Cumulative Local Recurrence Rate Research Articles

Long-term survival and functional outcomes of laparoscopic surgery for clinical stage I ultra-low rectal cancers located within 5 cm of the anal verge: A prospective phase II trial (Ultimate trial).

To clarify the long-term oncological outcomes and postoperative anal, urinary, and sexual functions after laparoscopic surgery for clinical stage I very low rectal carcinoma located near the anal canal. Laparoscopic surgery is widely applied for rectal cancer; however, concerns remain, with some studies showing poorer outcomes compared to open surgery. This single-arm, phase II trial included patients registered preoperatively from 47 institutions in Japan. The planned sample size was 300. The primary endpoint was the 3-year local recurrence rate. Anal, urinary, and sexual functions were evaluated using a prospective questionnaire. Three-hundred patients were registered between January 2014 and March 2017. Anus-preserving surgery was performed in 278 (93%), including 172 who underwent intersphincteric resection (58%) and 106 (36%) who underwent low anterior resection. The 3-year cumulative local recurrence rate was 6.3%. At 3 years postoperatively, 87% of patients used their own anus, and the median incontinence score improved from 12 at 3 months to 8 at 3 years. Only 5% of patients had severe incontinence (incontinence score of 16 points). Postoperative urinary function evaluation showed that International Prostate Symptom Score and Overactive Bladder Symptom Score decreased 1 week after surgery, but recovered to preoperative level 1 month after surgery. International Consultation on Incontinence Questionnaire-Sort Form remained almost stable after surgery. Sexual function evaluation using the International Index of Erectile Function-5 and International Index of Erectile Function-15 revealed that the patients had deteriorated 3 months after surgery but had recovered only slightly by 6 months. Laparoscopic surgery achieves feasible long-term oncological outcomes and a high rate of anus preservation with moderate anal function, and an acceptable incontinence score. While urinary function recovered rapidly, sexual function showed poor recovery.

Clinical Outcomes of Next-Generation Microwave Thermosphere Ablation for Hepatocellular Carcinoma with Primarily Hepatitis-Related Etiology.

We investigated the clinical outcomes of patients with hepatocellular carcinoma (HCC) who underwent next-generation microwave thermosphere ablation (MTA). A total of 429 patients with 607 HCCs (maximum tumor diameter ≤40 mm) were included. We defined the following areas of the liver as those where MTA therapy is difficult to perform: caudate lobe and areas near the primary and secondary branches of the intrahepatic portal vein, inferior vena cava, gallbladder, heart, duodenum, abdominal esophagus, collateral veins around the liver, and spleen. Factors which predisposed patients to local tumor recurrence in the context of tumor location and complications were examined. The primary etiologies of HCC were hepatitis-related: 259 (60.4%) cases of HCV, 31 (7.3%) cases of HBV, and two instances of both. Median maximum tumor diameter was 15.0 (interquartile range, 10.0-21.0) mm. There were 86 tumors in areas of the liver where MTA is difficult. The most common area was near the primary and secondary branches of the intrahepatic portal vein (26 nodules). The cumulative local tumor recurrence rates at 1, 2, and 3 years were 4.4%, 8.0%, and 8.5%, respectively. The cumulative local tumor recurrence rate differed significantly by tumor size group: 6.6%, 13.8%, and 29.4% at three years in the ≤20 mm group (n = 483), 20-30 mm group (n = 107), and ≥30 mm group (n = 17), respectively (p < 0.001). The cumulative local tumor recurrence rate was similar despite difficult-to-treat status (p = 0.169). In the multivariable analysis, tumor size (>15 mm) (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.11-4.16; p = 0.023) and ablative margin (<3 mm) (HR, 2.94; 95% CI, 1.52-5.71; p = 0.001) were significantly associated with local tumor recurrence. Only tumor size (>15 mm) (odds ratio, 3.41 95% CI, 1.53-7.84; p = 0.026) was significantly associated with complications. MTA is a safe and effective local ablation therapy for HCC, even for tumors located in areas of the liver where local ablation therapy is difficult.

Local Recurrence following Radiological Complete Response in Patients Treated with Subsegmental Balloon-Occluded Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma.

