Difference In Resection Rate Research Articles

Safety and Feasibility of Neoadjuvant-Modified FOLFIRINOX in Elderly Patients with Pancreatic Cancer.

The optimal treatment strategy for neoadjuvant chemotherapy in elderly patients with pancreatic cancer (PC) remains unclear. Hence, this study was aimed at evaluating the safety and feasibility of neoadjuvant-modified FOLFIRINOX (mFOLFIRINOX) in elderly patients with PC. We retrospectively collected data from 62 patients who received neoadjuvant mFOLFIRINOX between May 2015 and October 2023 and comparatively analyzed the clinicopathological data and outcomes between the non-elderly group (age: <75 years) and elderly group (age: >75 years). The non-elderly and elderly groups comprised 39 and 23 patients, respectively. Although elevated levels of aspartate aminotransferase (p = 0.0173) and alanine aminotransferase (p = 0.0378) and nausea (p = 0.0177) were more frequent in the elderly group, the incidence of severe adverse events was similar between the groups. Intergroup differences in resection rate (p = 0.3381), postoperative severe complication rates (p = 0.2450), and postoperative hospital stay (p = 0.3496) were not significant. Furthermore, no significant intergroup differences were found in survival in either the whole or the resection cohorts. The perioperative and postoperative outcomes of elderly patients treated with neoadjuvant mFOLFIRINOX were comparable with those of non-elderly patients. Neoadjuvant mFOLFIRINOX should be considered a feasible option for elderly patients with PC.

Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial

Patients with borderline resectable pancreatic ductal adenocarcinoma have relatively low resection rates and poor survival despite the use of adjuvant chemotherapy. The aim of our study was to establish the feasibility and efficacy of three different types of short-course neoadjuvant therapy compared with immediate surgery. ESPAC5 (formerly known as ESPAC-5f) was a multicentre, open label, randomised controlled trial done in 16 pancreatic centres in two countries (UK and Germany). Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, biopsy proven pancreatic ductal adenocarcinoma in the pancreatic head, and were staged as having a borderline resectable tumour by contrast-enhanced CT criteria following central review. Participants were randomly assigned by means of minimisation to one of four groups: immediate surgery; neoadjuvant gemcitabine and capecitabine (gemcitabine 1000 mg/m2 on days 1, 8, and 15, and oral capecitabine 830 mg/m2 twice a day on days 1-21 of a 28-day cycle for two cycles); neoadjuvant FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, folinic acid given according to local practice, and fluorouracil 400 mg/m2 bolus injection on days 1 and 15 followed by 2400 mg/m2 46 h intravenous infusion given on days 1 and 15, repeated every 2 weeks for four cycles); or neoadjuvant capecitabine-based chemoradiation (total dose 50·4 Gy in 28 daily fractions over 5·5 weeks [1·8 Gy per fraction, Monday to Friday] with capecitabine 830 mg/m2 twice daily [Monday to Friday] throughout radiotherapy). Patients underwent restaging contrast-enhanced CT at 4-6 weeks after neoadjuvant therapy and underwent surgical exploration if the tumour was still at least borderline resectable. All patients who had their tumour resected received adjuvant therapy at the oncologist's discretion. Primary endpoints were recruitment rate and resection rate. Analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN, 89500674, and is complete. Between Sept 3, 2014, and Dec 20, 2018, from 478 patients screened, 90 were randomly assigned to a group (33 to immediate surgery, 20 to gemcitabine plus capecitabine, 20 to FOLFIRINOX, and 17 to capecitabine-based chemoradiation); four patients were excluded from the intention-to-treat analysis (one in the capecitabine-based chemoradiotherapy withdrew consent before starting therapy and three [two in the immediate surgery group and one in the gemcitabine plus capecitabine group] were found to be ineligible after randomisation). 44 (80%) of 55 patients completed neoadjuvant therapy. The recruitment rate was 25·92 patients per year from 16 sites; 21 (68%) of 31 patients in the immediate surgery and 30 (55%) of 55 patients in the combined neoadjuvant therapy groups underwent resection (p=0·33). R0 resection was achieved in three (14%) of 21 patients in the immediate surgery group and seven (23%) of 30 in the neoadjuvant therapy groups combined (p=0·49). Surgical complications were observed in 29 (43%) of 68 patients who underwent surgery; no patients died within 30 days. 46 (84%) of 55 patients receiving neoadjuvant therapy were available for restaging. Six (13%) of 46 had a partial response. Median follow-up time was 12·2 months (95% CI 12·0-12·4). 1-year overall survival was 39% (95% CI 24-61) for immediate surgery, 78% (60-100) for gemcitabine plus capecitabine, 84% (70-100) for FOLFIRINOX, and 60% (37-97) for capecitabine-based chemoradiotherapy (p=0·0028). 1-year disease-free survival from surgery was 33% (95% CI 19-58) for immediate surgery and 59% (46-74) for the combined neoadjuvant therapies (hazard ratio 0·53 [95% CI 0·28-0·98], p=0·016). Three patients reported local disease recurrence (two in the immediate surgery group and one in the FOLFIRINOX group). 78 (91%) patients were included in the safety set and assessed for toxicity events. 19 (24%) of 78 patients reported a grade 3 or worse adverse event (two [7%] of 28 patients in the immediate surgery group and 17 [34%] of 50 patients in the neoadjuvant therapy groups combined), the most common of which were neutropenia, infection, and hyperglycaemia. Recruitment was challenging. There was no significant difference in resection rates between patients who underwent immediate surgery and those who underwent neoadjuvant therapy. Short-course (8 week) neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Neoadjuvant chemotherapy with either gemcitabine plus capecitabine or FOLFIRINOX had the best survival compared with immediate surgery. These findings support the use of short-course neoadjuvant chemotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma. Cancer Research UK.

