Differences In Recurrence Patterns Research Articles

Different pattern of recurrence after pancreatoduodenectomy according to the origin of peri-ampullary cancer

Different pattern of recurrence after pancreatoduodenectomy according to the origin of peri-ampullary cancer

Development of models to predict early post-transplant recurrence of hepatocellular carcinoma that also integrate the quality and characteristics of the liver graft: A national registry study in China

BackgroundDonor characteristics and graft quality were recently reported to play an important role in the recurrence of hepatocellular carcinoma after liver transplantation. Our aim was to establish a prognostic model by using both donor and recipient variables. MethodsData of 1,010 adult patients (training/validation: 2/1) undergoing primary liver transplantation for hepatocellular carcinoma were extracted from the China Liver Transplant Registry database and analyzed retrospectively. A multivariate competing risk regression model was developed and used to generate a nomogram predicting the likelihood of post-transplant hepatocellular carcinoma recurrence. ResultsOf 673 patients in the training cohort, 70 (10.4%) had hepatocellular carcinoma recurrence with a median recurrence time of 6 months (interquartile range: 4–25 months). Cold ischemia time was the only independent donor prognostic factor for predicting hepatocellular carcinoma recurrence (hazard ratio = 2.234, P = .007). The optimal cutoff value was 12 hours when patients were grouped according to cold ischemia time at 2-hour intervals. Integrating cold ischemia time into the Milan criteria (liver transplantation candidate selection criteria) improved the accuracy for predicting hepatocellular carcinoma recurrence in both training and validation sets (P < .05). A nomogram composed of cold ischemia time, tumor burden, differentiation, and α-fetoprotein level proved to be accurate and reliable in predicting the likelihood of 1-year hepatocellular carcinoma recurrence after liver transplantation. Additionally, donor anti–hepatitis B core antibody positivity, prolonged cold ischemia time, and anhepatic time were linked to the intrahepatic recurrence, whereas older donor age, prolonged donor warm ischemia time, cold ischemia time, and ABO incompatibility were relevant to the extrahepatic recurrence. ConclusionThe graft quality integrated models exhibited considerable predictive accuracy in early hepatocellular carcinoma recurrence risk assessment. The identification of donor risks can further help understand the mechanism of different patterns of recurrence.

High-risk Stage II Colorectal Cancers Carry an Equivalent Risk of Peritoneal Recurrence to Stage III.

Several risk factors for recurrence have been identified in stage II colorectal cancer. However, in contrast to stage III, the benefits of adjuvant chemotherapy for these patients remain controversial. We hypothesized that the different impacts of chemotherapy may be due to different patterns of recurrence between these stages. The aim of this study was to characterize recurrence in high-risk stage II colorectal cancer (CRC) in comparison with stage III. A total of 442 patients with curatively resected stage III and high-risk stage II CRCs were evaluated. The recurrence site and frequency were compared between these stages. The risk factors of recurrence by site were identified using multivariate analyses. During the follow-up (median: 6.4 years), 31% of stage III and 13% of high-risk stage II patients manifested recurrence. Recurrence in the liver, lung, and distant lymph nodes was significantly more frequent in stage III (18%, 12%, 11%) than in high-risk stage II (7%, 6%, 3%). Stage III was independently associated with recurrence in these organs. In contrast, the rate of peritoneal recurrence was 5% in both stages. Clinicians should be aware that high-risk stage II CRC has a similar risk of postoperative recurrence in the peritoneum to Stage III CRC.