The aim of this study was to determine the local recurrence (LR) rate and identify factors associated with LR in patients who achieve a radiological complete response (CR) after undergoing balloon-occluded transcatheter arterial chemoembolization (B-TACE) for hepatocellular carcinoma (HCC). From November 2017 to September 2021, 60 patients (44 men, 16 women; mean age, 63.5 years; range, 39-82 years) with 72 HCCs (mean diameter, 31 mm; range, 10-50 mm) who underwent subsegmental B-TACE were included in this retrospective study. Radiological and clinical evaluation of oily subsegmentectomy, defined as radiological CR of the HCC and peritumoral parenchymal necrosis, was performed. The CR rate was 97.2% (70 of 72 HCCs) at first follow-up (mean, 41 days; range, 14-110 days). Overall, 13 HCCs (19.7%) demonstrated LR at a mean of 29.8 months (range, 3-63 months) and cumulative LR rates were 1.5% 14.2% 21%, 21%, and 21% at 6, 12, 24, 36, and 48 months, respectively. In 28 (38.9%) of 72 HCCs, oily subsegmentectomy was achieved, tumor markers were normalized, and LR did not occur. The oily subsegmentectomy-positive group had a significantly lower LR rate than the oily subsegmentectomy-negative group (p = 0.001). Age ≥65 years (adjusted hazard ration (HR), 0.124; 95% confidence interval (CI), 0.037-0.412; p < 0.001) and peripheral location (adjusted HR, 0.112; 95% CI, 0.046-0.272; p < 0.001) were independent predictive factors of LR. Subsegmental B-TACE can be an effective method with a high initial CR rate and low LR incidence. Oily subsegmentectomy can be considered as an index of successful treatment because it did not demonstrate any LR.

Stereotactic Body Radiotherapy for Posterior Element Only Spinal Metastases: Outcomes and Validation of Recommended Clinical Target Volume Delineation Practice

Spine stereotactic body radiotherapy (SBRT) results in improved local control and pain response compared to conventional external beam radiotherapy. Consensus stipulates MRI-based delineation of the clinical target volume (CTV) is critical and is based on spine segment sector involvement. The applicability of these contouring guidelines to metastases confined to the posterior elements is unknown. The purpose of this study was to determine the patterns of failure, as well as the safety of treating posterior element metastases when the vertebral body was intentionally excluded from the CTV. A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included for the analyses. The primary outcome was local failure, as per SPINO recommendations, and secondary outcomes included patterns of failure, toxicities. Clinical and tumor factors were reported with descriptive statistics. The cumulative risk of local failure was estimated using the Fine-Gray method, accounting for death before local failure as a competing risk. A total of 24/605 patients and 31/1412 segments within the database were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%). At baseline, 4/11 (36.4%) segments with local failure (36.4%) had epidural disease and 8/11 (72.7%) had paraspinal disease. Most local failures were treated in the de novo setting (8/11, 72.7%). 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. Of these five, four had disease progression within the untreated vertebral body. No failures occurred exclusively within the untreated vertebral body. One patient (4.2%) experienced a grade 4 skin toxicity and one patient (4.2%) developed an iatrogenic Grade 1 vertebral compression fracture. Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the vertebral body can be excluded from CTV in spinal metastases confined to the posterior elements.

A FIRST REPORT ON OUTCOMES OF STEREOTACTIC BODY RADIOTHERAPY FOR POSTERIOR ELEMENT ONLY SPINAL METASTASES AND VALIDATION OF RECOMMENDED CLINICAL TARGET VOLUME DELINEATION PRACTICE

Abstract Spine stereotactic body radiotherapy (SBRT) improves local control and pain response compared to conventional external beam radiotherapy. Consensus stipulates MRI-based delineation of the clinical target volume (CTV) and is based on spine segment sector involvement. The applicability to metastases limited to the posterior elements remains to be validated. We aimed to determine the patterns of failure and safety of treating posterior element metastases when the vertebral body (VB) was intentionally excluded from the CTV. METHODS AND MATERIALS: A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included. The primary outcome was local failure and secondary outcomes included patterns of failure, toxicities. RESULTS: 24/605 patients and 31/1412 segments were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%) and 73% had baseline paraspinal disease extension. 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. 4/5 cases had recurrent disease extending into the VB, but no failure was observed exclusively within the VB. CONCLUSIONS: Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the VB can be excluded from CTV in spinal metastases confined to the posterior elements.

Treatment outcomes of the patient with sinonasal mucosal melanoma: the role of endoscopic resection and postoperative radiotherapy.

