Circumferential Tumor Research Articles

Validity of endoscopic resection for clinically diagnosed T1a-MM/T1b-SM1 N0 M0 esophageal squamous cell carcinoma.

Previous guidelines have not described clear recommendations for performing endoscopic resection (ER) of T1a-muscularis mucosa (MM)/T1b-submucosal (SM1) cancers that have invaded ≤ 200μm because these are considered to have a non-negligible risk of metastasis based on previous analyses of pathologically diagnosed (p)MM/SM1 cancers. Considering that the indication for ER is determined based on a clinical diagnosis, the applicability of ER should be investigated in clinical (c)MM/SM1 but not pMM/SM1 cancers. This study aimed to evaluate validity of ER for cMM/SM1 cancers. In total, 175 cMM/SM1 esophageal squamous cell carcinoma cases that were endoscopically or surgically resected between January 2008 and December 2018 were identified from a prospectively maintained database. We histologically evaluated resected specimens and divided them into low- (n = 92) and high-risk (n = 83) cancers for metastasis. Univariate analysis showed that longer tumor length and larger circumferential extent were significantly correlated with high-risk cancer (P < 0.001). Multivariate analysis showed that tumor circumference was an independent predictor of high-risk cancer (P = 0.036). The proportion of low-risk cancers among cases with ≤ 3/4, > 3/4 and < 1, and whole circumferential extent were 59, 17, and 14%, respectively, and the post-ER stricture rates of these groups were 12, 33, and 100%, respectively. ER is the first-line treatment for cMM/SM1 cancers with ≤ 3/4 circumferential extent considering that 59% of cMM/SM1 cancers were low-risk cancers for which ER is mostly curative. ER is not recommended for whole circumferential cMM/SM1 cancers given the low proportion of low-risk cancers and the high risk of stricture after ER.

Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up

ABSTRACT BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62% CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure Keywords: rectal cancer, extralevator abdominoperineal excision, local recurrence, overall survival

Predictive factors of pathological complete response after neoadjuvant chemoradiotherapy for middle-low rectal cancer

Objective: To explore the predictive factors of pathological complete response (pCR) after neoadjuvant chemoradiotherapy for middle-low rectal cancer. Methods: A case-control study was conducted. The inclusion criteria were as follows: (1) colonoscopy, digital examination or magnetic resonance imaging (MRI) showed a distance from the lower edge of the tumor to the dentate line of no more than 10 cm; (2) complete clinicopathological data were available; (3) preoperative biopsy revealed adenocarcinoma; (4) preoperative pelvic MRI or endorectal ultrasonography was performed; (5) no distant metastasis was found. Exclusion criteria: (1) preoperative radiotherapy and chemotherapy were not administrated according to the standard; (2) simultaneous multiple primary cancer and familial adenomatous polyposis were observed. According to the above criteria, clinicopathological data of 245 patients with middle-low rectal cancer undergoing preoperative neoadjuvant chemoradiotherapy in Changhai Hospital of Navy Medical University from January 2012 to December 2019 were retrospectively collected. Univariate analysis and multivariate logistic analysis were used to identify the clinical factors predicting pCR. pCR is defined as complete disappearance of cancer cells under the microscope in cancer specimens (including lymph nodes) after neoadjuvant chemoradiotherapy. Results: A total of 72 patients with pCR were enrolled in this study. Univariate analysis showed that preoperative T stage, tumor circumference, tumor morphology, carbohydrate antigen (CA) 19-9, interval between the end of neoadjuvant therapy and operation were associated with pCR (all P<0.05). The above 5 variables were included in multivariate logistic analysis and the results revealed that the T stage (OR=5.743, 95% CI: 2.416-13.648, P<0.001), tumor circumference (OR=7.754, 95% CI: 3.822-15.733, P<0.001), tumor morphology (OR=0.264, 95% CI: 0.089-0.786, P=0.017) and the interval between the end of neoadjuvant therapy and operation (OR=0.303, 95% CI: 0.147-0.625, P=0.001) were independent predictive factors of pCR, while CA 19-9 level was not an independent factor (OR=1.873, 95% CI:0.372-9.436, P=0.447). Conclusion: By knowing the clinical features of preoperative T stage, tumor circumference, tumor morphology and the interval between neoadjuvant chemoradiotherapy and operation, patients with higher likelyhood of pCR after neoadjuvant chemoradiotherapy may be identified.

