Achieve R0 Resection Research Articles

The selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre.

There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management. All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality/morbidity/Clavien-Dindo (CD) classification of morbidity, length of stay (LOS) and improvement of quality of life. There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) (39.0%), rectal recurrence (RR) (22.0%), locally advanced primary colon cancer (LAPCC T3c/d-T4) (21.1%), colon cancer recurrence (CR) (12.4%), locally advanced primary anal cancer (LAPAC-failure of CRT/T3c/d-T4) (3.0%) and anal cancer recurrence (AR) (2.2%). Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The LOS varied from 13.3 to 19.9days. RR operations had the highest morbidity (CD 1-2, 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals. Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardized referral pathway is encouraged.

Cholangiocarcinoma: results after treatment in a single institution in Medellin-Colombia

Objective: To describe the clinical and pathological features and prognostic factors and treatment outcomes in patients diagnosed with cholangiocarcinoma. Methods: Malignant Tumors of the bile duct originate specifically in the epithelium of the gallbladder and bile ducts. They are rare and correspond to 15% of hepatobiliary malignancies. The incidence rate in the United States of America is low, 1–2 cases for every 100,000 citizens, a slightly higher rate than that of Israel and Japan. In Colombia there is insufficient information available and therefore we don't understand the behavior of the illness among our population. Observational, descriptive, retrospective research from March of 2011 to March of 2016 of patients diagnosed with cholangiocarcinoma in the service of hepatobiliopancreatic diseases and transplants by the “IPS UNIVERSITARIA”. The evaluated results included: mortality, survival with surgical management and palliative, time of disease free and prognostic factors. Results: 109 patients were diagnosed with cholangiocarcinoma, 56 (51.37%) males, 53 (48.62%) females, of which 17 (15.59%) were intrahepatic, 57 (52.29%) hilar and 35 (32.11%) distal. Palliative treatment in 81 (74.31%) patients and surgical treatment in 28 (25.68%), of which 14 (50%) were Whipple and 14 (50%) hepatectomy, being achieved R0 resection in 22 (78.57%) patients and R1 resection in 6 (21.42%). The average overall survival time was 422 days, perioperative mortality of 14.28%. Conclusion: Cholangiocarcinoma is a complex and aggressive disease with a poor prognosis. Detection among patients in early stages and curative resection offer the best results for survival, though also high rates of morbidity and mortality.

Clinical effect of vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy for gastric cancer

