Presentation and Management of Gastrointestinal Stromal Tumors of the Duodenum: A Multi-Institutional Analysis

Background

Duodenal gastrointestinal stromal tumors (GISTs) are a small subset of GISTs, and their management is poorly defined. We evaluated surgical management and outcomes of patients with duodenal GISTs treated with pancreaticoduodenectomy (PD) versus local resection (LR) and defined factors associated with prognosis.

Methods

Between January 1994 and January 2011, 96 patients with duodenal GISTs were identified from five major surgical centers. Perioperative and long-term outcomes were compared based on surgical approach (PD vs LR).

Results

A total of 58 patients (60.4?%) underwent LR, while 38 (39.6?%) underwent PD. Patients presented with gross bleeding (n?=?25; 26.0?%), pain (n?=?23; 24.0?%), occult bleeding (n?=?19; 19.8?%), or obstruction (n?=?3; 3.1?%). GIST lesions were located in first (n?=?8, 8.4?%), second (n?=?47; 49?%), or third/fourth (n?=?41; 42.7?%) portion of duodenum. Most patients (n?=?86; 89.6?%) had negative surgical margins (R0) (PD, 92.1 vs LR, 87.9?%) (P?=?0.34). Median length of stay was longer for PD (11?days) versus LR (7?days) (P?=?0.001). PD also had more complications (PD, 57.9 vs LR, 29.3?%) (P?=?0.005). The 1-, 2-, and 3-year actuarial recurrence-free survival was 94.2, 82.3, and 67.3?%, respectively. Factors associated with a worse recurrence-free survival included tumor size [hazard ratio (HR)?=?1.09], mitotic count >10 mitosis/50 HPF (HR?=?6.89), AJCC stage III disease (HR?=?4.85), and NIH high risk classification (HR?=?4.31) (all P?Conclusions Recurrence of duodenal GIST is dependent on tumor biology rather than surgical approach. PD was associated with longer hospital stays and higher risk of perioperative complications. When feasible, LR is appropriate for duodenal GIST and PD should be reserved for lesions not amenable to LR.     

Progression while Receiving Preoperative Chemotherapy Should Not Be an Absolute Contraindication to Liver Resection for Colorectal Metastases

Purpose

Tumor progression while receiving neoadjuvant chemotherapy (PD) has been associated with poor outcome and is commonly considered a contraindication to liver resection (LR). This study aims to clarify in a large multicenter setting whether PD is always a contraindication to LR.

Methods

Data from the LiverMetSurvey international registry were analyzed. Patients undergoing LR for colorectal metastases without extrahepatic disease after neoadjuvant chemotherapy between 1990 and 2009 were reviewed.

Results

Among 2143 patients, PD occurred in 176 (8.2?%). Risk of progression was increased after 5-FU or irinotecan (22.7?% vs. 6.8?% after other regimens, p?p?p?p?=?0.0006). In the PD group, 3 independent prognostic factors were identified: carcinoembryonic antigen (CEA) ??200?ng/mL (p?=?0.003), >3 metastases (p?=?0.028), and tumor diameter ??50?mm (p?=?0.002). A survival predictive model showed that patients without any risk factors had 5-year survival rates of 53.3?%; good survival results were still observed if metastases were >3 or ??50?mm (29.9 and 19.1?%, respectively). On the contrary, survival was less than 10?% at 3?years in the presence of >1 prognostic factor or CEA of ??200?ng/mL.

Conclusions

PD is a negative prognostic factor, but it is not an absolute contraindication to LR. Patients with PD could be scheduled for LR except for those with >3 metastases and ??50?mm, or CEA ??200?ng/mL in whom further chemotherapy is recommended.     

Complete Pathologic Response after Combined Modality Treatment for Rectal Cancer and Long-Term Survival: A Meta-Analysis

Background

Complete pathologic response (CPR) after neoadjuvant chemoradiotherapy (combined modality treatment, CMT) for rectal cancer seems associated with improved survival compared to partial or no response (NPR). However, previous reports have been limited by small sample size and single-institution design.