Temporal Change and Risk Factor of Esophageal Stenosis after Salvage Radiotherapy for Superficial Esophageal Cancer with Non-Curative Endoscopic Submucosal Dissection

Recent studies revealed the favorable outcomes of chemoradiotherapy for superficial esophageal cancer, so much attention has been paid to radiotherapy (RT) for an additional treatment after non-curative endoscopic submucosal dissection (ESD) as an organ preservation strategy. Although one concern regarding toxicity in this treatment strategy is esophageal stenosis, there are no reports about its detail. The aim of this study is to investigate esophageal stenosis after salvage RT for superficial esophageal cancer with non-curative ESD. We retrospectively reviewed 50 superficial esophageal cancer patients received salvage RT after non-curative ESD at one institution between 2011 and 2018. Tumor location was cervical/upper thoracic/middle thoracic/lower thoracic in 5/4/29/12 patients, respectively. Pathological invasion depth was mucosal/submucosal/muscularis propria in 20/29/1 patients, respectively. Median tumor length was 3 cm (range: 0.5-10 cm) and the circumference of tumor was more than three quarters in 10 patients. Prevention of stenosis such as oral prednisolone or intralesional steroid injection was performed in 21 patients. Median total dose was 60 Gy/30 fractions (range: 40-66 Gy). Forty-five patients received concurrent chemotherapy. Comparison of date was analyzed by Fisher’s exact test. P-values <0.05 were considered to indicate statistical significance. Median follow-up time was 43 months (range: 12-91) for all patients. Grade 2 esophageal stenosis was observed in 16 patients and grade 3 was observed in 3 patients. Grade 3 esophageal stenosis was significantly higher in cervical esophageal cancer (p = 0.02). The frequency of grade 2 or worse esophageal stenosis decreased over time (before RT, 6 months after RT, 1year, 2years: 15, 13, 10, 6 patients). Endoscopic balloon dilation (EBD) was performed in 10 patients before RT and in 14 patients after RT. Nine of 10 patients who received EBD before RT needed EBD after RT. Only one patient needed EBD regularly one year after RT. All grade 3 esophageal stenosis improved grade 2 or less by EBD. Tumor circumference ≥ three quarters, tumor length ≥ 4 cm, implementation of stenosis prevention, and diabetes were significantly associated with EBD (p<0.05). Total dose and pathological invasion depth were not associated in EBD. Esophageal stenosis after salvage RT for esophageal cancer with non-curative ESD improved over time by natural course or EBD, and only few cases required long-term EBD. Our results suggest esophageal stenosis was manageable and acceptable. However, cervical esophageal cancer is a risk factor of severe esophageal stenosis, so we consider that it is important to carefully determine the indication for ESD in those cases.

S2915 Endoscopic Retrieval of Retained Video Capsule in Small Intestine Obscure Occult Gastrointestinal Bleeding

INTRODUCTION: Despite significant symptoms of iron deficiency anemia, subtle and ominous luminal pathology may be missed in the small intestine on both dedicated cross-sectional imaging and conventional endoscopic evaluation. In such cases, video capsule endoscopy may prove invaluable - although not without risk. CASE DESCRIPTION/METHODS: A 56-year-old man developed recurrent, symptomatic transfusion-dependent iron deficiency anemia and fecal occult positive stool despite no overt gastrointestinal bleeding. He had undergone subtotal colectomy with ileorectal anastomosis three years earlier for colorectal cancer and was on hemodialysis for end-stage renal failure. Recent negative evaluation included esophagogastroduodenoscopy, ileo-colonoscopy, computed tomogram enteroclysis, and push enteroscopy to the distal duodenum. Informed consent was obtained for video capsule endoscopy (VCE), including risk counseling for capsule retention. VCE showed fresh blood and recurring views of an ulcerated nodular lesion on multiple frames (Figure A, blue arrow) twenty hours into recording. The patient had no signs and symptoms of bowel obstruction. However, abdominal x-ray on two consecutive days revealed no change in capsule location in the left upper quadrant (Figure B). Repeat push enteroscopy identified the retained capsule in the proximal jejunum and a partially obstructing circumferential tumor distal to it (Figure C). The capsule was retrieved with a Roth net and the site was tattooed. Histology showed moderately differentiated adenocarcinoma. The jejunal tumor was removed surgically. DISCUSSION: This case illustrates a presentation of obscure occult gastrointestinal bleeding secondary to small bowel adenocarcinoma diagnosed by retained video capsule endoscopy. While the risk of capsule retention is low, informed consent regarding this risk is paramount. Once the capsule is retained, definitive curative resection of the affected small bowel section is almost mandatory irrespective of pathology. Retrieval of retained capsules in patients without clinical small bowel obstruction may be feasible endoscopically. Simultaneous endoscopic examination of the partially obstructed site can further facilitate diagnosis and location marking prior to surgery. Simple, cheap and readily available investigations such as serial abdominal x-rays can have an adjunct role in putting the pieces together to solve a seemingly complex diagnostic puzzle.Figure 1.: Figure A: Ulcerated nodular lesion (red arrow) in the small bowel on persistent views on video capsule endoscopy several hours into recording.Figure 2.: Figure B: Abdominal x-ray showing unchanged video capsule location (red arrow) in the left upper quadrant.Figure 3.: Figure C: Endoscopic view of retained video capsule (red arrow) in the proximal jejunum and a partially obstructing tumor distal to it (blue arrow).