The standard of care for sinonasal mucosal melanoma is surgery and postoperative radiotherapy (PORT). Our treatment strategy comprises endoscopic resection and PORT. We performed combined endoscopic and open resection or applied an external approach alone when sufficient resection was difficult to achieve endoscopically. The objective of this study was to evaluate the validity of our treatment strategy. We assessed 30 patients with sinonasal mucosal melanoma who underwent definitive therapy between January 2002 and April 2021, and conducted a retrospective analysis. The median follow-up period was 2.2years. The primary endpoint was overall survival. The Kaplan-Meier method was used for the calculation of survival rates, the cumulative incidence of distant metastasis, and local recurrence. Twenty-eight patients underwent surgery. The other two patients were treated by definitive proton beam therapy. Twenty-one of 28 (75%) patients underwent resection by endoscopic approach alone. Postoperative radiotherapy was performed for all 28 patients who underwent surgery. Twenty-one patients (70%) experienced recurrence during the observation period. Overall, distant metastasis was observed in 19 patients. Twelve patients died during the observation period, with 10 of the 12 patients (83%) dying of distant metastasis. The overall survival rate at 2 and 5years was 70% and 46%, respectively. The cumulative incidence rate of distant metastasis at 2years was 63%, while the 2-year cumulative incidence rate of local recurrence was 6.7%. The local disease was controlled by our treatment strategy. To improve treatment outcomes, control of the distant metastasis is needed.

Proton beam therapy for gliomas: a multicenter prospective registry study from all proton beam facilities in Japan

Abstract We reviewed the outcomes of glioma patients enrolled in a prospective observational registry study of proton beam therapy (PBT) in Japan. The inclusion criteria were glioma patients registered in the Electronic Data Capture system, the Proton-net, between May 2016 and July 2019. Data on patient characteristics, treatments, late adverse events, survival status, recurrence and secondary tumors were extracted and statistically analyzed. The primary endpoint was the overall survival (OS) rate, and the secondary endpoints were the progression-free survival (PFS) rate and cumulative local recurrence rate (cLRR). Of the 65 primary brain tumor patients registered, 29 glioma patients from eight of 19 PBT facilities met the inclusion criteria. There were 19 glioblastoma patients, eight of other malignant gliomas, and two of low-grade gliomas. For glioblastomas, with a median follow-up period of 16 months, the median survival time was 21.2 months and the OS at 1, 2, 3 and 4 years were 77.4%, 44.9%, 23.9% and 23.9%, respectively. The median PFS period was 10.1 months, the 1, 2, 3 and 4-year PFS were 32.4%, 19.4%, 9.7% and 9.7%, respectively. The 1, 2, 3 and 4-year cLRR were 56.1%, 68.8%, 78.4 and 78.4%, respectively. Grade 3 brain necrosis was observed in two patients. No secondary tumor was observed. This is the first report on the current status of PBT for gliomas in Japan. For glioblastomas, the outcomes of PBT are estimated to be equivalent to historical data of photon therapy. The results of a prospective comparative evaluation of PBT and photon therapy are awaited.

Stereotactic Body Radiation Therapy for Posterior Element-Only Spinal Metastases: A First Report on Outcomes and Validation of Recommended Clinical Target Volume Delineation Practice

Spine stereotactic body radiotherapy (SBRT) results in improved local control and pain response compared to conventional external beam radiotherapy. Consensus exists stipulating that MRI-based delineation of the clinical target volume (CTV) is critical and based on spine segment sector involvement. The applicability of contouring guidelines to metastases involving the posterior elements alone remains to be validated, and the purpose of this report was to determine the patterns of failure and safety of treating posterior element metastases when the vertebral body (VB) was intentionally excluded from the CTV. A retrospective review of a prospectively maintained database of 605 patients and 1412 spine segments treated with spine SBRT was performed. Only treated segments involving the posterior elements alone were included for the analyses. The primary outcome was local failure, as per SPINO recommendations, and secondary outcomes included patterns of failure, toxicities. 24/605 patients and 31/1412 segments were treated to the posterior elements only. Local failure occurred in 11/31 segments. The cumulative rate of local recurrence was 9.7% at 12 months and 30.8% at 24 months. Amongst local failures, the most common histologies were renal cell carcinoma (36.4%) and non-small cell lung cancer (36.4%) and 73% had baseline paraspinal disease extension. 6/11 (54.5%) failed exclusively within treated CTV sectors and 5/11 (45.5%) with both treated and adjacent untreated sectors. Four of these 5 cases had recurrent disease extending into the VB, but no failure was observed exclusively within the VB. Posterior element alone metastases are rare. Our analyses support SBRT consensus contouring guidelines such that the VB can be excluded from CTV in spinal metastases confined to the posterior elements.