The Pattern of Recurrence in Diabetic Macular Edema Treated by Dexamethasone Implant: The PREDIAMEX Study

To assess the time to functional and anatomic recurrence of macular edema (ME) after a first intravitreal dexamethasone implant in eyes with diabetic macular edema (DME). A 6-month observational, prospective, uncontrolled, multicenter, national case series. Thirty-seven patients included between January 2015 and June2016. Patients were monitored at baseline and then monthly over 6 months after the first treatment. Different patterns of recurrence were defined: qualitative and quantitative anatomic recurrences and functional recurrence. Median ME duration before the first dexamethasone implant was 2.04 months. All patients received a dexamethasone implant for the first time, but 73% of patients had not undergone any form of treatment previously. The mean time from baseline to qualitative anatomic, quantitative anatomic, and functional recurrence was 4.22 months (95% confidence interval [CI], 3.80-4.65 months), 4.73 months (95% CI, 4.34-5.12 months), and 4.89 months (95% CI, 4.53-5.26 months), respectively. Almost all patients (7/8) who demonstrated a qualitative anatomic recurrence showed a subsequent quantitative anatomic and functional recurrence days later. Mean improvement in best-corrected visual acuity was 10.1 letters (95% CI, 6.7-13.4 letters) and 7.3 letters (95% CI, 4.1-10.6 letters) at months 2 and 6, respectively. The mean reduction in central subfield macular thickness was 206 μm (95% CI, 157-255 μm) and 146 μm (95% CI, 98-195 μm) at months 2 and 6, respectively. Dexamethasone implant is a functionally and anatomically effective treatment for DME in real-life practice. Qualitative anatomic recurrence seems to be an early sign of quantitative anatomic and functional recurrence. Further studies should demonstrate if early retreatment at the qualitative anatomic recurrence stage could better protect patient visual function.

Pathological diaphragmatic invasion by colorectal liver metastases is associated with RAS mutation, peritoneal recurrence and worse survival

BackgroundRisk factors for pathological diaphragmatic invasion from colorectal liver metastases (CRLM) and differences in recurrence patterns and survival between patients with true pathological diaphragmatic invasion versus inflammatory adhesions only remain poorly understood. This study aimed at identifying risk factors for and survival impact of pathological diaphragmatic invasion in patients with CRLM. MethodsPatients with CRLM who underwent hepatectomy with or without diaphragmatic resection from 1998 to 2015 were retrospectively analyzed. Recurrence-free survival (RFS), overall survival (OS), and recurrence patterns were examined according to the presence or absence of pathological invasion. ResultsOf 1860 patients, 70 underwent hepatectomy with diaphragmatic resection and 1799 had hepatectomy only. Among the patients with gross diaphragmatic involvement, 15 (21%) had pathological invasion, and 55 (79%) had inflammatory adhesion only. Multiple tumors (p = 0.019) and RAS mutation (p = 0.047) were significantly associated with pathological invasion. Pathological invasion was associated with a higher incidence of peritoneal recurrence (33% vs. 11%, p = 0.041), worse median RFS (6 months vs. 11 months, p = 0.21) and OS (26 months vs. 51 months, p = 0.046) compared to inflammatory adhesion. ConclusionMultiple tumors and RAS mutant were predictors for pathological diaphragmatic invasion, which was associated with a higher incidence of peritoneal recurrence and worse OS.

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes

ObjectivesTo report and compare early oncological outcomes and cancer recurrence sites among patients undergoing open radical cystectomy (ORC) and robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). Methods and materialsA total of 184 patients underwent radical cystectomy for bladder cancer. ORC cases (n = 94) were performed between June 2005 and July 2014 while iRARC cases (n = 90) were performed between June 2011 and July 2014. Primary outcome was recurrence free survival (RFS). Secondary outcomes were sites of local and metastatic recurrence, cancer specific survival (CSS) and overall survival (OS). ResultsMedian follow-up for patients without recurrence was 33.8 months (interquartile range [IQR]: 20.5–45.4) for ORC; and 16.1 months (IQR: 11.2–27.0) for iRARC. No significant difference in age, sex, precystectomy T stage, precystectomy grade, or lymph node yield between ORC and iRARC was observed. The ORC cohort included more patients with≥pT2 (64.8% ORC vs. 38.9% iRARC) but fewer pT0 status (8.5% ORC vs.vs. 22.2% iRARC) due to lower preoperative chemotherapy use (22.3% ORC vs. 34.4% iRARC). Positive surgical margin rate was significantly higher in the ORC cohort (19.3% vs. 8.2%; P = 0.042). Kaplan-Meir analysis showed no significant difference in RFS (69.5% ORC vs. 78.8% iRARC), cancer specific survival (80.9% ORC vs. 84.4% iRARC), or OS (73.5% ORC vs.vs. iRARC 83.8%) at 24 months. Cox regression analysis showed RFS, cancer specific survival and OS were not influenced by cystectomy technique. No significant difference between local and metastatic RFS between ORC and iRARC was observed. ConclusionThis study has found no difference in recurrence patterns or oncological outcomes between ORC and iRARC. Recurrent metastatic sites vary, but are not related to surgical technique.