Retrospective risk analysis for acute urinary dysfunction after laparoscopic rectal cancer surgery in patients receiving epidural analgesia.

Urinary dysfunction (UD) is a frequent complication following rectal surgery. The aim of the present study was to investigate the risk factors for acute UD after laparoscopic low anterior resection (LALAR) for rectal cancer in patients receiving epidural analgesia. A retrospective study was conducted on 131 patients who underwent LALAR among those receiving epidural analgesia in a single institution between October 2008 and December 2019. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with acute UD. The overall incidence of acute UD was 16.0% (21/131). Univariate analysis showed that older age (P = 0.016) and earlier urinary catheter removal (P = 0.036) were associated with acute UD. Multivariate logistic regression analysis revealed that older age (10-year increments; odds ratio (OR) 2.046, 95% confidence interval (CI) 1.171-3.543, P = 0.011), urinary catheter removal before epidural analgesia discontinuation (OR 6.393, 95% CI 1.540-26.534, P = 0.011), and a large tumor circumference rate (10% increments; OR 1.263, 95% CI 1.043-1.530, P = 0.017) were independent risk factors for acute UD. Our findings suggest that older age, early removal of urinal catheter before epidural analgesia discontinuation, and large tumor circumference rate are risk factors of acute UD after LALAR for rectal cancer in patients receiving epidural analgesia.

A case of laparoscopy and endoscopy cooperative surgery for circumferential superficial nonampullary duodenal epithelial tumor.

A case of laparoscopy and endoscopy cooperative surgery for circumferential superficial nonampullary duodenal epithelial tumor.

Factors of incomplete colonoscopy for stenosing colorectal cancer: CT colonography features.

The purpose of this study was to examine the relation between computed tomography colonoscopy (CTC) features of colorectal cancer (CRC) and incomplete colonoscopy. The subjects of this retrospective study consisted of 108 patients with advanced CRC (57 men, 51 women; age range, 32-87years; median, 65years) who underwent CTC. We compared local CTC features between the groups of complete (n = 74) and incomplete colonoscopy (n = 34). We performed a receiver operating characteristic (ROC) analysis to assess a diagnostic performance of CTC features to predict incomplete colonoscopy. The cross-sectional area of tumor and stenosis of complete colonoscopy group were significantly smaller and larger than those of incomplete colonoscopy group (p = 0.001 and < 0.001). Circumferential tumor extent rate (CER) showed significantly higher in the incomplete colonoscopy group than complete colonoscopy group (p < 0.001). In the ROC analysis, the cross-sectional area of stenosis showed AUC of 0.916, which was the best to predict incomplete colonoscopy. CTC features including larger cross-sectional area of tumor, smaller cross-sectional area of stenosis and 100% CER were significantly associated with incomplete colonoscopy for the patients with CRC.

MB-FSGAN: Joint segmentation and quantification of kidney tumor on CT by the multi-branch feature sharing generative adversarial network.

The segmentation of the kidney tumor and the quantification of its tumor indices (i.e., the center point coordinates, diameter, circumference, and cross-sectional area of the tumor) are important steps in tumor therapy. These quantifies the tumor morphometrical details to monitor disease progression and accurately compare decisions regarding the kidney tumor treatment. However, manual segmentation and quantification is a challenging and time-consuming process in practice and exhibit a high degree of variability within and between operators. In this paper, MB-FSGAN (multi-branch feature sharing generative adversarial network) is proposed for simultaneous segmentation and quantification of kidney tumor on CT. MB-FSGAN consists of multi-scale feature extractor (MSFE), locator of the area of interest (LROI), and feature sharing generative adversarial network (FSGAN). MSFE makes strong semantic information on different scale feature maps, which is particularly effective in detecting small tumor targets. The LROI extracts the region of interest of the tumor, greatly reducing the time complexity of the network. FSGAN correctly segments and quantifies kidney tumors through joint learning and adversarial learning, which effectively exploited the commonalities and differences between the two related tasks. Experiments are performed on CT of 113 kidney tumor patients. For segmentation, MB-FSGAN achieves a pixel accuracy of 95.7%. For the quantification of five tumor indices, the R2 coefficient of tumor circumference is 0.9465. The results show that the network has reliable performance and shows its effectiveness and potential as a clinical tool.