On the cutting edge of glioblastoma surgery: where neurosurgeons agree and disagree on surgical decisions.

The aim of glioblastoma surgery is to maximize the extent of resection while preserving functional integrity. Standards are lacking for surgical decision-making, and previous studies indicate treatment variations. These shortcomings reflect the need to evaluate larger populations from different care teams. In this study, the authors used probability maps to quantify and compare surgical decision-making throughout the brain by 12 neurosurgical teams for patients with glioblastoma. The study included all adult patients who underwent first-time glioblastoma surgery in 2012-2013 and were treated by 1 of the 12 participating neurosurgical teams. Voxel-wise probability maps of tumor location, biopsy, and resection were constructed for each team to identify and compare patient treatment variations. Brain regions with different biopsy and resection results between teams were identified and analyzed for patient functional outcome and survival. The study cohort consisted of 1087 patients, of whom 363 underwent a biopsy and 724 a resection. Biopsy and resection decisions were generally comparable between teams, providing benchmarks for probability maps of resections and biopsies for glioblastoma. Differences in biopsy rates were identified for the right superior frontal gyrus and indicated variation in biopsy decisions. Differences in resection rates were identified for the left superior parietal lobule, indicating variations in resection decisions. Probability maps of glioblastoma surgery enabled capture of clinical practice decisions and indicated that teams generally agreed on which region to biopsy or to resect. However, treatment variations reflecting clinical dilemmas were observed and pinpointed by using the probability maps, which could therefore be useful for quality-of-care discussions between surgical teams for patients with glioblastoma.

Milan System for Reporting Salivary Gland Cytopathology: Differences in Resection Rate and Time to Surgical Follow-up Between Diagnostic Categories

Milan System for Reporting Salivary Gland Cytopathology: Differences in Resection Rate and Time to Surgical Follow-up Between Diagnostic Categories

Surgery for rectal cancer: Differences in resection rates among hospitals in the Netherlands

AimNumerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes. MethodsAll patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis. ResultsA total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56–1.88), 2.42 (2.19–2.67), and 4.04 (3.61–4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified. ConclusionThere is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care.

S0953 Novel Axially Parallel Endoscopic Submucosal Dissection Knife vs Insulated Tip Endoscopic Submucosal Dissection Knife: Outcomes of a Randomized ex-vivo Pilot Study