Abstract A02: Breast cancer recurrence patterns among ethnically distinct populations: A single institution large cohort study

Abstract African-American (AA) women with breast cancer have worse overall survival compared with European-American (EA) women with breast cancer for reasons that are incompletely understood. A primary risk factor for breast cancer-specific mortality is disease recurrence, yet racial distinctions in recurrence patterns remain poorly characterized. Evaluation of the risk of recurrence upon initial diagnosis is crucial for clinicians to customize an optimal treatment plan. Prognostic factors associated with recurrence include lymph node involvement, larger tumor size, earlier age at diagnosis, and triple-negative receptor status. These poor prognostic indicators have been associated with AA race. In this study, we examined rates and patterns of recurrence in a large cohort of breast cancer patients (n=10504) treated from 2005-2015 at Northside Hospital in Atlanta, GA. We observed that AA breast cancer patients (n=1850) exhibited a higher frequency of recurrences than EA breast cancer patients (n=7931) (p=0.047). Moreover, AA breast cancer patients exhibited a trend towards regional and distant recurrences, which are more fatal, whereas EA breast cancer patients displayed a higher inclination towards local recurrences that show a better prognosis. However, while these trends were robust, they did not achieve significance perhaps owing to the small number of patients in recurrence location subcategories. Importantly, overall survival was worse among AA patients with distant recurrences (n=26) than EA breast cancer patients with distant recurrences (n=80) (p=0.01). Furthermore, among patients who underwent lymph node surgery, regional recurrence was more likely among AAs (n=1030) than EAs (n=5252) (p=0.045). Among patients who received radiation, there was a non-significant trend towards AAs (n=874) exhibiting a greater propensity toward disease recurrence than EAs (n=3734). This study illuminates striking differences in recurrence patterns among AA and EA breast cancer patients by exposing that AA patients are more likely to experience more aggressive non-local recurrences, and are at a greater risk of mortality from distant recurrences. Collectively, these findings help to explain the accelerated progression of the disease and lower survival rates in AA breast cancer patients compared with their EA counterparts, underscoring the urgent need for clinicians to consider race in screening programs and when devising treatment plans. Citation Format: Nikita Wright, Pranay Neema, Remus Osan, Jun Xia, Stephen Wells, Josef G. Venable, Mildred Jones, Padmashree Rida, Ritu Aneja, Guilherme Cantuaria. Breast cancer recurrence patterns among ethnically distinct populations: A single institution large cohort study. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A02.

Adjuvant Therapy in Pancreas Cancer: Does It Influence Patterns of Recurrence?

Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC. Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated. There were 1,130 patients who were divided into those having surgery alone (n= 392), ACT (n= 291), or ACRT (n= 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT. This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC.

Resected pancreatic ductal adenocarcinomas with recurrence limited in lung have a significantly better prognosis than those with other recurrence patterns.