Objective To explore the safety and feasibility of vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy for gastric cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 12 gastric cancer patients who underwent vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy at the Southwest Hospital of the Third Military Medical University from January 2015 to November 2016 were collected. All patients underwent vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy for gastric cancer. During operation, lymph node dissection of the pyloric region, the right side of the cardia and the superior margin of the pancreas were noticed, and other surgical procedures were the same as the traditional Da Vinci robot-assisted radical gastrectomy. Observation indicators: (1) intra- and post-operative situations: surgical methods, digestive tract reconstruction, operation time, volume of intraoperative blood loss, number of lymph node dissected, results of postoperative pathological examination, recovery time of gastrointestinal function, time for liquid diet intake, duration of postoperative hospital stay, short-term surgery-related complications (postoperative bleeding, anastomotic fistula, obstruction and intra-abdominal infection); (2) follow-up situations: postoperative long-term complications (gastric retention, alkaline reflux gastritis, dumping syndrome, gallbladder disease and cholelithiasis), postoperative quality of life (diet, upper abdominal discomfort, nausea, vomiting and diarrhea), postoperative nutritional status [body weight, hemoglobin (Hb), total protein (TP), albumin (Alb)] and tumor recurrence. Follow-up using telephone interview and outpatient examination was performed up to December 2016. Telephone interview included detecting diet of patients, digestive tract symptoms and body weight. Routine blood test, liver and kidney functions, tumor markers, chest X-ray, abdominal computed tomography (CT) or color Doppler ultrasound and gastroscopy of outpatient examinations were performed to detect tumor recurrence and metastasis. Measurement data with normal distribution were represented as ±s and measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative situations: all the 12 patients underwent successful vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy for gastric cancer, without conversion to laparoscopic surgery or open surgery, including 2 patients with D1 lymphadenectomy, 2 patients with extended D1 lymphadenectomy and 8 patients with D2 lympha-denectomy. Five and 7 patients underwent respectively Billroth Ⅰ anastomosis and Billroth Ⅱ anastomosis of digestive tract reconstruction. Operation time, volume of intraoperative blood loss and number of lymph node dissected of 12 patients were (247±34)minutes, (94±23)mL and 27±7, respectively. Results of postoperative pathological examination showed that distal and proximal surgical margins of 12 patients were negative and achieved R0 resection; 326 lymph nodes were dissected, 6 patients didn′t have lymph node metastasis and 18 positive lymph nodes were detected in 6 patients. Recovery time of gastrointestinal function, time for liquid diet intake and duration of postoperative hospital stay in 12 patients were (57±14)hours, (64±14)hours and (7.3±0.9)days, respectively. There was no occurrence of short-term surgery-related complications. (2) Follow-up situations: 12 patients were followed up by telephone interview (10 receiving outpatient examinations) for 9 months (range, 1-20 months). Of 12 patients with long-term complications, 2 had loss of appetite, 1 had diarrhea, without occurrence of cholelithiasis, cholecystitis, gastric retention and dumping syndrome. Of 10 patients receiving outpatient examinations, body weight, Hb, TP and Alb were (56±12)kg, (126±10)g/L, (69.9±5.1)g/L, (43.2±3.3)g/L at 1 month postoperatively and (52±13)kg, (126±10)g/L, (72.1±2.4)g/L, (45.2±1.6)g/L at 3 months postoperatively, respectively, with negative carcinoembryonic antigen. There was no tumor recurrence and metastasis in 12 patients. Conclusion Vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy is safe and feasible for gastric cancer, which has not affected the lymph node dissection and incidence of surgery-related complications, and it also can improve the postoperative quality of life and maintain good nutritional status. Key words: Gastric neoplasms; Radical gastrectomy; Da Vinci robotic surgical system; Vagus nerve-preserving

Surgical treatment of stage IV gastric cancer

Stage Ⅳ gastric cancer is defined as gastric cancer with non-curative factors, and the long-term survival rate of patients with stage Ⅳ gastric cancer is around 10%. Chemotherapy has been used for the main therapy of the patients with unresectable stage Ⅳ gastric cancer. Palliative resection of the primary tumor has been recommended only for presence of obstruction, bleeding and other surgical emergency. Debulking operation was irrelevant to the outcome that has been considered by research results. However, the patients with stage Ⅳ gastric cancer of only one non-curative factors (No.16a2, b1 lymph node enlargement; degree of peritoneal metastasis as P0 and positive peritoneal cytology; a small number of liver metastases) have good long-term survival when these patients have achieved R0 or R1 resection. In this regard, comprehensive treatment including surgical resection is the main treatment policy for the patients with stage Ⅳ gastric cancer. In recent years, some clini-cal studies on improvement of prognosis through surgical resection after conversion therapy have received extensive attention. Key words: Gastric neoplasms, stage Ⅳ; Surgical procedures, operative; Chemotherapy; Conversion therapy

Additional chemotherapy and salvage surgery for poor response to chemoradiotherapy in rectal cancers.

A proportion of locally advanced rectal cancer patients who receive neoadjuvant chemoradiotherapy (NACRT) are still unresectable. This study was undertaken to assess the outcomes of giving additional chemotherapy to rectal cancer patients with unresectable disease after NACRT. Patients with poor response to NACRT where mesorectal fascia was still involved on MRI and R0 resection was doubtful, received additional four cycles of chemotherapy with either CAPOX or FOLFIRINOX regimen, and the response was reevaluated with MRI and reassessed for surgical resection. Between June 2012 and December 2014, 50 patients received additional chemotherapy with CAPOX regime (19%, 38%) or FOLFIRINOX (31%, 62%) after CRT. Median number of chemotherapy cycles received was four (range 2-8 cycles). Overall 34 (68%) patients underwent exploration and 31 (62%) underwent R0 resection. The median time to surgery following chemoradiation was 5 months (range 3-18 months). Complete pathological response was seen in seven (22%) patients. Patients with poor response to NACRT may be further downstaged using additional chemotherapy so as to achieve R0 resection in 62% of cases.

Conversion surgery for unresectable gastric cancer following complete response of distant metastasis by systemic chemotherapy.