Methods

A systematic literature review was conducted to detect studies comparing long-term results of patients with CPR and NPR after CMT for rectal cancer. Variables were pooled only if evaluated by 3 or more studies. Study end points included rates of CPR, local recurrence (LR), distant recurrence (DR), 5-year overall survival (OS), and disease-free survival (DFS).

Results

Twelve studies (1,913 patients) with rectal cancer treated with CMT were included. CPR was observed in 300 patients (15.6%). CPR and NPR patient groups were similar with respect to age, sex, tumor size, distance of tumor from the anus, and stage of disease before treatment. Median follow-up ranged from 23 to 46?months. CPR patients had lower rates of LR [0.7% vs. 2.6%; odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22?C0.90, P?=?0.03], DR (5.3% vs. 24.1%; OR 0.15, 95% CI 0.07?C0.31, P?=?0.0001), and simultaneous LR?+?DR (0.7% vs. 4.8%; OR 0.32, 95% CI 0.13?C0.79, P?=?0.01). OS was 92.9% for CPR versus 73.4% for NPR (OR 3.6, 95% CI 1.84?C7.22, P?=?0.002), and DFS was 86.9% versus 63.9% (OR 3.53, 95% CI 1.62?C7.72, P?=?0.002).

Conclusions

CPR after CMT for rectal cancer is associated with improved local and distal control as well as better OS and DFS.     

Systematic Pelvic and Aortic Lymphadenectomy in Advanced Ovarian Cancer Patients at the Time of Interval Debulking Surgery: A Double-Institution Case–Control Study

Background

The prognostic role of systematic lymphadenectomy remains unclear in advanced ovarian cancer (AOC). Only few retrospective case series have investigated the percentage of lymph node metastases after neoadjuvant chemotherapy. This multi-institutional case-control study analyzed the prognostic role of systematic lymphadenectomy in AOC patients at the time of interval debulking surgery (IDS).

Methods

From January 2005 to December 2010, the records of patients with AOC admitted to IDS at the Catholic University of Rome (n?=?101, controls) and at the University of Bologna (n?=?50, cases) were retrospectively analyzed. The cases, routinely submitted to systematic pelvic and aortic lymphadenectomy, were matched 1:2 with the controls, who did not routinely undergo lymphadenectomy. To correctly assess the prognostic role of lymphadenectomy, only patients with optimally debulked disease were included. Progression-free survival and overall survival were analyzed by a log-rank test.

Results

After an overall mean follow-up of 36?months (95?% confidence interval 33?C39), 35 and 63 recurrences (70.0 vs. 62.4?%; p?=?NS) and 15 and 24 deaths due to disease (30 vs. 23.7?%; p?=?NS) were observed in the case and controls, respectively. The 2-year progression-free survival rate was 36 versus 25?% (p?=?0.834), and the 2-year overall survival rate was 69 versus 88?% (p?=?0.777), in the case and controls, respectively. The median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the cases than in the controls (225 vs. 210?min, p?=?0.023, and 54 vs. 22.8?%, p?=?0.0001, respectively).

Conclusions

Lymphadenectomy at the time of IDS could be omitted, at least in high-risk patients.     

Outcome of laparoscopic major liver resection for colorectal metastases

Background

Minimally invasive liver resection (MILR) for colorectal liver metastases (CRLM) is gaining widespread acceptance. However, data are still lacking on the feasibility, long- and short-term outcomes of laparoscopic major hepatectomy (i.e., three or more liver segments).

Methods

Between October 2002 and December 2008, prospectively collected data of 117 patients who underwent major liver resection [97 open (OMLR) and 20 laparoscopic (LMLR) procedures] for CRLM were analyzed. Twenty patients in the LMLR group were matched with 20 patients of the OMLR based on 13 parameters. We compared the long- and short-term outcomes between these two groups.

