = 33). The groups were comparable aside from LR patients having higher rates of unknown nodal status (66.9% versus 39.4%; p = 0.003). By multivariable analysis, RS did not have a significant association with OS (hazard ratio (HR) = 0.43, 95% confidence interval (95%CI) = 0.10, 1.83; p = 0.255), nor did positive nodal status (HR = 0.66, 95%CI = 0.09, 5.03; p = 0.692) and unknown nodal status (HR = 1.30, 95%CI = 0.78, 2.17; p = 0.311). There was no difference in OS between the LR and RS groups, with median survival not reached by either group at 10 years (median follow-up = 60.4 months; p = 0.20).ConclusionsThere was no difference in OS between LR and RS for localized PC. RS and nodal status may not impact survival as previously identified, and LR should remain a valid initial surgical approach. Future higher-powered studies are necessary to assess the effects of surgical approaches on morbidity and oncologic outcomes.     

The oncologic safety of left colectomy with modified complete mesocolic excision for distal transverse colon cancer: Comparison with descending colon cancer

BackgroundThe optimal surgical approach for distal transverse colon cancer has not been well established. This study aimed to evaluate the oncologic safety of left colectomy with a modified complete mesocolic excision for distal transverse colon cancer as compared with descending colon cancer.Material and methodsThis study involved 383 patients who underwent left colectomy with modified complete mesocolic excision for non-metastatic distal transverse and splenic flexure colon (transverse group, N = 110) and descending colon cancer (descending group, N = 237) from 3 institutions. Recurrence-free survival (RFS) and overall survival (OS) were compared between the two groups.ResultsBaseline characteristics between the two groups were similar except for the length of the distal margin (transverse group = 11.0 cm vs descending group = 9.0 cm, p = 0.004). During a median follow-up of 47.0 months, RFS and OS were not different between the transverse and descending groups (5-year RFS: 82% vs 71%, p = 0.139; 5-year OS: 83% vs 79%, p = 0.416, respectively). In multivariable analysis, RFS and OS were not different between the two groups (transverse group vs. descending group: adjusted hazard ratio [aHR] = 1.557, 95% CI = 0.786–3.084, p = 0.204; aHR = 1.251, 95% CI = 0.530–2.952, p = 0.609).ConclusionThe oncologic outcomes of left colectomy with a modified complete mesocolic excision of distal transverse colon cancer were comparable to those of descending colon cancer. Left colectomy with a modified complete mesocolic excision can be an acceptable surgical treatment for distal transverse colon cancer.     

Influence of the surgical technique on survival in the treatment of carcinomas of the true cardia (Siewert Type II) - Right thoracoabdominal vs. transhiatal-abdominal approach

IntroductionIt is still a matter of debate whether subtotal esophagectomy via a right thoracoabdominal approach (RTA) or extended gastrectomy using a transhiatal-abdominal approach (TH) is the favorable technique in the treatment of Siewert type II esophago-gastric junction adenocarcinoma (EJA).Materials and methodsPatients undergoing RTA or TH for EJA at our institution between 2000 and 2013 were extracted from a prospective database. Of 270 patients 91 (33.7%) underwent RTA and 179 (66.3%) were treated by TH.Differences in baseline characteristics, 30d mortality and complications were investigated using the χ2-test or exact testing. Survival analysis was performed using the Kaplan-Meier method and log rank testing. Median survival and hazard ratios were calculated and multivariable analysis of predictors was performed using a Cox model. Confounders were balanced using propensity score matching (PSM).ResultsNo significant difference between the two procedures was detected regarding overall-survival (OS) and disease-free survival (DFS). 30d mortality rates were 1.1% in the RTA group and 4.5% in the TH group (p = 0.134). Morbidity was 34.1% in the RTA and 24.6% in the TH group (p = 0.006). Cox regression analysis identified age, ASA class and UICC stage as independent prognostic factors for OS. After PSM survival curves (OS + PFS) showed no significant difference.ConclusionThe present study could not detect a difference between RTA and TH from the oncologic point of view; RTA was not associated with higher 30d mortality. RTA for Siewert Type II EJA is justified whenever the oral tumor margin cannot be safely reached via a transhiatal approach.     

Planned combined onco-plastic (COP) surgical approach improves oncologic outcomes in soft tissue sarcomas

BackgroundCombined modality of radiotherapy and surgery is the standard of treatment of soft tissue sarcomas (STS). The goal of this study was to assess whether a Combined Onco-Plastic (COP) surgical approach in the setting of neo-adjuvant radiotherapy can improve the oncologic outcomes of STS and reduce the rate of wound complications.MethodsWe performed a retrospective review of all patients with STS treated at a single sarcoma centre (St Vincent’s Hospital, Melbourne) between 2007 and 2018. Patients were stratified into two groups based on whether they have received the COP approach or were closed primarily by the orthopaedic surgeon. We analysed oncological outcomes and rate of wound complications.ResultsA total of 546 patients with comparable demographics and tumor characteristics were included. The COP approach was performed in 75.6% of the patients. Wide margins were obtained in 97.4% of the cases, and this was significantly higher in the COP group (p < 0.001). The cumulative rate of local recurrence was 4.9%, with a 52% risk reduction in the COP approach, although this reduction was not significant (HR = 0.48; 95% CI 0.21–1.06; p = 0.070). The COP approach had better disease free survival (DFS) (aHR 1.86, 95% CI 1.45–2.37; p < 0.001) and Overall survival (risk of death aHR 0.49; 95% CI 0.30–0.79; p = 0.004). The overall wound complication rate was 18.6% with no difference between the two groups.ConclusionA planned collaboration between the orthopaedic oncologist and the plastic surgeon is beneficial in the treatment of STS after neo-adjuvant radiotherapy, allowing remarkably good oncological outcomes and a low rate of wound complications.