Laparoscopic versus open pelvic exenteration for locally advanced rectal cancer: analysis of short- and long-term effects

Objective: To explore the feasibility, safety, and short- and long-term efficacy of laparoscopic pelvic exenteration (LPE) in treating locally advanced rectal cancer. Methods: The clinical data of 173 patients who had undergone pelvic exenteration (PE) for locally advanced rectal cancer that had been shown by preoperative imaging or intraoperative exploration to have invaded beyond the mesorectal excision plane and adjacent organs in the Cancer Hospital, Chinese Academy of Medical Sciences (n=64) and Peking University First Hospital (n=109) from 2010 January to 2021 December were collected retrospectively. Laparoscopic PE (LPE) had been performed on 82 of these patients and open PE (OPE) on 91. Short- and long-term outcomes (1-, 3-, and 5-year overall and disease-free survival and 1- and 3-year cumulative local recurrence rates) were compared between these groups. Results: The only statistically significant difference in baseline data between the two groups (P>0.05) was administration of neoadjuvant therapy. Compared with OPE, LPE had a significantly shorter operative time (319.3±129.3 minutes versus 417.3±155.0 minutes, t=4.531, P<0.001) and less intraoperative blood loss (175 [20-2000] ml vs. 500 [20-4500] ml, U=2206.500, P<0.001). The R0 resection rates were 98.8% and 94.5%, respectively (χ2=2.355, P=0.214). At 18.3% (15/82), and the incidence of perioperative complications was lower in the LPE group than in the OPE group (37.4% [34/91], χ2=7.727, P=0.005). The rates of surgical site infection were 7.3% (6/82) and 23.1% (21/91) in the LPE and OPE group, respectively (χ2=8.134, P=0.004). The rates of abdominal wound infection were 0 and 12.1% (11/91) (χ2=10.585, P=0.001), respectively, and of urinary tract infection 0 and 6.6% (6/91) (χ2=5.601, P=0.030), respectively. Postoperative hospital stay was shorter in the LPE than OPE group (12 [4-60] days vs. 15 [7-87] days, U=2498.000, P<0.001). The median follow-up time was 40 (2-88) months in the LPE group and 59 (1-130) months in the OPE group. The 1-, 3-, and 5-year overall survival rates were 91.3%, 76.0%, and 62.5%, respectively, in the LPE group, and 91.2%, 68.9%, and 57.6%, respectively, in the OPE group. The 1, 3, and 5-year disease-free survival rates were 82.8%, 64.9%, and 59.7%, respectively, in the LPE group and 76.9%, 57.8%, and 52.7%, respectively, in the OPE group. The 1- and 3-year cumulative local recurrence rates were 5.1% and 14.1%, respectively, in the LPE group and 8.0% and 15.1%, respectively, in the OPE group (both P>0.05). Conclusions: In locally advanced rectal cancer patients, LPE is associated with shorter operative time, less intraoperative blood loss, fewer perioperative complications, and shorter hospital stay compared with OPE. It is safe and feasible without compromising oncological effect.

Long-term outcomes of upfront robotic rectal cancer surgery: a single-center, retrospective cohort study in Japan.

The purpose of this study was to evaluate the long-term outcomes of robotic rectal cancer surgery and to examine the risk factors for recurrence. In a high-volume center in Japan, we retrospectively enrolled patients with pStage I-III rectal cancer within 15cm of the anal verge who underwent robotic surgery from 2011 to 2017. Almost all patients underwent upfront surgery, and lateral lymph-node dissection (LLND) was performed for patients with locally advanced lower rectal cancer. We evaluated the 5-year overall survival (OS), relapse-free survival (RFS), and cumulative local recurrence (LR) rates and examined the risk factors for the RFS. We evaluated 488 patients who underwent robotic rectal cancer surgery, including 5.1% who underwent preoperative chemoradiotherapy to obtain clear resection margins and 33.6% who underwent LLND. There were 203, 87, and 198 patients with pStage I, II, and III, respectively, and the positive resection margin rate was 1.0%. The 5-year OS, RFS, and LR rates were 95.5%, 81.7%, and 2.2%, respectively. The independent risk factors for the RFS were the presence of venous invasion, extramural tumor deposits without lymph-node structure, and pT ≥ 3. This study demonstrated the favorable long-term outcomes of robotic rectal cancer surgery.

Carbon-ion radiotherapy versus radiofrequency ablation as initial treatment for early-stage hepatocellular carcinoma.