Results

Median duration of surgery was 257.5 (range 75–360)?min in LMLR versus 232.5 (range 120–400)?min in OMLR (P?=?0.228). Median blood loss during surgery was 550?ml in each group (range 100–4,000 vs. 100–2,500?ml, P?=?0.884). There was no statistically significant difference in the rate of postoperative complications (both severity and location). Median magnitude of tumor-free resection margin was 7.5 versus 5.5?mm in the laparoscopy versus open group, respectively (P?=?0.651). Median disease-free survival (DFS) of the entire study population was 18.4?months [95% confidence interval (CI) 11.9–50.0?months]. Median overall survival (OS) was 50.7?months (95% CI 36.2?months to undetermined). The estimated DFS and OS rates at 1, 2, and 5?years were comparable in the two groups (P?=?0.637 and 0.872, respectively).

Conclusion

Laparoscopic MLR for selected CRLM is feasible and might result in comparable oncologic outcomes as in open liver resection.     

Metastasectomy for Distant Metastatic Melanoma: Analysis of Data from the First Multicenter Selective Lymphadenectomy Trial (MSLT-I)

Background

For stage IV melanoma, systemic medical therapy (SMT) is used most frequently; surgery is considered an adjunct in selected patients. We retrospectively compared survival after surgery with or without SMT versus SMT alone for melanoma patients developing distant metastases while enrolled in the first Multicenter Selective Lymphadenectomy Trial.

Methods

Patients were randomized to wide excision and sentinel node biopsy, or wide excision and nodal observation. We evaluated recurrence site, therapy (selected by treating clinician), and survival after stage IV diagnosis.

Results

Of 291 patients with complete data for stage IV recurrence, 161 (55?%) underwent surgery with or without SMT. Median survival was 15.8 versus 6.9?months, and 4-year survival was 20.8 versus 7.0?% for patients receiving surgery with or without SMT versus SMT alone (p??60?months vs. 12.4?months; 4-year survival 69.3?% vs. 0; p?=?0.0106), M1b (median 17.9 vs. 9.1?months; 4-year survival 24.1 vs. 14.3?%; p?=?0.1143), and M1c (median 15.0 vs. 6.3?months; 4-year survival 10.5 vs. 4.6?%; p?=?0.0001) disease. Patients with multiple metastases treated surgically had a survival advantage, and number of operations did not reduce survival in the 67 patients (42?%) who had multiple surgeries for distant melanoma.

Conclusions

Our findings suggest that over half of stage IV patients are candidates for resection and exhibit improved survival over patients receiving SMT alone, regardless of site and number of metastases. We have begun a multicenter randomized phase III trial comparing surgery versus SMT as initial treatment for resectable distant melanoma.     

Ezrin Expression Is an Independent Prognostic Factor in Gastro-intestinal Cancers

Background

Ezrin, a member of the ezrin–radixin–moesin (ERM) family of plasma membrane–cytoskeleton linker proteins, has been associated with metastatic behavior.

Methodology

Microarrayed pathological tissues of surgically resected colorectal cancer liver metastasis (CRLM) and whole tissue sections of cancer of the ampulla of Vater (CAV) were analyzed to determine ezrin expression levels and correlation with survival. The requirement of ezrin in invasive capability was assessed using in vitro assays.

Results

Surgically resected CAV showing a low ezrin score have a better 5-year disease-specific survival than those showing a high ezrin score (P?<?0.0001). Similarly, high ezrin expression at the invasive front of CRLM resulted in poor disease-free survival (P?=?0.05). Multivariate analysis demonstrated high ezrin expression to be an independent adverse prognostic factor for CAV (hazard ratio (HR) 15.22 (95 % confidence interval (CI) 1.98–117.03), P?<?0.01) and CRLM (HR 6.42 (95 % CI 1.01–52.43), P?=?0.05), among other clinically relevant variables such as lymph node metastasis (for CAV) and the presence of extrahepatic disease, large hepatic metastases (>5 cm), and close surgical resection margins (<5 mm) (all for CRLM). In vitro experiments indicated that ezrin expression was vital for cellular processes such as adhesive and invasive activity.

Significance

High ezrin expression indicates an adverse prognosis in primary CAV and CRLM.     