INTRODUCTION: Endoscopic Submucosal Dissection (ESD) is utilized for the treatment of large gastrointestinal tract lesions or lesions not amenable to standard endoscopic mucosal resection. Insulated tip (IT-ESD) knife is a commonly used knife for ESD. A recent axially paralleled ESD (AP-ESD) knife has shown promising results in tissue resection. The primary aim of this study was to compare the efficacy, safety, physical and mental workload of AP-ESD knife to IT-ESD knife in ex-vivo models. METHODS: This was a randomized-controlled, pilot study comparing IT-ESD to AP-ESD knife in ex-vivo porcine models. AP-ESD knife is a single use, electrocautery enhanced knife that allows for safe dissection and low risk of perforation given the parallel orientation of the knife to the mucosa [s]. A total of 18 participants divided into two groups (novices, n = 9 and experts n = 9) without prior experience with AP-ESD knife were randomized 1:1 into two groups (group 1: AP-ESD followed by IT-ESD; group 2: IT-ESD followed by AP-ESD). A standard template was used to create 2 × 2 cm gastric lesions. The primary outcome was complete en-bloc resection. Secondary outcomes included differences in procedure time, perforation rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload. RESULTS: 18 participants each performed 2 tissue resections (1 AP-ESD and 1 IT-ESD), for a total of 36 procedures. Complete en-bloc resection was achieved in 33 models (resection rate 91.6%). No differences were observed in complete resection or perforation rate between IT-ESD and AP-ESD (88.2% vs 94.4%, P = 0.51 and 11.8 vs 11.1%, P = 0.95, respectively). Participants had a longer time with AP-ESD (1045 +/- 779 vs 783+/-532 seconds, P = 0.04) however there was no difference in demand using total NASA TLX (33 +/- 11 vs 39 +/- 9, P = 0.07). While experts (N = 9) had longer time with AP-ESD (895 +/- 649 seconds vs 595 +/- 383, P = 0.05), there was no difference in resection rate, perforation rate or NASA TLX demand. On the other hand, Novices (N = 9) showed no difference in resection rate, perforation rate or procedure time, however did have higher demand with AP-ESD (45 +/- 9 vs 37 +/- 11, P = 0.05). CONCLUSION: AP-ESD knife yielded similar rates of resection and perforation compared to a standard IT-ESD knife. Experts endoscopists required more time for dissection, likely due to an undefined learning curve with this new device and extensive familiarity with conventional knives.Figure 1.: Novel Axially Paralleled Endoscopic Submucosal Dissection (AP-ESD) Knife.

ESPAC-5F: Four-arm, prospective, multicenter, international randomized phase II trial of immediate surgery compared with neoadjuvant gemcitabine plus capecitabine (GEMCAP) or FOLFIRINOX or chemoradiotherapy (CRT) in patients with borderline resectable pancreatic cancer.

4505 Background: Patients with borderline resectable pancreatic cancer have poor survival and low resection rates. Neoadjuvant therapy may improve the outcome for these patients. The aim of this trial was to determine the feasibility and efficacy of a comparison of immediate surgery versus neoadjuvant GEMCAP or FOLFIRINOX or CRT. Methods: Eligible patients with NCCN defined borderline resectable (following central review of the baseline CT scan) and biopsy proven pancreatic cancer were randomised (stratified by centre) to receive immediate surgery, or neoadjuvant therapy of either 2 cycles of GEMCAP, or 4 cycles of FOLFIRINOX or 50.4Gy capecitabine-based CRT in 28 daily fractions over 5 ½ weeks. Patients were restaged at 4-6 weeks and underwent surgical exploration if still borderline resectable. Resected patients received adjuvant therapy. Follow up was 12 months. There was quality assurance of surgery and CRT. Primary endpoints were recruitment rate and resection rate (R1/R0). Secondary endpoints included overall survival and toxicity. A target of 90 patients was set to determine feasibility and resection rates. Rates will be presented as point estimates and survival compared across treatment arms using a log-rank test. Analyses will be on an ITT basis. Results: Between August 2014 and December 2018, 90 patients were randomised with 88 included in the full analysis set (32 immediate surgery, 20 GEMCAP, 20 FOLFIRINOX, 16 CRT). Median age was 63 years, 44% were men. WHO performance status was 0 and 1 in 45% and 55% respectively. Median CA19-9 was 603 kU/L at baseline. 44 (79%) patients completed neoadjuvant therapy. Recruitment rate was 21 patients per year. Resection rate was 62% for immediate surgery and 55% for neoadjuvant therapy (p=0.668). R0 resection rate on resected patients was 15% and 23% respectively (p=0.721). One year survival rate was 40% [95% CI, 26% – 62%] for immediate surgery and 77% [95%CI, 66% - 89%] for neoadjuvant therapy. Log-rank analysis showed an HR=0.27 [95% CI, 0.13 – 0.55]; χ2 (1) = 14.91, P&lt;0.001. 9 out of the 51 neoadjuvant patients included in the safety set reported 12 serious adverse events of grade 3 or above. Conclusions: There was no difference in resection rate between arms, however neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Clinical trial information: 89500674 .