Carbon-ion radiotherapy (C-ion RT) has shown potential as a curative treatment for patients with hepatocellular carcinoma (HCC). However, no reports have compared the effectiveness of C-ion RT and radiofrequency ablation (RFA). This study aimed to compare clinical outcomes between C-ion RT and RFA for patients with early-stage HCC. Medical records of consecutive patients with HCC (single lesion ≤5cm or two to three lesions ≤3cm) who received either C-ion RT or RFA as initial treatment were retrospectively reviewed. Propensity score matching (PSM) was used to adjust for clinical factors between both groups. A total of 560 patients were included, among whom 69 and 491 received C-ion RT and RFA, respectively. After PSM (C-ion RT, 54 patients; RFA, 95 patients), both groups were well balanced. Carbon-ion radiotherapy had significantly lower cumulative intrasubsegmental recurrence rate after PSM compared to RFA (p=0.004) (2-year, 12.6% vs. 31.7%; 5-year, 15.5% vs. 49.6%, respectively). However, no significant difference in cumulative local recurrence rate, stage progression-free survival, or overall survival (OS) was observed between both groups. In the RFA group, 6 of 491 patients (1.2%) showed grade 3 adverse events, whereas no grade 3 or higher adverse events were observed in the C-ion RT group. Carbon-ion radiotherapy provided a lower cumulative intrasubsegmental recurrence rate, but a comparable cumulative local recurrence rate, stage progression-free survival, and OS compared to RFA. Thus, C-ion RT appears to be one of the effective treatment options for early-stage HCC when RFA is deemed not indicated.

Hyperfractionation versus Conventional Fractionation of Preoperative Intensity-Modulated Radiotherapy with Oral Capecitabine in Locally Advanced Mid-Low Rectal Cancer: A Propensity Score Matching Study.

Purpose In theory, the hyperfractionated radiotherapy can enhance biological effect dose against tumor and alleviate normal tissue toxicity. This study is to assess the efficacy and safety of preoperative hyperfractionated intensity-modulated radiotherapy (IMRT) with oral capecitabine in patients with locally advanced rectal cancer (LARC). Methods We retrospectively screened patients with LARC from January 2015 to June 2016. Patients that received hyperfractionated IMRT or conventional fractionated IMRT were eligible in the hyperfractionation (HF) group or conventional fractionation (CF) group, respectively. The primary outcome was the complete response rate. Secondary outcomes included toxicity, postoperative complications, anus-reservation operation rate, local recurrence and distant metastases rate, overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Results 335 patients were included in the analysis. The complete response rate for the hyperfractionated and conventional fractionated IMRT was 20.41% vs. 23.47% (P = 0.583). The anus-reservation operation rate was 68.37% vs. 65.31% (P = 0.649). There were no cases of grade 4 toxicity during radiotherapy; the rate of grade 3 toxicity and postoperative complications was both comparable between groups. However, in the CF group, more patients had a second operation due to complications (0.0% vs. 5.68%, P = 0.011). The cumulative local regional recurrence and distant metastases rates of the HF group and CF group were 5.10% vs. 9.18% (P = 0.267) and 22.45% vs. 24.49% (P = 0.736), respectively. The 5-year OS, CSS, and DFS in the HF group and CF group were 86.45% vs. 73.30% (P = 0.503), 87.34% vs. 75.23% (P = 0.634), and 70.80% vs. 68.11% (P = 0.891), respectively. Conclusions The preoperative hyperfractionated IMRT with oral capecitabine, with an acceptable toxicity and favorable response and survival, could reduce the rate of secondary surgery.

Prognostic Factors and Nomogram Construction for First Local Recurrent Retroperitoneal Sarcoma Following Surgical Resection: A Single Asian Cohort of 169 Cases.