The prognostic role of horizontal and circumferential tumor extent in cervical cancer: Implications for the 2019 FIGO staging system

ObjectiveThe FIGO 2019 update on cervical cancer staging removed horizontal tumor extent (HZTE) as a staging variable. Evidence is needed to substantiate this change. The prognostic significance of HZTE and a related variable, circumferential tumor extent (%CTE), is similarly unknown. We aimed to investigate the association of HZTE and %CTE with survival outcomes in cervical cancer patients. MethodsWe identified patients treated with primary surgery for stage I cervical cancer in a single institution during a 9-year period. HZTE and, when available, %CTE were obtained from pathology records. Cases were staged using 2019 FIGO staging. Correlations between HZTE, %CTE and FIGO stage with recurrence-free (RFS) and disease-specific survival (DSS) were determined using univariable and multivariable analyses. Results285 patients were included with a median follow-up of 48 (range 7–123) months. HZTE was statistically associated with RFS and DSS on univariate and multivariate analysis. None of the 168 stage IA patients in our series had tumor recurrence or death during follow-up, including 42 with HZTE ≥7 mm. None of the patients with a tumor horizontal extent <7 mm experienced recurrence or death. %CTE correlated only with RFS on univariate analysis. 2019 FIGO stage did not independently correlate with RFS or DSS in our sample. ConclusionsHZTE is an independent predictor of survival in cervical carcinoma. In stage IA tumors, however, HZTE does not offer superior prognostic value, supporting the 2019 FIGO recommendations to remove this variable from staging in these cases. HZTE may be useful in larger tumors in which staging depends on maximum tumor size. %CTE is not an independent prognostic variable in cervical cancer, and we advise against its use.

Pancreaticoduodenectomy for a primary duodenal capicua transcriptional repressor (CIC) -rearranged sarcoma with severe bleeding: a case report

BackgroundCapicua transcriptional repressor (CIC) -rearranged sarcoma is characterized by small round cells, histologically similar to Ewing sarcoma. However, CIC-rearranged sarcoma has different clinical, histological, and immunohistochemical features from Ewing sarcoma. It is important to differentiate between these tumors.Case presentationThe patient is a 44-year-old man with a duodenal tumor diagnosed in another hospital who presented with a history of melena. Laboratory studies showed anemia with a serum hemoglobin of 6.0 g/dL. He was hospitalized and gastrointestinal bleeding was controlled successfully with endoscopy. However, he suffered from appetite loss and vomiting and progression of anemia a few weeks after presentation. Upper gastrointestinal endoscopy showed a circumferential soft tumor in the second portion of the duodenum and the endoscope could not pass distally. Computed tomography scan showed a greater than 10 cm tumor in the duodenum, with compression of the inferior vena cava and infiltrating the ascending colon. A definitive pathologic diagnosis could not be established despite four biopsies from the tumor edge. Due to gastrointestinal obstruction and progression of anemia, a pylorus-preserving pancreaticoduodenectomy with partial resection of the inferior vena cava and right hemicolectomy was performed as a complete tumor resection. The tumor was diagnosed as a CIC-rearranged sarcoma, but 2 months postoperatively local recurrence and distant metastases to the liver and lung were found. The patient died 3 months after surgery.ConclusionsAlthough the only definitive treatment for CIC-rearranged sarcoma is surgical resection, the CIC-rearranged sarcoma is highly malignant with a poor prognosis even after radical resection. More research is needed to establish optimal treatment strategies.

The impact of circumferential tumour location on the clinical outcome of rectal cancer patients managed with neoadjuvant chemoradiotherapy followed by total mesorectal excision

AimTo investigate the impact of circumferential tumour location on neoadjuvant chemoradiotherapy (CRT) response and its prognostic value for locally advanced rectal cancer (LARC) patients after CRT and surgery. MethodsA retrospective study was performed on 486 patients with LARC who received neoadjuvant CRT and surgical treatment. The rate of pathological complete response (pCR) and survival among patients with anteriorly, laterally, and posteriorly located tumours were compared. Logistic regression was performed to identify pCR predictors. ResultsThe anterior tumours exhibited the highest pCR rate of 26.7%, which was slightly higher than the 20.0% and 12.3% for lateral and posterior tumours, respectively (P = 0.006). The 5-year Overall survival (OS) rates after CRT were similar among the anterior, lateral, and posterior groups (anterior vs lateral vs posterior: 81.1% vs 89.9% vs 84.1%, P = 0.6368). Multivariate analysis revealed that the circumferential tumour location, post-CRT serum CEA and post-CRT tumour thickness measured by MRI were independently correlated with achieving pCR. ConclusionThis study is the first, to the best of our knowledge, to show that anterior LARC exhibited the highest pCR rate after neoadjuvant CRT. Patients with anterior rectal cancers do not have different prognoses from those with non-anterior cancers if they undergo neoadjuvant CRT.