The majority of patients with curative resection of pancreatic ductal adenocarcinoma recur within 5 years of resection. However, the prognosis associated with different patterns of recurrence has not been well studied. A retrospective review of patients who underwent curative surgical resection of pancreatic cancer was performed. Of the 209 patients, 174 patients developed recurrent disease. Of these 174, 28(16.1%) had recurrent disease limited to lung metastases, 20(11.5%) had recurrence in the lung plus one or more other sites excluding the liver, 73(42.0%) had liver metastasis alone or liver metastasis with any other site except lung, 28(16.1%) local recurrence only, and 25(14.3%) peritoneal recurrence alone or together with local recurrence. Patients with recurrence limited to lung had a 8.5 months(Mo) median survival from recurrence to death, which was significantly better than the survival associated with recurrence in the liver(5.1Mo), in the peritoneum(2.3Mo) or locally(5.1Mo) in multivariable analyses. Among all groups, the time from surgery to the diagnosis of recurrence in patients who recurred in only in the lung was also the longest. However, 75% of patients were found to have indeterminate lung nodules on their surveillance CT scans prior to the diagnosis of recurrence in lung. This delayed diagnosis of lung recurrence may have a negative impact on survival after recurrence. In conclusion, pancreatic cancer with lung recurrence has a significantly better prognosis than recurrence in other sites. Further studies are needed to investigate how different diagnostic and treatment modalities affect the survival of this unique subpopulation of pancreatic cancer patients.

Factors associated with early recurrence after curative surgery for gastric cancer.

To characterize patterns of gastric cancer recurrence and patient survival and to identify predictors of early recurrence after surgery. Clinicopathological data for 417 consecutive patients who underwent curative resection for gastric cancer were retrospectively analyzed. Tumor and node status was reclassified according to the 7(th) edition of the American Joint Committee on Cancer tumor-node-metastasis classification for carcinoma of the stomach. Survival data came from both the patients' follow-up records and telephone follow-ups. Recurrent gastric cancer was diagnosed based on clinical imaging, gastroscopy with biopsy, and/or cytological examination of ascites, or intraoperative findings in patients who underwent reoperation. Predictors of early recurrence were compared in patients with pT1 and pT2-4a stage tumors. Pearson's χ (2) test and Fisher's exact test were used to compare differences between categorical variables. Survival curves were constructed using the Kaplan-Meier method and compared via the log-rank test. Variables identified as potentially important for early recurrence using univariate analysis were determined by multivariate logistic regression analysis. Of 417 gastric cancer patients, 80 (19.2%) were diagnosed with early gastric cancer and the remaining 337 (80.8%) were diagnosed with locally advanced gastric cancer. After a median follow-up period of 56 mo, 194 patients (46.5%) experienced recurrence. The mean time from curative surgery to recurrence in these 194 patients was 24 ± 18 mo (range, 1-84 mo). Additionally, of these 194 patients, 129 (66.5%) experienced recurrence within 2 years after surgery. There was no significant difference in recurrence patterns between early and late recurrence (P < 0.05 each). For pT1 stage gastric cancer, tumor size (P = 0.011) and pN stage (P = 0.048) were associated with early recurrence of gastric tumors. Patient age, pT stage, pN stage, Lauren histotype, lymphovascular invasion, intraoperative chemotherapy, and postoperative chemotherapy were independent predictors of early recurrence in patients with pT2-4a stage gastric cancer (P < 0.05 each). Age, pT stage, pN stage, Lauren histotype, lymphovascular invasion, intraoperative chemotherapy, and postoperative chemotherapy are independent factors influencing early recurrence of pT2-4a stage gastric cancer.

Anatomical and functional recurrence after dexamethasone intravitreal implants: a 6-month prospective study.

To evaluate the efficacy, safety, and delay of anatomical and functional recurrence after a first intravitreal injection of dexamethasone implant in eyes with cystoid macular edema (CME) secondary to retinal vein occlusion (RVO). A 6-month prospective, monocentric and noncomparative case-series of 26 eyes of 26 patients. Best-corrected visual acuity (BCVA) and central subfield thickness (CST) were measured at baseline and each visit at 1 week, and months 1, 2, 3, 4, 5, and 6 after a first treatment. Primary efficacy outcome was the proportion of eyes with a minimum three-line improvement from baseline BCVA at each visit and at 6 months. We also defined different patterns of recurrence: qualitative anatomical recurrence, quantitative anatomical recurrence and functional recurrence. A P-value <5% was considered statistically significant. Mean population age was 69.3 years (SD=12.2; range=42-94 years). Mean ME duration before treatment was ~9.2 months (SD=11.43; range=0.4-40 months). Eighty eight percent of eyes achieved a three-line improvement from baseline at 2 months (P=0.02). The mean delay from baseline until qualitative anatomical, functional, or quantitative anatomical recurrence was 4.11 months (±0.86), 4.31 months (±1.33), and 4.40 months (±1.14), respectively. Qualitative anatomical recurrence occurred on average 14.4 days (SD=42.18) before a minimum of one-line BCVA impairment (functional recurrence). Dexamethasone intravitreal treatment seems to be effective for ME after RVO even with long-duration ME or poor visual acuity before treatment. Other longer studies should assess the delay of recurrence after second and further treatments with DEX implants or combined therapies for ME after RVO.