152 Background: In case of gastric cancer (GC), conversion surgery (CS) can be defined as resection of the primary cancer by gastrectomy which had not been originally planned but was indicated after confirming complete response (CR) in the distant metastasis (DM) by chemotherapy. In the present study, we looked at prognostic significance of CS, which is intended to cure originally unresectable GC. Methods: From 2004 to Feb in 2016, 24 GC patients who were treated by chemotherapy and achieved CR in DM underwent CS among 909 patients with gastrectomy in our department. 10 out of 24 patients who had peritoneal metastases (P) as a single non-curative factor underwent intraperitoneal chemotherapy (IP) in addition to systemic chemotherapy. CR was confirmed by CT and/or laparoscopic examination. Results: 15 patients had P, 13 had distant lymph node metastases (LYM), 2 had liver metastases, and 2 had lung metastases. Chemotherapeutic regimens consisted of systemic chemotherapy plus IP of taxane in 10 patients, S-1/CDDP in 7, capecitabine/CDDP/trastsuzumab in 3, and others in 4. Median duration of chemotherapy before surgery was 7.3 months (2.3-17.5). Total gastrectomy was performed in 18 patients and distal gastrectomy in 6, achieving R0 resection in 21 patients and R1 in 3. 10 patients with P who underwent IP relapsed within 12 months postoperatively except for 2 and had significantly shorter overall survival time than those with other DM except for P (median: 20 vs. 42 months, P = 0.004). Among 14 patients who had DM other than P as target lesions, 9 are disease-free with postoperative median follow up time of 35 months (6.8-82), and 5 patients had recurrence (LYM in 4 and P in 1) with postoperative median survival time of 25 months (4.8-45). DM of the patients without recurrence had achieved CR within shorter period (median: 3.6 vs. 6.7 months) and had higher pathological response rate of the primary lesion (89% vs. 40%) compared to patients with recurrence. Conclusions: Outcome of GC patients who underwent CS after achieving CR in DM was promising, especially in those without P. Further issues such as appropriate chemotherapeutic period, and prognostic factors to decide on the indication for CS need to be solved.

Treatment strategy for colorectal liver metastases: Clinical impact of FOLFOXIRI regimen for unresectable cases.

780 Background: Recent advances in systemic chemotherapy, including molecular target agents, can introduce “Conversion surgery” and achieve R0 resection even for initially unresectable colorectal liver metastasis (CRLM). We investigated the optimal indication for initial surgical induction and treatment strategy for unresectable CRLM. Methods: Our current surgical indication for CRLM as follows: i) curative resection is achievable, ii) no limitation of tumor size and number, and iii) future remnant liver volume over 35%. Additionally, same indication is applied even after chemotherapy.Two hundreds forty-one cases from 1994 to 2015, consisted of 134 initially resectable case and 107 unresectable cases, were included. Among 107 unresectable cases, 55 cases received current chemotherapy such as FOLFOX, FOLFILI, XEROX and FOLFOXIRI. Results: 1) Optimal indication for initially resectable case:Multivariate analysis revealed MDN (Maximum Diameter × Number) index more than 30 of metastatic liver tumor (HR3.06), non-curative resection of metastatic liver tumor (HR4.082) and poor differentiation of primary tumor (HR11.14).2) Treatment strategy of unresectable case for “Conversion surgery” (FOLFOXIRI vs. other regimen): Forty-two unresectable cases with MDN > 30 were included. Of those 14 cases, FOLFOXIRI regimen was applied. Regarding clinicopathological factors, the use of molecular targeted drug was introduced in all patients of FOLFOXIRI group, but 67.9% patients of other regimen group. The “Conversion” rate in FOLFIXIRI group and other regimen group were 64.3% and 39.3% (p = 0.126), and median period until “Conversion” were 6.2 courses and 11.8 courses (p = 0.038). Regarding tumor necrotic rate, FOLFOXIRI regimen induced higher necrotic rate than other regimen group (77.9% vs. 50.4%, p = 0.073). Overall survival in FOLFOXIRI group has been better than that in other regimen group and 3-years survival rates were 83.3% and 48.0% (p = 0.044). Also, relapse free survival in FOLFOXIRI group was significantly better than that in other regimen group (p = 0.002). Conclusions: MDN can predict surgical outcome for CRLM. FOLFOXIRI plus molecular target drug may be a promising option for CRLM with MDN > 30.