Strong YB-1 Expression Predicts Liver Recurrence Following Resection for Colorectal Metastases

Introduction

The Y-box binding protein-1 (YB-1) is a multifunctional oncoprotein involved in the proliferation and aggressiveness of cancer cells. The aim of this study was to determine whether strong YB-1 expression in neoplastic cells of colorectal liver metastases (CRLM) may have an impact on liver disease-free survival following liver resection.

Materials and Methods

Immunohistochemistry was performed to evaluate YB-1 in 66 patients who underwent liver resection for CRLM. YB-1 expression was classified as weak (low-staining intensity) and strong (high-staining intensity).

Results

YB-1 expression was observed in the cytoplasm of all CRLM. YB-1 expression was weak in 17 patients (25.8 %) and strong in 49 patients (74.2 %). Liver recurrence rate was significantly higher in the strong than in the weak expression group: 55.1 vs. 23.5 % (p?=?0.023). Multivariable logistic regression analysis showed that YB-1 strong expression was the only independent risk factor for liver recurrence. The 5-year specific liver disease-free survival rate was 76.0 % in the weak expression group and 41.5 % in the strong expression group (p?=?0.034). These results were not influenced by clinical prognostic factors of tumor recurrence.

Conclusions

This is the first study showing that the degree of YB-1 expression in tissue specimens of CRLM predicts liver recurrence following liver resection.     

Surgical Management of Melanoma Lung Metastasis: An Analysis of Survival Outcomes in 292 Consecutive Patients

Background

The role of surgical resection of melanoma lung metastases (MLM) remains controversial. Some authorities advocate an aggressive surgical approach, while others recommend a conservative strategy. This study sought to identify the clinicopathologic and predictors of outcome after surgical management of MLM in a large series of melanoma patients from a single institution.

Methods

All patients undergoing surgical management of MLM between November 1984 and April 2010 were identified and predictors of outcome analyzed.

Results

Of the 292 patients eligible for the study, 112 (38%) had previously undergone surgery for nonpulmonary recurrences. Four patients (1%) died within 30?days of surgery for MLM. The median progression-free survival time was 10?months. The median overall survival and 3- and 5-year survival were 23?months [95% confidence interval (CI) 17?C30], 41 and 34%, respectively. Metastasis size >2?cm [hazard ratio (HR) 1.4, 95% CI 1.0?C1.8, P?=?0.03, HR 1.6, 95% CI 1.2?C2.2; P?=?0.002] and positive surgical margin (HR 1.5, 95% CI 1.2?C1.9, P?P?=?0.003) were independently associated with poorer progression-free survival and overall survival, respectively. The presence of more than one metastasis (HR 1.4, 95% CI 1.1?C1.7, P?=?0.013) was independently associated with poorer overall survival.

Conclusions

The results support the role of pulmonary metastasectomy in selected patients with MLM. Patients with small (<2?cm) and solitary tumors that can be completely resected with a negative margin are most likely to experience prolonged survival.     

Prognostic Impact of Positive Surgical Margins After Resection of Colorectal Cancer Liver Metastases: Reappraisal in the Era of Modern Chemotherapy

Background

The purpose of the present study was to assess the prognostic impact of positive surgical margins (R1) after liver resection (LR) of colorectal liver metastases (CRLM) in the era of modern chemotherapy regimens. R1 resection is a negative prognostic factor after LR of CRLM. The significance of R1 margins in the era of effective chemotherapy is unknown.

Methods

From January 2000 to December 2009, 215 patients (177 men: 62 %; median age 60 years; range 30–84 years) underwent LR of CRLM. The LR was considered R1 (margin <1 mm) in 49 patients (23 %) and R0 in 166 patients (77 %). Overall, 108 (50 %) patients received preoperative chemotherapy and 156 (72 %) patients received postoperative chemotherapy.