Risk groups in bladder cancer patients treated with radical cystectomy.

Objective To stratify patients with bladder cancer into homogeneous risk groups according to statistically significant differences found in PFS (progression-free survival). To identify those patients at increased risk of progression and to provide oncological follow-up according to patient risk group.Materials and Methods A retrospective study of 563 patients treated with radical cystectomy (RC). In order to determine which factors might predict bladder tumour progression and death, uni- and multivariate analyses were performed. The risk groups were identified according to “inter-category” differences found in PFS and lack of differences, thus revealing intra-category homogeneity.Results Median follow up time was 37.8 months. Recurrence occurred in a total of 219 patients (38, 9%). In 63% of cases this was distant recurrence. Only two variables retained independent prognostic value in the multivariate analysis for PFS: pathological organ confinement and lymph node involvement. By combining these two variables, we created a new “risk group” variable. In this second model it was found that the new variable behaved as an independent predictor associated with PFS.Four risk groups were identified: very low, low, intermediate and high risk:• Very low risk: pT0 N0• Low risk: pTa, pTis, pT1, pT2 and pN0• Intermediate risk: pT3 and pN0• High risk: pT4 N0 or pN1-3.Conclusions We retrospectively identified 4 risk groups with an independent prognostic value for progression-free survival following RC. Differences in recurrence patterns after RC between risk groups have led us to set different intervals in monitoring for cancer.

Comparison of adenocarcinoma and adenosquamous carcinoma in patients with early-stage cervical cancer after radical surgery

ObjectiveTo compare outcomes after radical hysterectomy in patients with stage IB1 adenocarcinoma (AdCa) and adenosquamous carcinoma (AdSCCa) of the uterine cervix. MethodsWe performed a retrospective analysis of 265 patients with AdCa and 72 patients with AdSCCa. Demographic, clinicopathologic, surgical, and follow-up data were compared. ResultsThere were no differences in demographic and clinicopathologic characteristics between the two histologic types (AdCa vs. AdSCCa). Only mean size of tumor and lymphovascular space invasion was larger and more frequent in AdSCCa (2.7cm vs 2.3cm, P=0.019 & 29.2% vs 14.7%, P=0.008). After a median follow-up time of 68months, 39 (14.7%) and 13 (18.1%) AdCa and AdSCCa patients, respectively, had recurrent disease (P=0.467), and 33 (12.5%) and 11 (15.3%) patients, respectively, died of their disease (P=0.555). 5-year RFS rates were 89% and 85% (P=0.582), respectively, and 5-year OS rates were 93% and 89% (P=0.787). Histologic type had no clinical impact on RFS and OS in multivariate analysis adjusting for significant prognostic factors. There were no differences in pattern of recurrence and time to recurrence between the two histologic types. When patients were stratified into three risk groups according to the criteria of GOG protocols 92 and 109, histologic type had no clinical impact on RFS and OS in any of the risk groups. ConclusionThere are no differences in clinicopathologic factors, patterns of recurrence, time to recurrence, RFS and OS between patients with AdCa and AdSCCa.