Downsizing of locally advanced stage III (bulky) BRAF V600E/K melanoma with combination targeted therapy to achieve R0 resection

Downsizing of locally advanced stage III (bulky) BRAF V600E/K melanoma with combination targeted therapy to achieve R0 resection

Phase II study of conversion therapy using S1/paclitaxel chemotherapy plus apatinib in unresectable gastric cancer (Ahead-G325 trial).

53 Background: Occasionally, an initially unresectable gastric cancer (GC) can be converted to a resectable one by chemotherapy. Combination with inhibitors against VEGFR-2 can lead to a clinical improvement. We aimed to investigate the efficacy and safety of S1/paclitaxel chemotherapy plus apatinib, a novel inhibitor of VEGFR-2, in the conversion therapy of unresectable GC. Methods: This was a multicentre, single-arm, open-label, phase II design. Eligible patients (pts) were aged 20-70 years and had histologically proven unresectable, HER-2 negative, advanced GC with a single non-curable factor confined to either the liver (H1), peritoneum (P1), or para-aortic lymph nodes (16a1/b2). The ECOG performance status was 0-2. No prior radiotherapy, chemotherapy, target therapy or immunotherapy was allowed. Patients received 2 cycles of S1/paclitaxel chemotherapy (S1: 60 mg, oral, bid for 2 weeks followed by a drug-free interval of 1 week; paclitaxel: 150 mg/m2, iv, 3h, on day 1) plus apatinib (500 mg, oral, qd) and 1 cycle of S1/paclitaxel chemotherapy prior to radical surgery. Three cycles of adjuvant chemotherapy (S1 and apatinib) were given 4-6 weeks after surgery. Primary endpoint was R0 resection rate. Thirty-three pts were enrolled. Results: Among the 28 pts eligible for preoperative efficacy evaluation, 21 achieved partial response (PR), 5 had stable disease (SD), and 2 had progressive disease (PD), resulting in an overall response rate of 75.0% and a disease control rate of 92.9%. Of the 21 pts with PR, 3 refused consents for surgery and 18 achieved R0 resection. The incidence of adverse events (AEs) was 73.9%. The common hematologic AEs were neutropenia (60.9%), leukopenia (52.2%) and hemoglobin decrease (47.8%), and nonhematologic AEs included hyperbilirubinemia (56.5%), hand-foot syndrome (34.8%), oral mucositis (30.4%), fatigue (30.4%), proteinuria (21.7%) and hypocalcemia (21.7%). There was no severe surgery-related complication. Conclusions: Combination of apatinib with S1/paclitaxel chemotherapy shows clinical benefits in unresectable GC, with acceptable safety profile. Clinical trial information: NCT02529878.

Role of cetuximab in conversion therapy in advanced KRAS WT colorectal cancer with liver limited disease: A systematic review and meta-analysis.

748 Background: Majority of advanced colorectal cancer (CRC) patients with liver limited disease (LLD) that undergo curative partial liver resection relapse within 5 years. Peri-operative chemotherapy is currently utilized, however the benefit of this is modest only. The addition of anti-EGFR therapy with cetuximab to chemotherapy has consistently demonstrated improvements in objective response rate (ORR) but its impact on potentially curative R0 resection, progression free survival (PFS) and overall survival (OS) remains debatable. The aim of this study was to evaluate the evidence for the use of cetuximab with chemotherapy, in the peri-operative setting for patients with advanced KRAS-WT CRC and unresectable LLD. Methods: Comprehensive literature search was conducted using PubMed and MEDLINE. Inclusion criteria identified studies evaluating the efficacy of chemotherapy and cetuximab vs. chemotherapy alone in advanced KRAS-WT CRC with unresectable LLD. Phase II studies evaluating chemotherapy-cetuximab without control arms were also included. Pooled data was included in meta-analysis and analysed using the Stata v.7. The primary endpoint was the R0 resection rate. Secondary endpoints were ORR, PFS and OS. Results: 5 trials, describing a total of 617 patients, were included in the analysis1–5. Patients receiving cetuximab in addition to chemotherapy were more likely to achieve R0 resection than patients receiving chemotherapy alone (OR 2.13; 95% CI 1.23-3.68, p < 0.05). Patients on cetuximab had improved ORR compared to patients not on cetuximab (OR 2.59; 95% CI 1.74-3.87, p < 0.05). Patients receiving cetuximab had a mean PFS 3.1 months higher than patients not on cetuximab (95% CI 2.76-3.45, p < 0.05). Patients on cetuximab also had a mean OS 0.67 months longer than those not on cetuximab (95% CI 0.44-0.91, p < 0.05). Conclusions: The addition of cetuximab to chemotherapy in the treatment of advanced KRAS-WT CRC with unresectable LLD leads to better outcomes compared to chemotherapy alone.