ObjectiveThis study aimed to explore the prognostic factors for first local recurrent retroperitoneal soft tissue sarcoma (FLR-RPS) and construct predictive nomograms in the Asian population.MethodsIn a single Asian sarcoma center, data of patients with FLR-RPS were retrospectively analyzed from January 2011 to September 2020. We developed and internally validated prognostic factors determined by the Cox regression model, as well as nomograms for predicting recurrence-free survival (RFS) and overall survival (OS). The concordance index and calibration curve were used to determine the nomogram’s discriminative and predictive ability.ResultsWith 169 patients, the median follow-up duration was 48 months and the 5-year OS rate was 60.9% (95% confidence interval (CI), 51.9%–69.9%). OS was correlated with chemotherapy at the time of initial surgery and tumor grading. The 5-year cumulative local recurrence rate and distant metastasis rate were 75.9% (95% CI, 67.5%–84.3%) and 10.1% (95% CI, 4.2%–16.0%), respectively, and the length of the disease-free interval following the primary operation was associated with disease recurrence. The 6-year OS and cumulative recurrence rate after surgery in our cohort were comparable with those in the TARPSWG cohort, but the proportion of local recurrence was higher (80.4% vs. 59.0%), and distant metastasis was less common (10.1% vs. 14.6%). In this study, two nomogram prediction models were established, which could predict the 1-, 2-, and 5-year OS and RFS, and the concordance indices were 0.74 and 0.70, respectively. The calibration plots were excellent.ConclusionsFor the FLR-RPS patients, some can still achieve an ideal prognosis. The treatment of FLR-RPS in Asian populations can be aided by the predictive model established in this study.

Proton Beam Therapy in Managing Unresectable Hepatocellular Carcinoma with Bile Duct Invasion.

Simple SummaryHepatocellular carcinoma with bile duct invasion is well known for its poor survival outcome, and no definite treatment guideline has been suggested. This study analyzed the treatment outcome and toxicity of proton beam therapy in managing patients with unresectable hepatocellular carcinoma with bile duct invasion. After a median follow-up of 19.9 months, proton beam therapy provided an optimal in-field control rate for these patients. The overall survival results were comparable with surgical series. This study concluded that proton beam therapy offers desirable treatment outcomes with acceptable toxicities. Based on the results, proton beam therapy provides patients with another optimal alternative for treating this notorious subtype of hepatocellular carcinoma.Hepatocellular carcinoma (HCC) with bile duct invasion is a rare and notorious subtype of HCC. This study included patients that had unresectable HCC with bile duct invasion and proton beam therapy between November 2015 and February 2021. Twenty patients fit the inclusion criteria. The median tumor size was 6.3 cm. Nine patients (45.0%) had major vascular invasions. All included patients received the radiation dose of 72.6 gray relative biological effectiveness due to the proximity of porta hepatis and tumor. The median follow-up time was 19.9 months. The median overall survival was 19.9 months among deceased patients. The 1-year cumulative local recurrence rates were 5.3%, with only two patients developing in-field failure. The 1-year and 2-year overall survival rates were 79.4% and 53.3%. The 1-year progression-free survival was 58.9%. Four patients developed radiation-induced liver disease. The 1-year cholangitis-free survival was 55.0%. Skin toxicity was the most common acute toxicity and rarely severe. Eight patients developed ≤ grade 3 gastrointestinal ulcers. Proton beam therapy offers desirable survival outcomes for unresectable HCC patients with bile duct invasion. Optimal local tumor control could also be obtained within acceptable toxicities.

Transanal versus Laparoscopic Total Mesorectal Excision in Male Patients with Low Tumor Location after Neoadjuvant Therapy: A Propensity Score-Matched Cohort Study.

Background Since Sylla and Lacy successfully reported the transanal total mesorectal excision in 2010, taTME was considered to have the potential to overcome some problematic laparoscopic cases in male, low advanced rectal cancer. However, the evidence is still lacking. This study compared the short and long outcomes of taTME with laTME in these “challenging” patients to explore the advantages of taTME among the patients. Method After propensity score matching analysis, 106 patients were included in each group from 325 patients who met the including standard. Statistical analysis was used to compare the differences of perioperative outcomes, histopathological results, and survival results between taTME and laTME groups. Results The mean time of pelvic operation in the taTME group was significantly shorter than in the laTME group (62.2 ± 14.2 mins vs 81.1 ± 18.9 mins, P = 0.003). The complication incidence rate and the rate of protective loop ileostomy in the taTME group were significantly lower than those in the laTME group (19.8% vs 38.7%, P = 0.003 and 70.8% vs 92.5%, P < 0.001). In long-term result, there was no significant difference between the two groups for 3-year OS (87.3% vs 85.4%, P = 0.86) or 3-year DFS (74.9% vs 70.1%, P = 0.92). The 2-year cumulative local recurrence rate was similar between the two groups (1.1% vs 5.8%, P = 0.22). Conclusion This study demonstrated that taTME might reduce the incidence of postoperative complications, especially of anastomotic leakage in these “challenging” patients. taTME may be considered to have clear advantages for “challenging” patients.