Extended Field Intensity Modulated Radiation Therapy With Concomitant Boost for Lymph Node–Positive Cervical Cancer: Analysis of Regional Control and Recurrence Patterns in the Positron Emission Tomography/Computed Tomography Era

Positron emission tomography/computed tomography (PET/CT) is commonly used for nodal staging in locally advanced cervical cancer; however the false negative rate for para-aortic disease are 20% to 25% in PET-positive pelvic nodal disease. Unless surgically staged, pelvis-only treatment may undertreat para-aortic disease. We have treated patients with PET-positive nodes with extended field intensity modulated radiation therapy (IMRT) to address the para-aortic region prophylactically with concomitant boost to involved nodes. The purpose of this study was to assess regional control rates and recurrence patterns. Sixty-one patients with cervical cancer (stage IBI-IVA) diagnosed from 2003 to 2012 with PET-avid pelvic nodes treated with extended field IMRT (45 Gy in 25 fractions with concomitant boost to involved nodes to a median of 55 Gy in 25 fractions) with concurrent cisplatin and brachytherapy were retrospectively analyzed. The nodal location was pelvis-only in 41 patients (67%) and pelvis + para-aortic in 20 patients (33%). There were a total of 179 nodes, with a median number of positive nodes of 2 (range, 1-16 nodes) per patient and a median nodal size of 1.8 cm (range, 0.7-4.5 cm). Response was assessed by PET/CT at 12 to 16 weeks. Complete clinical and imaging response at the first follow-up visit was seen in 77% of patients. At a mean follow-up time of 29 months (range, 3-116 months), 8 patients experienced recurrence. The sites of persistent/recurrent disease were as follows: cervix 10 (16.3%), regional nodes 3 (4.9%), and distant 14 (23%). The rate of para-aortic failure in patients with pelvic-only nodes was 2.5%. There were no significant differences in recurrence patterns by the number/location of nodes, largest node size, or maximum node standardized uptake value. The rate of late grade 3+ adverse events was 4%. Extended field IMRT was well tolerated and resulted in low regional recurrence in node-positive cervical cancer. The dose of 55 Gy in 25 fractions was effective in eradicating disease in involved nodes, with acceptable late adverse events. Distant metastasis is the predominant mode of failure, and the OUTBACK trial may challenge the presented paradigms.

Patterns of Failure in Squamous Cell Carcinoma of the Anal Canal: A Comparison Between Intensity Modulated Radiation Therapy and 3-Dimensional Conformal Radiation Therapy

Patterns of Failure in Squamous Cell Carcinoma of the Anal Canal: A Comparison Between Intensity Modulated Radiation Therapy and 3-Dimensional Conformal Radiation Therapy

Differences in Patterns of Recurrence in Early-Stage Versus Locally Advanced Non-Small Cell Lung Cancer

The benefits of screening for non-small cell lung cancer (NSCLC) have been established for high-risk individuals, and recent guidelines advocate continued surveillance after curative therapy. Yet the optimal posttreatment surveillance strategy remains to be determined. We compared patterns of recurrence and modes of detection in surgically treated patients with pathologic early-stage and locally advanced NSCLC. Consecutive patients who had undergone resection for stage I-IIIA NSCLC from 2004 to 2009 were identified from a prospectively maintained institutional database. All patients received interval chest computed tomography (CT) scans every 6 to 12 months after treatment. In total, 1,640 patients were identified: 181 of 346 patients with stage IIIA NSCLC (52%) and 257 of 1,294 patients with stage I-II NSCLC (20%) experienced recurrences. Surveillance CT detected asymptomatic recurrences in 157 stage I-II patients (61%) and 89 stage IIIA patients (49%) (p=0.045). Symptoms led to detection of recurrences more often in stage IIIA patients (73, 40%) than in stage I-II patients (81, 32%). Distant recurrences were more common in stage IIIA patients than in stage I-II patients (153, 85%, vs 190, 74%; p=0.01). In stage IIIA patients, the risk of recurrence was highest during the first 2 years after operation, but it remained substantial into year 4. Stage IIIA patients had fewer recurrences detected by surveillance CT, a higher rate of symptomatic presentation, a markedly higher risk of recurrence, and a higher propensity for distant recurrence. Surveillance strategies may need to account for stage-specific differences.

Obesity was associated with a decreased postoperative recurrence of rectal cancer in a Japanese population.