A Novel Neoadjuvant Therapy for Operable Locally Invasive Non–Small-Cell Lung Cancer. Phase I Study of Neoadjuvant Stereotactic Body Radiotherapy. LINNEARRE I (NCT02433574)

BackgroundDespite improved staging and surgical techniques, the rate of incomplete resection (R1) of non–small-cell lung cancer (NSCLC) has not significantly decreased. Patients with R1 resection have worse survival compared with those with complete resection (R0). Stereotactic body radiotherapy (SBRT) is a rapid and convenient radiotherapy treatment that delivers high-dose radiotherapy to tumors with high precision while sparing normal organs. Although its efficacy in treating small lung tumors is documented, its use as neoadjuvant therapy for locally advanced (LA) NSCLC has not been examined. We hypothesized that a short course of preoperative SBRT is feasible and can be delivered safely as a neoadjuvant therapy in patients at risk for incomplete resection. MethodsIn this phase I study, 20 patients with cT3 to 4, N0 to 1, M0 NSCLC at risk for incomplete resection will be treated with neoadjuvant SBRT followed by surgery and adjuvant chemotherapy. Four groups of 5 patients will be treated with escalating doses (35, 40, 45, and 50 Gy) in 10 daily fractions. The primary outcome is feasibility (ie, the ability to complete SBRT and surgery as planned; within 7 weeks). Secondary outcomes include acute and late adverse events; R0, R1, and R2 rates; and secondary surrogates of feasibility and safety. RelevanceThis study is an important first step in introducing a new therapeutic modality to patients with LA NSCLC that could improve surgical outcomes in the future. If neoadjuvant SBRT is found to be feasible and safe for LA NSCLC, its effect in achieving R0 resection could be investigated in randomized trials.

Locally advanced pancreatic cancer successfully treated by distal pancreatectomy with celiac axis resection (DP-CAR) after S-1 with radiation therapy followed by gemcitabine/nab-paclitaxel therapy: a case report

BackgroundThe prognosis for pancreatic cancer remains dismal because many patients are diagnosed with unresectable cancer at the initial diagnosis. Recently, conversion surgery was reported as an effective treatment for initially unresectable pancreatic cancer with a favorable response to non-surgical treatment lasting over 240 days. Here, we describe a case of locally advanced pancreatic cancer (LAPC) successfully resected after treatment with S-1 and radiation followed by gemcitabine/nab-paclitaxel therapy.Case presentationA 73-year-old man with LAPC was referred to our hospital. Computed tomography findings revealed a 2.5-cm mass in the pancreatic body that had invaded the celiac artery, common hepatic artery, and splenic artery. Superior mesenteric artery (SMA) encasement was not observed, but tumor abutment over 180° with the main tumor was detected. Staging laparoscopy showed no findings of distant metastasis, and washing cytology revealed no malignancy. He was diagnosed with unresectable pancreatic cancer. Treatment with S-1 with radiation therapy followed by gemcitabine with nab-paclitaxel was performed. Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and encasement of the main artery was diminished. Though abutment to the main artery, including the SMA, was still detected, distal pancreatectomy with celiac artery resection was performed. The histopathological findings around the celiac artery revealed fibrous changes with an Evans classification of grade IIb. There was no residual cancer at the periphery; thus, R0 resection was achieved. The patient has been healthy and without recurrence for more than 12 months since the initial treatment.ConclusionsGemcitabine/nab-paclitaxel therapy revealed high response rate for metastasic pancreatic cancer (PC), but the effect for LAPC proposing conversion surgery was not well discussed. In this case, we achieve R0 resection combined with chemoradiation therapy and gemcitabine/nab-paclitaxel therapy. This regimen was also effective for LAPC and may be used to increase the population of conversion surgery by its high response rate.