Socioeconomic determinants of the surgical treatment of colorectal liver metastases

ObjectiveWe hypothesized that differences in resection rates of colorectal liver metastases exist based on socioeconomic status (SES) inequalities. MethodsThe NCDB was utilized to study patients of different median household income diagnosed with colon adenocarcinoma from 2010 to 2015. ResultsA total of 21,258 patients met inclusion criteria, of whom 3,587 (16.9%) underwent metastasectomy. Patients of the highest income quartile were more likely to undergo metastasectomy compared to the lowest quartile (OR 1.20, CI 1.07–1.37, p = 0.003). Overall, patients in the highest income quartile had a median OS of 17.1 months compared with 13.0 months for the lowest quartile (HR 0.85, CI 0.81–0.90, p < 0.001). While metastasectomy was associated with improved OS across all groups, the disparity by income quartile widened (29.2 vs. 22.0 months, respectively; HR 0.51, CI 0.49–0.54, p < 0.001). ConclusionHigher income patients were more likely to undergo metastasectomy compared with lower income patients and were associated with longer OS.

Racial Disparities in Resection of Early Stage Non-Small Cell Lung Cancer: Variability Among Surgeons.

Racial disparities in resection of non-small cell lung cancer (NSCLC) are well documented. Patient-level and system-level factors only partially explain these findings. Although physician-related factors have been suggested as mediators, empirical evidence for their contribution is limited. To determine if racial disparities in receipt of thoracic surgery persisted after patients had a surgical consultation and whether there was a physician contribution to disparities in care. The authors identified 19,624 patients with stage I-II NSCLC above 65 years of age from the Surveillance-Epidemiology and End-Results-Medicare database. They studied black and white patients evaluated by a surgeon within 6 months of diagnosis. They assessed for racial differences in resection rates among surgeons using hierarchical linear modeling. Our main outcome was receipt of NSCLC resection. A random intercept was included to test for variability in resection rates across surgeons. Interaction between patient race and the random surgeon intercept was used to evaluate for heterogeneity between surgeons in resection rates for black versus white patients. After surgical consultation, black patients were less likely to undergo resection (adjusted odds ratio, 0.57; 95% confidence interval, 0.47-0.69). Resection rates varied significantly between surgeons (P<0.001). A significant interaction between the surgeon intercept and race (P<0.05) showed variability beyond chance across surgeons in resection rates of black versus white patients. When the model included thoracic surgery specifalization the physician contribution to disparities in care was decreased. Racial disparities in resection of NSCLC exist even among patients who had access to a surgeon. Heterogeneity between surgeons in resection rates between black and white patients suggests a physician's contribution to observed racial disparities. Specialization in thoracic surgery attenuated this contribution.

P109 GEOGRAPHICAL DIFFERENCES IN RESECTION RATES ASSOCIATED WITH SURVIVAL IN SWEDEN-IS SURGERY UNDERUSED?

Abstract Aim To investigate associations between resection rates and survival in esophageal and gastroesophageal junctional cancer. Background &amp; Methods Surgical resection is the mainstay of curative treatment for cancer in the esophagus and the gastroesophageal junction. Merely about one third of these patients undergo resectional surgery although proportions vary. We set out to study differences in resection rates by county and their influence, if any, on survival. A national cohort of patients with esophageal- and gastroesophageal junctional cancer, diagnosed 2006-2015, was set up by cross linking several national registries. The annual resection rate of each geographical county was calculated and divided into three groups (low, middle and high). Survival was analyzed with a Cox proportional hazards model including resection rate, sex, age, year of diagnosis, clinical TNM status, relevant comorbidities, neoadjuvant treatment as well as proportion intended curative oncological treatment. Results 6532 patients were diagnosed during the study period whereof 1733 (26.3 %) underwent open or endoscopic resectional surgery. 860 (49.6%) patients received neoadjuvant treatment. In the studied decade, rates ranged from 21% to 33% in the 21 counties. Overall mean survival after diagnosis was 8.1, 9.9 and 12.1 months in the low, middle and high-resection rate groups respectively. In the multivariate Cox analysis, higher resection rate was associated with improved survival (HR 0.87, 95% CI 0.84-0.90, p&lt;0.001). Conclusion In this national population-based cohort study, patients undergoing treatment in counties with higher resection rates had an associated improved survival. Local underuse of the surgical modality cannot be excluded.

Results of Transcranial Resection of Olfactory Groove Meningiomas in Relation to Imaging-Based Case Selection Criteria for the Endoscopic Approach.