Abstract P3-05-01: Molecular effects of surgical resection on primary breast tumor

Abstract Rationale: Surgery results in rapid and progressively severe exposure of tumor tissue to hypoxia, up to the point of complete removal, but its effect on tumor gene expression is not well characterized. We document the molecular effects of surgery on primary breast cancer tumor with a serial tissue sampling strategy, including an intra-operative sample. Methods: We included treatment naïve, non-metastatic breast cancer patients and sampled tumor and tumour adjacent normal tissue during surgery at three time points: beginning of surgery (Sample A), after half the tumor circumference had been devascularized (Sample B) and from completely resected tumor (Sample C). Patients were divided into two groups: discovery and validation. Tumor or adjacent normal samples from the discovery group underwent whole transcriptome paired-end sequencing (RNA-Seq) generating at least 50 million reads using next generation sequencing. Findings from discovery group were evaluated in a validation group using qRT-PCR and Nanostring nCounter gene expression profiling. Results: 81 breast cancer patients were eligible for this study of whom 46 with at least 1 quality passed sample at time-point A, B or C comprised the discovery group whose samples underwent RNA-seq. Validation group comprised two subsets: 35 independent patients (8 patients’ samples qRT-PCR, data included here; 27 patients’ samples nCounter gene expression, data will be presented) and 17 patients from discovery group whose samples also underwent nCounter gene expression profiling (data will be presented). Individual patient based analyses for A vs B vs C in discovery group revealed 249 significantly de-regulated genes in at least 20% of patients, in at least one comparison (AvB or BvC or AvC). Genes involved in stress response (FOSB, FOS, JUN, JUNB, DUSP1, CYR61, EGR1-3, ATF3, RGS1, RGS2), inflammation (IL20, IL8, SOCS3, GABRP, PIGR, NR4A1-2, CCL2- 3, CCL21, CCL14, CCL18-19, CXCL2, CXCL9-10, CXCL14), invasion &amp; migration (PTGS2, MMP9-13), lipid metabolism (CD36, LIPE, TAT, FABP4, PLIN1, PLIN4, LPL, LEP), epithelial markers (KRT5, KRT7, KRT14-17, KRT23, KRT6A-6B) and cellular differentiation(SOX10, LRP2, S100A2, S100A7-A9, S100B, S100P) were significantly deregulated at time-point B versus A and many of these genes were also significantly deregulated in C versus A comparison, suggesting sustained deregulation through surgical resection. Replicative analysis involving comparison of tumors grouped by time points (A vs B vs C) identified 192 genes uniquely de-regulated in any one of the 3 comparisons, of which 42 overlapped with patient-wise analysis. These 42 genes included all the AP-1 transcription factor network signaling genes, epithelial markers (KRT14, KRT6A), inflammation related genes (SOCS3, PIGR, GABRP, NR4A1, NR4A2), lipid metabolism related genes (PLIN1) and cellular differentiation &amp; cell fate related genes (SOX10, LRP2). Pathway analyses will be presented. qRT-PCR on paired samples in 8 independent patients validated the differential expression of eight genes in either AvB or AvC or both comparisons: FOS, FOSB, JUNB, DUSP1, RGS1, NR4A2, ZFP36, andMMP13. Comparison of biopsy (corresponding to A) with surgical samples (corresponding to C) in 6 cancer types (breast, cervical, lymphoma, mesothelioma, esophageal and sarcoma) in TCGA studies showed statistically significant de-regulation of 11 AP-1 transcription factor network signaling related genes in at least 4 cancers, further validating our experimental results. Conclusions: Our experiment, uniquely including an intra-operative tumor sample, shows that surgical removal induces a conserved stress response in the primary tumor that is potentially capable of bestowing metastatic capability on the tumor cells. Citation Format: Sudeep Gupta, Rohan Chaubal, Nilesh Gardi, Sunil Pachakar, Dimple Bhatia, Poonam Gera, Nita Nair, Shalaka Joshi, Vani Parmar, Purvi Thakkar, Garvit Chitkara, Rasika Kadam, Sejal Gujarathi, Harsh Oza, Rohini Hawaldar, Vaibhav Vanmali, Kenneth Buetow, Amit Dutt, Rajendra Badwe. Molecular effects of surgical resection on primary breast tumor [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-05-01.