Metastasectomy for recurrent or metastatic biliary tract cancers: A single center experience.

To assess efficacy or long-term result of metastasectomy for recurrent or metastatic biliary tract carcinoma (BTC), we conducted a retrospective review of the outcomes of metastasectomy for recurrent or metastatic BTCs, comprising intrahepatic cholangiocellular carcinoma (IHCCC), proximal and distal common bile duct cancer (pCBDC and dCBDC), gallbladder cancer (GBC), and ampulla of Vater cancer (AoVC). The clinicopathological features and outcomes of BTC patients who underwent surgical resection for the primary and metastatic disease at the Gachon University Gil Medical Centre from 2003 to 2013 were reviewed retrospectively. We found 19 eligible patients. Primary sites were GBC (seven patients, 37%), IHCCC (five patients, 26%), dCBDC (three patients, 16%), pCBDC (two patients, 11%), and AoVC (two patients, 11%). Eight patients (42%) had synchronous metastasis whereas 11 (58%) had metachronous metastasis. The most common metastatic site was liver (nine patients, 47%), lymph node (nine patients, 47%), and peritoneum (three patients, 16%). Nine patients (47%) achieved R0 resection, whereas four (21%) and six (32%) patients had R1 and R2 resection, respectively. With a median follow-up period of 26.7 months, the estimated median overall survival (OS) was 18.2 months (95% confidence interval, 13.6-22.9 months). Lower Eastern Cooperative Oncology Group performance status (P = 0.023), metachronous metastasis (P = 0.04), absence of lymph node metastasis (P = 0.009), lower numbers of metastatic organs (P < 0.001), normal postoperative CA19-9 level (P = 0.034), and time from diagnosis to metastasectomy more than 1 year (P = 0.019) were identified as prognostic factors for a longer OS after metastasectomy. For recurrent or metastatic BTCs, metastasectomy can be a viable option for selected patients.

Modified docetaxel, cisplatin and capecitabine for stage IV gastric cancer in Japanese patients: A feasibility study.

AIMTo evaluate the feasibility of chemotherapy including fluoropyrimidine, platinum and taxane with modified dosages for unresectable gastric cancer in Japanese patients.METHODSWe performed a feasibility study of a modified docetaxel, cisplatin and capecitabine (DCX) regimen for stage IV gastric cancer. In particular, 30 or 40 mg/m2 of docetaxel on day 1, 60 mg/m2 of cisplatin on day 1, and 2000 mg/m2 of capecitabine for 2 wk were administered every three weeks.RESULTSThree patients were treated with modified DCX (mDCX) with 30 mg/m2 docetaxel, and five patients were treated with this regimen with 40 mg/m2 docetaxel. Grade 3 or 4 neutropenia was observed in six of the eight patients; no patients exhibited febrile neutropenia. Partial response was achieved in four of the eight patients. Three patients underwent gastrectomy, which achieved R0 resection without residual tumors in dissected lymph nodes. In one of these three patients, resected specimens revealed pathological complete response in the primary lesion and in lymph nodes.CONCLUSIONmDCX was well tolerated by Japanese patients with stage IV gastric cancer. This regimen might be useful for allowing gastric cancer patients with distant lymph node metastasis to undergo conversion surgery.

Role of splenectomy in proximal gastric cancer patients undergoing total gastrectomy.

The aim of the addition of splenectomy to a D2 gastrectomy in patients with gastric cancer is to achieve R0 resection and to improve patient survival. However, the survival benefit of splenectomy remains uncertain and the associated morbidity and mortality rates may compromise the beneficial effects of splenectomy (1,2). Given splenic hilar lymph node metastasis has not been observed in early gastric cancer (3), researchers have suggested that a splenectomy for the purpose of splenic hilar node clearance should be performed for patients with high suspicion of metastasis near the splenic hilum or direct tumor invasion of the spleen (3-6).