Results

With a median follow-up of 36 months (range 1–141 months), the 5-year overall survival (OS) rate (47 vs 40 %; p = 0.05) and the disease-free survival (DFS) rate (36 vs 23 %; p = 0.006) were significantly lower in the R1 group. Recurrence developed in 152 patients (71 %) and the rate of recurrence was significantly higher (84 vs 67 %; p = 0.02) in the R1 group. On multivariate analysis, N+ status of the colorectal primary tumor (p = 0.008), presence of radiologically occult disease (p = 0.04), and R1 resection (p = 0.03) were independent adverse predictors of OS. The N+ status of the primary tumor (p = 0.003) and R1 resection (p = 0.02) were independent adverse predictors of DFS. On multivariate analysis use of postoperative chemotherapy was the only independent predictor of improved DFS (p = 0.02) in the R1 group.

Conclusions

A positive resection margin remains a significant poor prognostic factor after LR of CRLM in the era of modern chemotherapy. Postoperative chemotherapy reduces recurrence rates after R1 resection of CRLM.     

Impact of Simultaneous Diaphragm Resection During Hepatectomy for Treatment of Metastatic Colorectal Cancer

Introduction

For colorectal cancer patients with liver metastases involving the hepatic dome or invading the diaphragm, a concomitant diaphragm resection is often required to achieve negative surgical margins. The purpose of this study is to determine whether diaphragm resection during partial hepatectomy for metastatic colorectal cancer influences short-term perioperative outcomes and overall survival.

Methods

Demographics, treatments, and outcomes of 442 patients who underwent hepatic resection for metastatic colorectal cancer from 1996 to 2010 at a high-volume center were reviewed. Recurrence and survival were measured from the date of metastectomy. Actuarial curves were generated using the Kaplan?CMeier method and compared using log?Cranks testing. Multivariate predictors of worse survival were compared using a Cox-proportional hazards model.

Results

A total of 442 patients underwent hepatectomy for metastatic colorectal cancer. Of these, 34 required simultaneous diaphragm resection (DR) and 408 did not (LR). No significant differences existed in patient demographics or comorbidities. The DR group had longer median operative times (336 vs. 267?min, p?=?0.0008) but had comparable rates of perioperative morbidity and mortality. Median overall survival was shorter in the DR group compared to the LR group (18.8 vs. 36?months, p?=?0.0017). When controlling for potential cofounders, liver metastases size?>?5?cm (HR 1.45 95?% CI (1.08?C1.99), p?=?0.015) and diaphragm resection (HR?=?1.72 95?% CI (1.03?C2.86), p?=?0.038) predicted worse survival.

Conclusions

Simultaneous diaphragm resection during partial hepatectomy does not significantly influence perioperative morbidity or mortality despite longer operative times. However, patients who require diaphragm resection have less favorable survival rates as compared to those who do not.     

The Improvement of Surgical Treatment for Patients with Gallbladder Cancer: Analysis of 208 Consecutive Cases Over the Past Decade

Objectives

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

Methods

A retrospective review of all patients with gallbladder cancer admitted during the past 11?years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n?=?77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n?=?131).

Results

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P?=?0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9?% vs. 19?%, P?=?0.040) and disease-free survival (P?=?0.017). Median survival in group 1 was 14.7?months, while in group 2 it was 22.3?months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P?=?0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P?=?0.108).

Conclusions

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.     

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

Background

The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR).

Methods

This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12?months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an “intention-to-treat” basis.

Results

A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5?%, mostly due to locally advanced disease (88.4?%). A greater risk of conversion was observed among patients with a tumor size greater than 5?cm regardless the tumor site (P?=?0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P?=?0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P?=?0.853) and mortality rates (P?=?0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P?=?0.058). During a median follow-up time of 72?months, there was no significant difference in overall survival between the two groups (P?=?0.622).

Conclusions

LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.     

Multivisceral and standard resections in colorectal cancer

Purpose

The current study was designed to identify prognostic factors for long-term survival in patients with advanced colorectal cancer in a consecutive cohort.

Methods

A total of 123 patients were operated because of T4 colorectal cancer between 1 January 2002 and 31 December 2008 in the Clinic of Surgery, UK-SH Campus Luebeck.