3061 Solitary Brain Metastasis as the Initial Manifestation of Descending Colon Cancer

INTRODUCTION: Brain metastasis of colon cancer is often accompanied by metastasis to other organs, and the prognosis is poor. However, long-term survival is reported in some solitary brain metastasis cases. We present a case of descending colon cancer with brain metastasis and relatively long survival after surgery. CASE DESCRIPTION/METHODS: Having suffered from amnesia, dysgeusia and headache for 2 weeks, a 58-year-old woman visited a nearby hospital. With a projected tumor in the right occipital brain, she was referred and then admitted to our hospital. A CT scan showed a descending colon tumor, while the PET/CT scan showed fluid accumulation in a right brain tumor and a descending colon lesion. An open resection was indicated to remove a 35 × 40 mm brain tumor, followed by colonoscopy 7 days later, with the scope unable to pass through the entire circumferential tumor. Histopathologic diagnosis confirmed moderately and highly differentiated adenocarcinoma of the colon and moderately differentiated adenocarcinoma of the brain. This indicated colon cancer spread to the brain. The patient was treated with total brain irradiation of 30 Gy/10 times. With no evident distant metastases, she underwent left hemicolectomy 27 days after the brain surgery, removing a nearly 2-cm omental nodule neighboring the tumor. The serosa showed that the main lesion (a non-exposed type-2 tumor of 40 × 50 mm) retracted surrounding tissue. It mainly comprised moderately differentiated adenocarcinoma and poorly differentiated adenocarcinoma at the infiltration tip. Vascular invasion into the subserosa (SS) was observed with five lymph node metastases (N2) and adenocarcinoma in omental nodules (P1). Experiencing a good postoperative course and after treatment with chemotherapy, the patient survived 20 months after the brain surgery without evident brain metastasis relapse, despite liver metastasis 7 months after surgery. DISCUSSION: Although rare (0.4-1.8%), brain metastases have a high metastasis rate (82%), resulting in a low one-year survival rate after diagnosis (16%) and poor prognosis. However, long-term survival is frequently reported in cases with solitary brain metastasis. Resection is indicated for brain metastasis of colon cancer when life prognosis is longer than several months; excision causes no serious neurological symptoms; and brain metastasis spreads to no other organs or is well controlled. Surgical treatment, therefore, was considered suitable for our patient.

Clinicopathological factors associated with positive circumferential margins in rectal cancers

Positive circumferential resections are associated with local disease recurrence and reduced survival in rectal cancer. We studied a cohort of consecutive rectal cancer resections to assess for clinicopathological differences and survival in patients with positive and negative circumferential margins. Rectal cancers were identified from a retrospective histopathology database of colorectal resections performed at five western Sydney hospitals from 2010 to 2016. Univariate and multivariate analysis with binary logistic regression were performed on histopathology data matched with survival times from the New South Wales Registry of Births Deaths and Marriages. A total of 502 rectal cancer patients were identified including 66 (13.1%) with involved circumferential margins. Patients with positive and negative circumferential margins had a similar distribution of age, gender and use of neoadjuvant radiotherapy. Tumours with involved circumferential margin comprised 98.5% T3 and T4 disease of which 51.5% received neoadjuvant radiotherapy. These were significantly associated with metastatic disease, increasing tumour size, circumferential and perforated tumours on univariate analysis. Multivariate analysis identified abdomino-perineal resection (odds ratio (OR) 3.35; P = 0.003), en-bloc multivisceral resection (OR 2.56; P = 0.032), T4 stage (OR 6.99; P < 0.001), perineural (OR 5.61; P < 0.001) and vascular invasion (OR 2.46; P = 0.022) as independent risk factors. Five-year survival was significantly worse for patients with involved circumferential margins (26% versus 69%; P < 0.001). Circumferential margin status reflects not only technical success but also aggressive disease phenotypes which require adjuvant therapy. Further work is needed to determine whether omission of radiotherapy has had an effect on long-term outcomes in some of our at-risk patients.

Surgical techniques in the management of rectal cancer: a modified Delphi method by colorectal surgeons in Australia and New Zealand.

Technological developments have allowed advances in minimally invasive techniques for total mesorectal excision such as laparoscopy, robotics, and transanal surgery. There remains an ongoing debate about the safety, benefits, and appropriate clinical scenarios for which each technique is employed. The aim of this study was to provide a panel of expert opinion on the role of each surgical technique currently available in the management of rectal cancer using a modified Delphi method. Surveys were designed to explore the key patient- and tumor-related factors including clinical scenarios for determining a surgeon's choice of surgical technique. Open surgery was favoured in obese patients with an extra-peritoneal tumor and a positive circumferential resection margin (CRM) or T4 tumor when a restorative resection was planned. Laparoscopy was favoured in non-obese males and females, in both intra- and extra-peritoneal tumors with a clear CRM. Robotic surgery was most commonly offered to obese patients when the CRM was clear and if an abdominoperineal resection was planned. Transanal total mesorectal excision (taTME) was preferred in male patients with a mid or low rectal cancer, particularly when obese. Transanal endoscopic microsurgery/transanal minimally invasive surgery local excision was only offered to frail patients with small, early stage tumors. All surgical techniques for rectal cancer dissection have a role and may be considered appropriate. Some techniques have advantages over others in certain clinical situations, and the best outcomes may be achieved by considering all options before applying an individualised approach to each clinical situation.