Comparison of local recurrence in transcatheter arterial chemoembolization of hepatocellular carcinoma with or without accumulation of iodized oil beyond corona enhancement area: Short-term results.

BackgroundLocal tumor recurrence of hepatocellular carcinoma (HCC) often occurs in blood drainage areas. Corona enhancement is determined by computed tomography during hepatic arteriography (CTHA) and is considered to represent the blood drainage area. This study aimed to investigate the relationship between embolization of corona enhancement area and local tumor recurrence of patients with HCC who underwent transcatheter arterial chemoembolization (TACE).Patients and methodsThe study retrospectively selected 53 patients with 60 HCC nodules that showed corona enhancement area on late-phase CTHA and showed homogenous accumulation of iodized oil throughout the nodule on non-contrast-enhanced CT performed immediately after TACE. We divided the nodules into two groups, according to whether the accumulation of iodized oil covered the entire corona enhancement area (group A) or not (group B). Local tumor recurrence was compared between the two groups.ResultsThe cumulative local tumor recurrence rates for group A (n = 36) were 2.8%, 2.8%, 8.3% at 3, 6, and 12 months, respectively, whereas the recurrence rates for group B (n = 24) were 20.8%, 45.8%, 75% at 3, 6, and 12 months, respectively. The cumulative local tumor recurrence rates for group A were significantly lower than those for group B (hazard ratio, 0.079; 95% confidence interval, 0.026–0.24; p < 0.001).ConclusionsThe results of the study suggest that the corona enhancement area may be an accurate safety margin in TACE which should be performed until the embolic area covers the entire corona enhancement area.

Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high volume centers.

Data on endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs) are insufficient owing to their rarity. There are two main ER techniques for SDETs: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In addition, modified EMR techniques, such as underwater EMR (UEMR) and cold polypectomy, are becoming popular. We conducted a large-scale retrospective multicenter study to clarify the detailed outcomes of duodenal ER. Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs; defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using the Kaplan-Meier method. In total, 3107 patients (including 1017 undergoing ESD) were included. En bloc resection rates were 79.1 %, 78.6 %, 86.8 %, and 94.8 %, and delayed AE rates were 0.5 %, 2.2 %, 2.8 %, and 6.8 % for cold polypectomy, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher in the ESD group than in non-ESD groups for lesions < 19 mm (7.4 % vs. 1.9 %; P < 0.001), but not for lesions > 20 mm (6.1 % vs. 7.1 %; P = 0.64). The local recurrence rate was significantly lower in the ESD group than in the non-ESD groups (P < 0.001). Furthermore, for lesions > 30 mm, the cumulative local recurrence rate at 2 years was 22.6 % in the non-ESD groups compared with only 1.6 % in the ESD group (P < 0.001). ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.

Can Multigene Testing Provide Additional Risk Stratification for Patients Considered Eligible for Accelerated Partial Breast Irradiation?

Following breast conserving surgery, the risk of ipsilateral in-breast recurrence is equivalent between whole breast radiation therapy (WBRT) and accelerated partial breast irradiation (APBI) in patients with low-risk tumors according to ASTRO guidelines. The Oncotype DX Recurrence Score (RS) is prognostic for both local and distant recurrence in ER+/HER2- breast cancer. Whether the RS can identify patients at increased risk for local recurrence among those considered eligible for APBI is unclear.We retrospectively identified consecutive patients with clinical T1-2, ER+/HER2-, node-negative tumors with an available RS, and who were treated with APBI from 2010-2019 at a single institution. RS testing was performed for all patients with ER+/HER2-, invasive cancers ≥ 0.5 cm who were candidates for chemotherapy. Patients were considered for APBI based on the 2009 ASTRO guidelines. Characteristics were compared between patients with RS ≤ 25 and RS > 25 using Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. The 6-year cumulative incidence rate (CIR) of local recurrence was estimated using Kaplan-Meier methods and was compared between groups using the log-rank test.223 patients were identified; the median (IQR) age was 63 years (57-68) and median (IQR) tumor size was 1.0 cm (0.8-1.4). 201 patients (90%) had RS ≤ 25 and 22 patients (10%) had RS > 25. Nine patients aged ≤ 50 years were included, all of whom had RS ≤ 25. Compared with the RS ≤ 25 group, patients with RS > 25 more frequently had tumors that were progesterone receptor negative (55% vs. 9%; P < 0.001), grade III (50% vs. 11%; P < 0.001) and were more likely to have received chemotherapy (73% vs. 5%; P < 0.001). Uptake of endocrine therapy was similar in the RS ≤ 25 group compared with RS > 25 group (97% vs. 95%; P = 0.39), as was median (IQR) duration of endocrine therapy at 3 years (2-5) for both groups (P = 0.9). The median (range) follow-up was 3.6 years (0.1-10.2) and was similar between groups (P = 0.64). Overall, 4 ipsilateral in-breast recurrences occurred during follow-up, with 2 events (1.0%) in the RS ≤ 25 group and 2 events (9.1%) in the RS > 25 group (P = 0.05). The 6-year CIR of local recurrence was higher among patients with RS > 25 compared with RS ≤ 25 (6-year CIR [95% CI] 0.01 [0-0.04] vs. 0.08 [0-0.21]; P = 0.006). Due to a low number of events, a multivariable analysis of factors associated with local recurrence could not be performed.The overall risk of local recurrence following APBI in patients with early-stage, ER+ tumors is low, but our findings suggest that the RS may identify patients at increased risk for local failure among a favorable risk population. Prospective studies are needed to assess whether genomic profiling can be used for additional risk stratification for patients considered eligible for APBI, to identify patients for whom de-escalation of WBRT may not be advisable.