Perioperative Triplet Chemotherapy and Cetuximab in Patients With RAS Wild Type High Recurrence Risk or Borderline Resectable Colorectal Cancer Liver Metastases

BackgroundFor borderline resectable colorectal cancer liver metastases (CLM), systemic treatment can help to achieve R0 resection and reduce the risk of relapse. We assessed the role of perioperative triplet chemotherapy in combination with cetuximab in patients with RAS wild type high recurrence risk and/or borderline resectable CLM. Patients and MethodsThis was a monocenter, open-label phase II study. Borderline resectability was defined technically as tumor involvement of >1 hepatic vein, or >4 hepatic segments, need for 2-stage hepatectomy or radiofrequency ablation, and/or biologically (high risk): ≥4 metastatic nodules, or synchronous metastases. Patients were treated with 4 pre- and postoperative cycles of biweekly COI-E (cetuximab 500 mg/m2 and irinotecan 180 mg/m2 on day 1, oxaliplatin 85 mg/m2 on day 2, and capecitabine 1000 mg/m2 twice per day on days 2-6). The primary end point was overall response rate. ResultsForty patients were enrolled. Nine patients with KRAS mutation were excluded after amendment in 2010. In an extended RAS test we did not find additional RAS mutations. The final population was comprised of 31 patients with RAS wild type CLM (technically borderline resectable 39%; synchronous 84%; ≥4 metastatic nodules 29%). The overall response, R0 resection, and pathological response rates were 87%, 84%, and 33%, respectively. At a median follow-up of 4 years, median progression-free survival and overall survival were 17.8 and 62.5 months, respectively. Treatment toxicity was relevant but did not jeopardize the surgical plan. ConclusionThe COI-E regimen was associated with high response and R0 resection rates in patients with RAS wild type CLM with borderline resectability and/or high-risk features.

Clinical and pathologic parameters predicting recurrence of facial basal cell carcinoma: a retrospective audit in an advanced care center.

This study was designed to investigate the associations between clinical, pathologic, and therapeutic parameters of facial basal cell carcinoma (BCC) and recurrence rates in patients treated at an advanced care center. A retrospective cohort study was performed. Patients who presented to an advanced care center within a 6-year period with facial BCC and who received surgical treatment were included for further review according to predefined inclusion criteria. The predictor variable was defined as "negative-margin (R0) resection after the first surgery". The primary outcome variable was defined as "BCC recurrence". Descriptive and inferential statistics were computed. The significance level was set at P ≤ 0.05. A total of 71 patients (29 female, 42 male; average age: 71.76 years) were found to meet all of the study inclusion criteria. All BCCs had been referred, and 50.7% had been submitted to previous surgery. The mean ± standard deviation tumor diameter was 2.3 ± 1.8 cm. Recurrence of BCC was observed in 11 patients (15.5%). Large tumor diameters, increased patient age, and failure to achieve R0 resection at the first surgical appointment significantly increased recurrence rates. Complete facial BCC excision at the first surgical appointment is pivotal in reducing the likelihood of recurrence. The influence of the anatomic location of facial BCC on recurrence rates may be limited.

Initial Experience of Robotic Sleeve Resection for Lung Cancer Patients

The purpose of this study was to identify the technical aspects and short-term results of robotic sleeve resection for lung cancer patients. Twenty-one consecutive cases of robotic sleeve resection from September 2014 to September 2015 were reviewed. There were 17 single sleeve resection (bronchial) and 4 double sleeve resection (bronchial and vascular) cases. Nineteen of 21 cases (90.5%) achieved R0 resection. The mean console time was 120.4 ± 37.3 minutes. The mean operation time was 158.4 ± 42.0 minutes. There was no massive bleeding (800 mL or more) during operation. The mean intraoperative blood loss was 157.1 ± 97.8 mL. One case (4.8%) was converted to thoracotomy owing to severe calcification of lymph node. There was no intraoperative death. The overall complication rate was 19.0%. The major complications were subcutaneous emphysema (14.4%), cardiac arrhythmia (9.6%), pneumonia (9.6%), pyothorax (9.6%), bronchial anastomosis bleeding (4.8%), bronchial anastomosis leakage (4.8%), and multiple organ failure (4.8%). The 30-day mortality rate was 4.8%. The mean postoperative length of stay was 10.7 ± 7.6 days. Robotic sleeve resection is technically feasible and can be carried out with acceptable short-term results.