Usefulness of Histogram-Profile Analysis in Ring-Enhancing Intracranial Lesions

Several intracranial pathologies present as a ring-enhancing lesion on conventional magnetic resonance imaging (MRI), creating diagnostic difficulty. We studied the characteristics of the anatomical border of gadolinium enhancement on T1-weighted imaging (WI) and hypointensity on T2WI to employ a simple technique of histogram-profile analysis of MRI for differentiation of various ring-enhancing intracranial lesions. After approval from the institutional review board, preoperative MRI (T2WI, postcontrast T1WI) scans were analyzed retrospectively in 18 patients with histologically confirmed brain abscess, 66 glioblastomas, 46 brain-metastases, and 16 tumefactive multiple sclerosis (MS). T2WI and postcontrast T1WI were overlapped, and histogram-profile analysis was performed with in-house image-fusion software. The pattern of differential-peaks in histogram-profile was assessed visually. Kaplan-Meier survival analysis incorporating histogram-profile patterns was performed in patients with glioblastoma. The histogram-profile study revealed 4 distinct patterns. Pattern 1 showed no differential T2-hypointensity trough, pattern 2 had T2-hypointensity trough inside, whereas pattern 3 had T2-hypointensity trough overlapping the enhanced margin. Pattern 4 had T2-hypointensity trough immediately external to the enhanced margin. Pattern 1 was specific for tumefactive MS (93.3%), whereas pattern 4 was specific for glioblastoma (40.7%). Pattern 4 glioblastoma was subdivided into rim (T2-hypointensity ≥50% of circumference of contrast-enhanced tumor) and arc (T2-hypointensity <50% of circumference of contrast-enhanced tumor). Pattern 4 glioblastoma was further subdivided into group A (edema: T2-hyperintensity ≥50% of circumference of contrast-enhanced tumor) and group B (less edema: T2-hyperintensity <50% of circumference of contrast-enhanced tumor). Patients with pattern 3 glioblastoma (37.6%) had better survival compared with others (P= 0.0341) and pattern 4B had decreased survival compared with pattern 4A (P= 0.0001) and others (P= 0.0003). Tumefactive MS and a subset of glioblastomas show specific patterns in histogram-profile analysis. The difference in anatomical border also determines difference in survival in glioblastoma. Histogram-profile analysis is a simple and efficient technique to differentiate these pathologies.

Abnormal vascularization of soft-tissue sarcomas on conventional MRI: Diagnostic and prognostic values

PurposeTo assess the prevalence of abnormal vessels inside and surrounding soft-tissue sarcomas (STS) on conventional MRIs so as to evaluate their correlations with particular histotypes, histological grades, and prognosis. MethodThis single-center retrospective study included 157 adult patients (median age: 61) with histologically-proven non-metastatic STS. All had pre-treatment conventional contrast-enhanced MRI. Two radiologists reported: presence of abnormal flow-voids, number and distribution (peri-tumoral and/or intra-tumoral), percentage of tumor circumference it covered, maximal diameter. The radiological findings were correlated with histopathology. Associations were evaluated with Chi-2 or t-tests. Survival analysis (for metastasis-free survival (MFS) and overall survival (OS)) included log-rank tests and multivariate Cox-model. ResultsTwenty-nine of 157 (18.5%) STS showed abnormal flow-voids that were peri-tumoral (9/157, 5.7%), intra-tumoral (5/157, 3.2%) or both intra- and peri-tumoral (15/157, 9.6%). Ten STS had more than 5 flow-voids, all being grade II-III, namely: 4 undifferentiated sarcomas, 2 solitary fibrous tumors, 1 alveolar soft-part sarcoma (ASPS), 2 leiomyosarcomas and 1 pleomorphic liposarcoma. The distribution of flow-voids was associated with survivals in the univariate analysis: patients with abnormal peritumoral flow-voids (APTFV) showed poorer OS and MFS (p = 0.039 and 0.014, respectively). These associations did not remain significant in multivariate analysis. Radio-pathological correlations revealed large tortuous tumoral neo-vessels with intra-vascular thrombi of tumor cells in ASPS and in one case of undifferentiated sarcoma displaying enrichment in genes involved in neo-angiogenesis at transcriptional level. ConclusionsAPTFV on conventional MRIs may be associated with a higher risk of metastatic relapse and poorer OS in STS patients.