Results

A total of 78 patients underwent a multivisceral resection. The postoperative morbidity was elevated in the patient group with multivisceral resections (34.6% vs. 26.7%). Nevertheless, we detected no significant differences concerning 30?days mortality (7.7% vs. 8.9%; p?=?0.815). The main prognostic factor that reached significance in the multivariate analysis was the possibility to obtain a R0 resection (p?<?0.0001) resulting in a 5-year survival rate of 55% for patients with curative resection. There were no statistically significant differences in 5-year survival between multivisceral and non-multivisceral resections (p?=?0.608). Also we were not able to detect any significant differences for cancer of colonic or rectal origin (p?=?0.839), for laparoscopic vs. open procedures (p?=?0.610), and for emergency vs. planned operations (p?=?0.674). Moreover, the existence of lymph node metastases was not a predictive factor concerning survival as there was no difference between patients with and without lymph node metastases (p?=?0.658).

Conclusions

Multivisceral resections are associated with the same 5-year survival as standard resections. Therefore, the aim to perform a R0 resection should always be the main goal in surgery for colorectal cancer. In planned operations, a laparoscopic approach is justified in selected patients.     

Colorectal Cancer with Synchronous Resectable Liver Metastases: Monocentric Management in a Hepatobiliary Referral Center Improves Survival Outcomes

Background

Management of patients with synchronous colorectal liver metastases (SCRLM) should be individually tailored. This study compares patients managed by hepatobiliary centers from diagnosis with those referred for liver resection (LR).

Methods

Between 1998 and 2010, a total of 284 patients with SCRLM underwent resection; 106 resectable patients (1–3 unilobar metastases, diameter <100 mm, liver-only disease) were divided into two groups: 66 managed from diagnosis (group A) and 40 referred for LR (group B).

Results

Group A contained a greater proportion of multiple metastases (55.0 vs. 34.8 %, P = 0.042). Group B always received colorectal surgery as up-front treatment (vs. 18.2 %, P < 0.0001). In group B, chemotherapy before LR was more common (72.5 vs. 33.3 %, P = 0.0001) and lasted longer (P = 0.010). More patients in group B exhibited disease progression before LR (17.5 vs. 3.0 %, P = 0.025). Group A underwent fewer surgical procedures (80.3 % simultaneous resection vs. 0 %, P < 0.00001), with similar short-term outcomes. After a median follow-up of 42.0 months, group A exhibited higher 5 year disease-free survival (DFS, 64.8 vs. 30.8 %, P = 0.005) and fewer extrahepatic recurrences (21.5 vs. 47.5 %, P = 0.005). The late-referral group (>6 months, n = 24) had shorter median overall survival (OS) and DFS than group A (49.1 and 25.3 months vs. not achieved and not achieved, P < 0.05). The early-referral group exhibited OS and DFS similar to group A. Multivariate analysis confirmed late referral as a negative predictive factor of OS and DFS.

Conclusions

Monocentric management of SCRLM in hepatobiliary centers is associated with shorter preoperative chemotherapy, better disease control, fewer surgical procedures (simultaneous resection), and, compared with late-referred patients, better survival.     

Treating Patients with Colon Cancer Liver Metastasis: A Nationwide Analysis of Therapeutic Decision Making

Background

Criteria for resectability of colon cancer liver metastases (CLM) are evolving, yet little is known about how physicians choose a therapeutic strategy for potentially resectable CLM.

Methods

Physicians completed a national Web-based survey that consisted of varied CLM conjoint tasks. Respondents chose among three treatment strategies: immediate liver resection (LR), preoperative chemotherapy followed by surgery (C????LR), or palliative chemotherapy (PC). Data were analyzed by multinomial logistic regression, yielding odds ratios (OR).