Pre-operative chemoradiotherapy using capecitabine and cetuximab followed by definitive surgery in patients with operable rectal cancer

BackgroundAchieving a high rate of complete pathological response with pre-operative chemoradiotherapy in rectal cancer is an unmet need. We evaluated the efficacy and toxicity of the combination of cetuximab, capecitabine and radiation therapy in the pre-operative setting of localized rectal cancer. Patients and methodsPatients with clinically staged T3, T4 or nodepositive rectal cancer were treated with concurrent capecitabine and radiotherapy with weekly cetuximab starting one week before the start of radiation. This was followed by total mesorectal excision within 6-8 weeks. All patients achieving R0 resection received adjuvant capecitabine for 6 cycles. ResultsFifteen patients were treated and all underwent surgery. Sphincter preservation was achieved in 11 patients (73.3%) and pathological complete response in two. With a median follow up of 48 months (range 8.4-57.5), 12 patients were relapse-free and 14 were alive with 4-year relapse free survival of 80%. Overall survival was 93%. Significant grade 3 and 4 toxicity was mainly cetuximab-induced skin reactions (33%), radiation-induced skin toxicity (13%) and diarrhea (20%). ConclusionsAdding cetuximab to pre-operative concurrent capecitabine and radiotherapy provides modest efficacy with manageable toxicity.

Expression and clinical significance of C-terminal tensin-like protein in colorectal cancer

Objective To investigate the expression of C-terminal tensin-like (CTEN) protein and its correlations with clinicopathological characteristics and prognosis in patients with colorectal cancer. Methods The retrospective case-control study was adopted. The clinical data of 153 patients with colorectal cancer who were admitted to the Affiliated Hospital of Jiangsu University between January 2010 and December 2012 were collected. The expression of CTEN protein were detected by immunohistochemistry. Observed indices included: (1) expression of CTEN protein was detected by immunohistochemistry. (2) Relationships between the expressions of CTEN protein and clinicopathological characteristics of patients. (3) Relationships between the expressions of CTEN protein and prognosis of patients. The follow-up of telephone interview was performed to detect survival of patients untill May 2015. Count data were analyzed using two-sided chi-square test. Survival curve was drawn using the Kaplan-Meier method, and survival analyses was done using the Log-rank test. Univariate and multivariate analyses of prognosis were done using COX regression model. Results (1) Expressions of CTEN protein in cancer tissues and adjacent tissues were located at the cytoplasms. The positive expression rate of CTEN protein was 92.16%(141/153) and 20.26%(31/153) in cancer tissues and adjacent tissues, respectively, with a statistically significant difference (χ2=160.647, P 0.05). All the 153 patients were followed up for 4.8-62.3 months with a median time of 27.5 months. The 3-year tumor-free survival (Ⅰ-Ⅲ stages) and overall survival (Ⅰ-Ⅳ stages) rates were 52.23% and 39.71% of patients with high expression of CTEN protein, 76.89% and 74.12% in patients with low expression of CTEN protein, respectively, showing significant differences (χ2=15.727, 15.131, P<0.05). Patients with colorectal cancer of Ⅳ stages didn′t achieve R0 resection and were not involved in tumor-free survival. Results of univariate analysis showed that tumor maximum diameter, histologic grade, TNM stage, tumor with perineural and/or vascular invasion and expression of CTEN protein were associated with the prognosis of patients [HR=4.39, 2.08, 5.73, 3.56, 2.03, 95% confidence interval (CI): 2.49-7.74, 2.21-3.55, 3.29-9.98, 1.82-6.95, 1.18-3.48, P<0.05]. Results of multivariate analysis showed that maximum diameter≥5 cm, Ⅳ stage of TNM stage and high expression CTEN protein were independent risk factors affecting the poor prognosis of patients with colorectal cancer (HR=2.24, 3.57, 2.03, 95 %CI: 1.13-4.20, 1.94-6.59, 1.03-3.98, P<0.05). Conclusions The expression of CTEN protein is up-regelated in colorectal cancer compared with adjacent normal tissues. There is increased expression of CTEN protein in colorectal cancer tissues with maximum diameter of tumor ≥5 cm, high TNM stage and perineural and/or vascular invasion. High expression of CTEN protein is also an independent predicting factor of prognosis. Key words: Colorectal neoplasms; C-terminal tensin-like protein; Prognosis; Immunohistochemical staining