Oncological outcomes analysis of colorectal cancer with unfavorable histological features

Objective: To explore the effect of unfavorable histological features on the clinical outcomes of patients receiving radical resection of colorectal cancer. Methods: A retrospective analysis of patients with colorectal cancer who received radical surgery between January 2013 and December 2015 at Department of General Surgery, Peking Union Medical College Hospital was performed. The impact of unfavorable histological features on the oncological outcomes of patients with lymph node-negative colorectal cancer were analyzed.A total of 167 patients were enrolled, including 98 males and 69 females with age of (63.6±11.6) years. Observation indicators included age, T stage, lymphovascular invasion, perineural invasion, tumor deposits, number of lymph node dissection, degree of differentiation, tissue type, and circumferential margin. Univariate analysis was performed with χ(2) test and multivariate analysis was performed with Cox regression model. Results: Univariate analysis showed that positive circumferential margins (CRM), tumor deposits and age were associated with disease free survival (DFS) rate; positive CRM, age, tumor deposits, and lymph nodes dissection less than 12 were significantly associated with overall survival (OS) rate (all P<0.05). Multivariate analysis showed that over 70 years of age (HR=1.053, 95% CI: 1.013 to 1.095, P=0.009), poorly differentiated adenocarcinoma (HR=7.572, 95%CI: 1.815 to 31.587, P=0.005), tumor deposits (HR=4.711, 95% CI: 1.809 to 12.264, P=0.002), mucinous adenocarcinoma (HR=3.063, 95% CI: 1.003 to 9.354, P=0.049), lymphovascular invasion (HR=2.885, 95% CI: 1.062 to 7.832, P=0.038), and nerve infiltration (HR=6.610, 95% CI: 1.037 to 42.122, P=0.046) were adverse prognostic factors of DFS rate; poorly differentiated adenocarcinoma (HR=12.200, 95% CI: 1.985 to 74.972, P=0.007), tumor nodules (HR=5.379, 95% CI: 1.636 to 17.685, P=0.006), over 70 years of age (HR=1.062, 95% CI: 1.013 to 1.114, P=0.013), and perineural invasion (HR=8.043, 95% CI: 1.026 to 63.055, P=0.047) were adverse prognostic factors of OS rate. There was no significant difference in the 3-year DFS rate and 3-year OS rate between T1-2 group and T3-4 group (P>0.05). Conclusion: Over 70 years of age, poorly differentiated adenocarcinoma, mucinous adenocarcinoma, tumor nodules, lymphovascular invasion, and perineural invasion are independent adverse prognostic factors of lymph node-negative colorectal cancer.

Salvage Radiation Therapy with Elective Nodal Irradiation for Superficial Esophageal Cancer after Incomplete Endoscopic Resection

Endoscopic resection (ER) is widely used as an effective treatment for superficial esophageal cancer. However, the risk of lymph node metastasis increases in case of muscularis mucosae or deeper invasion, and additional treatment such as radiotherapy (RT) or surgery is required in those cases. The aim of this study is to investigate the efficacy and toxicity of salvage RT after incomplete ER as an organ preservation strategy. We retrospectively reviewed 37 esophageal cancer patients received salvage RT after incomplete ER at one institution between 2000 and 2014. There were 34 males and 3 females, and the median age was 67 (range: 53-85). All patients had squamous cell carcinoma. Pathological invasion depth was muscularis mucosae/submucosal layer/muscularis propria in 14/22/1 patients, respectively. The circumference of tumor was less than three quarters in 25 patients, more than three quarters in 4 patients, entire in 4 patients and unknown in 4 patients. All patients received external beam radiotherapy (EBRT). Among them, 8 patients received intraluminal brachytherapy (IBT) following EBRT. Elective nodal irradiation (ENI) was administered in all patients. Median EBRT dose was 60 Gy/30 fractions (range: 50.4-66Gy). IBT was administered to a total dose of 10 Gy/4 fractions. Twenty-five patients received concurrent platinum and 5FU-based chemotherapy. The Kaplan–Meier method was used to generate actual survival curves. Fisher’s exact test was used for statistical comparisons. Median follow-up time was 56 months (range: 3-212 months) for all patients. The 5-year progression free survival and overall survival rates were 61% and 75%, respectively. Local recurrence and regional lymph node recurrence was not observed. Distant metastasis was observed in 2 patients (5%). Metachronous esophageal cancer was observed in 6 patients (16%) and 4 patients were salvaged by ER. The 5-year incidence rates of metachronous tumor were 15%. Double cancer after RT was observed in 15 patients (41%). The causes of death were attributed to esophageal cancer in 1 patient, metachronous esophageal cancer in 1 patient, other malignancies in 8 patients, and other causes in 6 patients. Although grade 2 esophageal stenosis was observed in 7 patients (19%), and significantly high in patients with tumor circumference more than 3/4 (p<0.001). Grade 3 or worth stenosis was not observed. Late cardiac toxicities ≥ grade 3 was observed in 6 patients (pericardial effusion in 2, ischemic heart disease in 1 and arrhythmia in 3 patients) and one patient died of arrhythmia. Salvage radiotherapy after incomplete esophageal ER is effective treatment as an organ preservation strategy. Although muscularis mucosae and submucosal cancer have a high risk of lymph node metastasis, our results suggest that ENI contribute to reduce regional node metastases. Early detection of metachronous esophageal cancer and other malignancies is important for survivors.