Results

Of 219 respondents, 79?% practiced at academic centers and 63?% were in practice ??10?years. Median number of cases evaluated was four per month. Surgical training varied: 51?% surgical oncology, 44?% hepato-pancreato-biliary/transplantation, 5?% no fellowship. Although each factor affected the choice of CLM therapy, the relative effect differed. Hilar lymph node disease predicted a strong aversion to LR with surgeons more likely to choose C????LR (OR 8.92) or PC (OR 49.9). Solitary lung metastasis also deterred choice of LR, with respondents favoring C????LR (OR 4.43) or PC (OR 6.97). After controlling for clinical factors, surgeons with more years in practice were more likely to choose PC over C ?? LR (OR 1.94) (P?=?0.005). Surgical oncology-trained surgeons were more likely than hepatobiliary/transplant-trained surgeons to choose C????LR (OR 2.53) or PC (OR 4.15) (P?<?0.001).

Conclusions

This is the first nationwide study to define the relative impact of key clinical factors on choice of therapy for CLM. Although clinical factors influence choice of therapy, surgical subspeciality and physician experience are also important determinants of care.     

Evaluation of the MD Anderson Prognostic Index for Local-Regional Recurrence After Breast Conserving Therapy in Patients Receiving Neoadjuvant Chemotherapy

Background

We previously developed a prognostic index for assessing local-regional recurrence (LRR) risk in patients undergoing breast conservation therapy (BCT) after neoadjuvant chemotherapy. The prognostic index assigns a point for each of the following variables: clinical N2/N3 disease, lymphovascular invasion, residual pathologic tumor size >2?cm, and multifocal residual disease on pathology. The current study was undertaken to evaluate this prognostic index in an independent cohort.

Methods

We identified 551 patients treated from 2001 to 2005 with neoadjuvant chemotherapy, mastectomy or BCT, and radiation. These patients were not used in the original development of the prognostic index. Outcomes were stratified by prognostic index. The 5-year LRR-free survival was calculated using the Kaplan?CMeier method, and differences were compared using the log-rank test.

Results

For patients undergoing BCT, the 5-year LRR-free survival rates were 92, 92, 84, and 69% when the prognostic index was 0 (n?=?91), 1 (n?=?82), 2 (n?=?38), or 3?C4 (n?=?13) (P?=?0.01). The 5-year LRR-free survival rates were similar between patients undergoing mastectomy or BCT when the prognostic index score was 0, 1, or 2. When the prognostic index score was 3?C4, the 5-year LRR-free survival was significantly lower for patients treated with BCT compared with mastectomy (69 vs. 93%, P?=?0.007).

Conclusion

The previously developed prognostic index was successful in stratifying patients with respect to LRR in an independent cohort undergoing BCT after neoadjuvant chemotherapy. The prognostic index can be used to identify patients at high risk for LRR who may be considered for more extensive surgery or enrollment into clinical trials evaluating novel strategies for local-regional control.     

The Impact of Obesity on Breast Cancer: A Retrospective Review

Background

Obesity has been linked to many adverse health consequences, including breast cancer; however, the impact on clinical presentation, tumor characteristics, and survival outcomes has yet to be clearly defined.

Methods

Retrospective review of a prospectively collected database of patients treated at a single institution for invasive breast cancer from 2000?C2008 comparing two groups: nonobese (body mass index of <30) and obese (body mass index of ??30) patients. Continuous variables, categorical variables, and survival data were analyzed.

Results

Of 1352 total patients, 76% were classified as nonobese and 24% were obese. When comparing age, obese patients presented less frequently than nonobese patients <50?years old (10% vs. 90%), and when comparing patients >50?years old (18% vs. 82%, P?=?0.0019). Obese patients were more likely to present with disease detected by imaging when compared to nonobese patients (67% vs. 56%, P?=?0.0006). Obese patients had larger tumors (1.7?cm vs. 1.4?cm, P?P?=?0.026). On multivariate analysis, obesity was associated with nonpalpable tumors, larger tumors, a higher incidence of LN metastasis, lower incidence of Her2 positivity, lower incidence of multifocality, and less likely to undergo reconstruction after mastectomy.