Obesity contributes to the technical difficulty of rectal surgery and is considered to be a risk factor for postoperative complications. The impact of obesity on the long-term outcomes of rectal cancer surgery remains unclear. A total of 263 consecutive rectal cancer patients who underwent surgery were categorized into two groups according to the body mass index (BMI) based on the Asian BMI classification: non-obese (BMI <25 kg/m(2)) and obese (BMI ≥25 kg/m(2)). The postoperative survival and recurrence rates and oncological surgical quality indicators were compared between groups using the univariate and multivariate analyses. The differences in recurrence patterns were assessed by a competing risk regression analysis. 64 (24%) patients were included in the obese group. The number of retrieved lymph nodes was significantly greater in the non-obese group than in the obese group (22.4 vs. 16.0, P < 0.01). The 5-year disease-free survival (DFS) rates were 86.5 and 68.8% in the obese and non-obese groups, respectively (P = 0.01). The multivariate analysis demonstrated that obesity significantly decreased the postoperative recurrence rate (P = 0.04). Moreover, the BMI was significantly associated with distant metastasis (P = 0.04). Obese rectal cancer patients have high DFS rates and a decreased incidence of distant metastases compared to non-obese patients. The BMI may be a key factor for predicting the postoperative prognosis and determination of an appropriate strategy for the treatment of rectal cancer patients.

Predictors and outcomes of recurrence after resection of colorectal liver metastases

To explore the outcomes of different recurrence patterns and recurrence-related factors after hepatectomy in patients with colorectal liver metastases (CRLM). The outcomes of different recurrence patterns and recurrence-related factors for surgical resection of CRLMs was reviewed retrospectively. A total of 152 postoperative recurrent cases were included between 2000 and 2013. The median overall survival was 28.9 months and 5-year survival 22.1% for the entire group. The median disease-free survival was 7.6 months. Among them, 60 patients had disease recurrence within 6 months after hepatectomy (early recurrence) and their median overall survival was 19.4 months versus 35.1 months (n = 92) for those with a disease-free interval of over 6 months (P = 0.000).Repeat resection was associated with better outcomes, but different patterns of recurrence were not. Lymph node metastases of primary tumor, number of metastases and efficacy of neo-adjuvant chemotherapy (NACT) were independently associated with recurrence. Recurrence after hepatectomy of CRLMs is affected by lymph node metastases of primary tumor, number of metastases and efficacy of NACT. Additional survival advantage may be achieved by resection of recurrent disease.