A Surveillance Endoscopy Strategy Based on Local Recurrence Rates after Colorectal Endoscopic Submucosal Dissection.

Backgrounds: It is not clear when and how frequently surveillance endoscopy should be performed after colorectal endoscopic submucosal dissection (ESD). We aimed to suggest a surveillance endoscopy strategy by investigating the cumulative local recurrence rates and identifying risk factors for local recurrence after colorectal ESD. Methods: We reviewed the medical records of 770 patients who underwent colorectal ESD for 778 lesions at our institution from 2005 to 2016. We investigated the cumulative local recurrence rates and risk factors for local recurrence. Results: Local recurrence developed in 12 (1.5%) of 778 lesions during the follow-up period of 37.4 ± 31.7 months. The one-, three-, and five-year cumulative local recurrence rates were 0.4%, 1.7%, and 2.2%, respectively. The risk factors for local recurrence were piecemeal resection (odds ratio (OR) 3.948, 95% confidence interval (CI) 1.164–13.385; p = 0.028) and histological incomplete resection (OR 8.713, 95% CI 2.588–29.334; p < 0.001). Local recurrence tended to develop frequently after ESD of early cancers. Conclusions: Short-term surveillance endoscopy should be recommended after piecemeal ESD, histological incomplete resection, and ESD of early colorectal cancers. Surveillance endoscopy with longer intervals can be suggested after en bloc ESD with the histological complete resection of benign colorectal tumors.

Re-evaluation of controversial issues in the treatment of cT3N0-2 rectal cancer: a 10-year cohort analysis using propensity-score matching

Although neoadjuvant treatment is thought to provide optimal local control for stage II and III rectal cancers, many patients have been reported cured by total mesorectal excision (TME), alone or with additional chemotherapy (CTX). This study retrospectively evaluated outcomes in 2643 patients with cT3N0-2 rectal cancers undergoing curative TME during 2005-2015. Recurrence and survival outcomes were measured in three propensity-score matched groups, consisting of patients who underwent preoperative chemoradiotherapy (CRT) with postoperative CTX (NAPOC), postoperative CRT (POCRT), and exclusively postoperative CTX (EPOCT). Near-complete or complete TME was conducted in more than 95.9% of patients and 80% of scheduled dose of postoperative CTX was completed in 99%. Except for higher SR rate in the POCRT group than the NAPOC group (p = 0.008), 5-year cumulative local and systemic recurrence (LR and SR) rates were 4.9% and 15.2% for cT3N0, and 4.2% and 21% for cT3N1-2 patients (LR, p = 0.703; SR, 0.065), respectively, with no significant differences associated with treatment exposure (p = 0.11-1). The 5-year cumulative disease-free (75.6% vs 65.7%, p = 0.018) and overall survival (87.1% vs 79.4%, p = 0.018 each) rates were higher in the NAPOC group than the POCRT group with cT3N1-2. However, any significant survival differences were not identified between the NAPOC and EPOCT groups according to tumor sub-stages or locations (p = 0.395-0.971). We found any treatment modalities including competent TME and postoperative adjuvant CTX efficiently reducing LR generating robust survival outcome in the propensity-matched cohorts, demanding further randomized controlled trials by clinical sub-stages II-III.