Conclusions

Obese patients clinically present at older ages with mammographically detected breast cancer at more advanced stages than nonobese patients. Strategies to encourage screening among the obese patient population are important.     

Definition of T3/4 and Regional Lymph Nodes in Gallbladder Cancer: Which Is More Valid, the UICC or the Japanese Staging System?

Background

The Union for International Cancer Control (UICC) and Japanese Society of Biliary Surgery (JSBS) staging systems differ in their staging of gallbladder cancer: they define hepatic invasion with or without invasion of another organ as T3 and either T3 or T4, respectively, and posterosuperior pancreatic lymph node (PSPLN) metastases as M1 and N2, respectively.

Methods

We retrospectively evaluated the survival of 224 patients who had undergone macroscopically curative resection for gallbladder cancer and assessed the influence of the differences between the two staging systems on survival.

Results

JSBS staging stratified the survival curves better for stages III or IV. Fifty-seven patients were classified as UICC-T3 but JSBS-T4. These patients had better survival than did 43 patients with UICC-T4/JSBS-T4 and comparable survival to 17 patients with UICC-T3/JSBS-T3. UICC stage IIIB is composed of two subgroups: U-T2N1 (18 patients) and U-T3N1 (21 patients). Their 5-year survivals were 85 and 41?%, respectively (P?=?0.01). The latter was comparable to that of 28 T3N0 patients (35?%, P?=?0.93). The survival of the UICC-M1 patients with disease restricted to PSPLNs was significantly better than that of those with involvement beyond PSPLNs (5-year survival 35 vs. 17?%; P?=?0.04).

Conclusions

Although UICC staging more accurately defines the T category, JSBS staging better stratifies the prognosis of patients with gallbladder cancer, mainly because UICC stage IIIB includes T1/2N1M0, which is associated with significantly better survival than T3N0M0. It would be appropriate to classify PSPLNs as regional lymph nodes.     

Completely laparoscopic versus open gastrectomy for early and advanced gastric cancer: a matched cohort study

Introduction

The application of laparoscopic gastric surgery has rapidly increased for the treatment of early gastric cancer. However, laparoscopic gastrectomy for advanced tumor remains controversial, particularly in terms of oncologic outcomes. This study was designed to compare 3-year survival of laparoscopic versus open curative gastrectomy in early and advanced gastric cancer.

Methods

This was a retrospective matched cohort study. We included patients between 2003 and 2010 with an R0 resection. A totally laparoscopic technique was used and D2 lymph node dissection was practiced routinely. We performed an intracorporeal hand-sewn esophagojejunostomy in all laparoscopic total gastrectomy cases. We matched all laparoscopic cases 1:1 with open cases according to TNM AJCC seventh edition. We used Mann–Whitney or t test and Chi-square test to compare both groups. Kaplan–Meier analysis with log-rank test was performed to compare survival.

Results

We included 31 open and 31 laparoscopic cases (mean age 63?±?14?years; 66% males). Both groups were identical in type of gastrectomy (71% total and 29% subtotal). There were no statistical difference between laparoscopic and open groups in age, sex, N category, tumor location and size, histological differentiation, and T category (48% T1, 13% T2, 16% T3, and 23% T4 in both groups), with 48% early and 52% advanced tumors. The median number of resected lymph nodes was similar: 35 (23–53) for laparoscopic and 39 (23–45) for open cases (P?=?0.81). The median follow-up was 50?months. The overall 3-year survival was 82% for laparoscopic surgery and 87% for the open surgery group (P?=?0.56). There were no difference in 3-year survival for the laparoscopic versus the open surgery groups for advanced tumors (74 vs. 75%, P?=?0.88), N+?tumors (73 vs. 73%, P?=?0.99) and for the different AJCC stages (stage 1: 94 vs. 100%, stage 2: 89 vs. 82%, and stage 3: 50 vs. 50%, P?=?0.32, 0.83, and 0.98 respectively).

Conclusions

In this preliminary report, with 52% of advanced tumor, the 3-year overall and stage-by-stage survival was comparable for laparoscopic and open curative gastrectomy.