Takotsubo Cardiomyopathy

63-year-old woman has had 2 hospital admissions for central chest pain occurring in the setting of emotional stress over the last 11 years. Her other medical history included anxiety, hypertension, and dyslipidemia. At 52 years of age, she presented to the hospital with central chest pain after a major argument with her mother. An ECG demonstrated sinus rhythm with 1-mm ST-segment elevation in leads I and aVL. Her serum troponin I was mildly elevated at 0.63 μg/L (normal <0.03 μg/L). A coronary angiogram demonstrated no significant flow-limiting coronary artery lesions. A left ventriculogram demonstrated severe left ventricular dysfunction resulting from a large area of akinesis involving the anterior and apical wall segments. Subsequently, she developed pulmonary edema, which was treated with diuretic therapy. A transthoracic echocardiogram performed 4 days after admission demonstrated full recovery of the patient’s left ventricular dysfunction, consistent with a diagnosis of Takotsubo cardiomyopathy. She was treated with aspirin, a statin, and a calcium channel blocker. The patient had been followed up regularly with transthoracic echocardiograms, which demonstrated normal left ventricular systolic function (Movies I and II in the online-only Data Supplement). Recently, 11 years after her first hospital admission with chest pain, the patient presented to our hospital with central chest pain after arguments with her son. She experienced significant emotional stress on learning that her son was abusing illicit recreational substances. An ECG demonstrated sinus rhythm with nonspecific T-wave flattening in the lateral leads. Her serum troponin I rapidly peaked at 1.76 μg/L (normal <0.03 μg/L). A coronary angiogram demonstrated mild atheroma in the left anterior descending artery and right coronary artery only (Figure 1). A left ventriculogram demonstrated midventricular akinesis in a noncoronary distribution. Contraction in the basal and apical segments was preserved (Figure 2 and Movie III in the online-only Data Supplement). These findings were consistent with a diagnosis of midventricular Takotsubo cardiomyopathy. She was treated with a β-blocker and angiotensin receptor blocker. She remained well after discharge with recovery of left ventricular function (Movies IV and V in the online-only Data Supplement). Discussion Takotsubo cardiomyopathy frequently occurs in the setting of significant emotional or physical stress or acute medical illnesses. Some patients develop recurrent Takotsubo cardiomyopathy in the setting of further stressors, with normal left ventricular systolic function between these episodes. The factors determining recurrence are poorly understood. One proposed mechanism is an excess of catecholamine, which results in myocardial toxicity. This theory is supported by evidence of elevated plasma catecholamine levels in patients with Takotsubo cardiomyopathy compared with patients with acute myocardial infarction. 1 Therefore, β-blockers have been used as one of the key pharmacological agents in the treatment of Takotsubo cardiomyopathy. Our patient was managed with a calcium channel blocker after her first presentation, and we hypothesize that the absence of β-blockade in the initial treatment regimen may have contributed to her recurrent presentation. What is even more enigmatic is the variable pattern of ventricular involvement in recurrent cases of Takotsubo cardiomyopathy. The first cases of midventricular variant of Takotsubo cardiomyopathy in the Western literature were described in 2006. 2 Since then, various case reports have been published describing different patterns of recurrence. 3 A consistent theme appears to emerge in the cases of recurrent Takotsubo cardiomyopathy described in literature: Recurrent Takotsubo cardiomyopathy often occurred in a different ventricular region. Our patient developed acute pulmonary edema from severe left ventricular apical involvement during her first presentation. Her recurrent presentation occurred in the midventricle only. Consequently, she was not as unwell during the recurrent presentation and did not develop pulmonary edema. We hypothesize that the previous episode of apical Takotsubo cardiomyopathy protected her left ventricular apex from being involved during the recurrent episode. The mechanisms mediating this phenomenon are unclear. It may be that the first episode protected the left ventricular apex via a phenomenon analogous to regional ischemic preconditioning. 4 Transient ischemia of the left ventricular apex during the first presentation may have imprinted memory in the apical

Segmentectomy for clinical stage IA lung adenocarcinoma showing solid dominance on radiology

This study aimed to compare prognosis after segmentectomy and after lobectomy for radiologically determined solid-dominant clinical stage IA lung adenocarcinoma. From a multicentre database of 610 consecutive patients with clinical stage IA lung adenocarcinoma who underwent complete resection after preoperative high-resolution computed tomography (HRCT) and F-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), 327 patients with a radiologically determined solid-dominant tumour (solid component on HRCT ≥50%) who underwent lobectomy (n = 286) or segmentectomy (n = 41) were included. No significant difference existed in recurrence-free survival (RFS) between the lobectomy and segmentectomy groups (3-year RFS, 84.4 vs 84.8%, respectively; P = 0.69). There was no significant difference in recurrence pattern between these two groups (local, 5.6 vs 7.3%, P = 0.72; distant, 9.1 vs 4.9%, P = 0.55, respectively). Even in patients with pure solid tumours, no significant difference was observed in RFS between lobectomy and segmentectomy groups (3-year RFS, 76.8 vs 84.7%, respectively; P = 0.48), as well as in those with a mixed ground-glass opacity tumour (3-year RFS, 91.0 vs 85.0%, respectively; P = 0.60). Multivariate Cox analysis demonstrated that solid tumour size on HRCT (P = 0.048) and maximum standardized uptake value (SUVmax) on FDG-PET/CT (P < 0.001), not the surgical procedure (P = 0.40), were independent prognostic factors for RFS. RFS depends on solid tumour size on HRCT and SUVmax on FDG-PET/CT, rather than on the surgical procedure, in patients with radiologically detected solid-dominant clinical stage IA lung adenocarcinoma. Patient prognosis is similar after lobectomy and after segmentectomy for solid-dominant tumour.