Endoscopic endonasal surgery (EES) is increasingly used for olfactory groove meningiomas (OGMs). The role of EES for large (≥4 cm) or complex OGMs is debated. Specific imaging features have been reported to affect the degree of gross total resection (GTR) and complications following EES for OGMs. The influence of these factors on transcranial resection (TCR) is unknown. To examine the impact of specific imaging features on outcome following TCR to provide a standard for large and endoscopically less favorable OGMs against which endoscopic outcomes can be compared. Retrospective study of patients undergoing TCR for OGMs 2002 to 2016. Fifty patients (mean age 62.1 yr, mean maximum tumor diameter 5.04 cm and average tumor volume of 48.8 cm3) were studied. Simpson grade 1 and 2 resections were achieved in 80% and 12%, respectively. A favorable functional outcome (modified Rankin Scale [mRS] 0-2) was attained in 86%. The degree of resection, mRS, mortality (4%), recurrence (6%), infection (8%), and cerebrospinal fluid leak requiring intervention (12%) were not associated with tumor calcification, absence of cortical cuff, T2 hyperintensity, tumor configuration, tumor extension beyond midpoint of superior orbital roof, or extension to posterior wall of frontal sinus. There was no difference in resection rates but a trend towards greater complications between 3 arbitrarily divided groups of large meningiomas of increasing complexity based on extensive extension or vascular adherence. Favorable outcomes can be achieved with TCR for large and complex OGMs Factors that may preclude endoscopic resection do not negatively affect outcome following TCR.

Significance of neoadjuvant therapy for borderline resectable pancreatic cancer: a multicenter retrospective study.

Neoadjuvant therapy (NAT) is increasingly used to improve the prognosis of patients with borderline resectable pancreatic cancer (BRPC) albeit with little evidence of its advantage over upfront surgical resection. We analyzed the prognostic impact of NAT on patients with BRPC in a multicenter retrospective study. Medical data of 165 consecutive patients who underwent treatment for BRPC between January 2010 and December 2014 were collected from ten institutions. We defined BRPC according to the National Comprehensive Cancer Network guidelines, and subclassified patients according to venous invasion alone (BR-PV) and arterial invasion (BR-A). The rates of NAT administration and resection were 35% and 79%, respectively. There were no significant differences in resection rates and prognoses between patients in the BR-PV and BR-A subgroups. NAT did not have a significant impact on prognosis according to intention-to-treat analysis. However, in patients who underwent surgical resection, NAT was independently associated with longer overall survival (OS). The median OS of patients who underwent resection after NAT (53.7months) was significantly longer than that of patients who underwent upfront (17.8months) or no resection (14.9months). The rates of superior mesenteric or portal vein invasion, lymphatic invasion, venous invasion, and lymph node metastasis were significantly lower in patients who underwent resection after NAT than in those who underwent upfront resection despite similar baseline clinical profiles. Resection after NAT in patients with BRPC is associated with longer OS and lower rates of both invasion to the surrounding tissues and lymph node metastasis.

Surgical outcome of endoscopic endonasal surgery for non-functional pituitary adenoma by a team of neurosurgeons and otolaryngologists

This study aimed to assess the efficacy of endoscopic endonasal surgery, conducted by a team of neurosurgeons and otolaryngologists. We studied 40 patients who were undergoing surgery for primary non-functional pituitary adenomas with Knosp grades 1 to 3, at Keio University Hospital between 2005 and 2012. We compared the endoscopic endonasal transsphenoidal approach (team-eTSS; T-eTSS), with a microscopic transsphenoidal approach (mTSS). Analyses were conducted for differences between the two groups in tumor resection rates, operating durations, and complications from the non-functional pituitary adenomas. We also compared the heminostril and binostril approaches for T-eTSS. Tumor resection rates were higher when the surgeries were conducted by T-eTSS than mTSS. In particular, when the maximum tumor diameter was more than 25 mm, resection rates were significantly higher for T-eTSS than for mTSS. There were no unexpected complications in either group. There was no significant difference in resection rates between the heminostril and binostril approaches when T-eTSS was performed. T-eTSS is an efficacious surgical option for non-functional pituitary adenomas, particularly when the adenoma is of large size. Benefits of the heminostril approach are evident.

Self-Expandable Metal Stent Placement as a Bridge to Laparoscopic or Open Surgery for Obstructive Colorectal Cancer: Short-Term Outcomes of Nineteen Consecutive Cases

Purpose Laparoscopic colorectal resection is a feasible and less invasive procedure with short-term advantages compared with open surgery; however, the evidence for its efficacy for treating obstructive colorectal cancer (CRC) is lacking. In this study, we aimed to determine short-term outcomes of SEMS placement for obstructive CRC followed by laparoscopic colorectal resection. Methods As of August 2013, 51 patients with obstructive CRC underwent stent insertion. Thirty-two patients received palliation therapy not intended for tumor resection. After decompression of the proximal intestine, nine and 10 patients underwent laparoscopic and open surgery, respectively. Clinicopathological, intraoperative, and postoperative data were retrospectively collected. Results There were no differences in resection rates and curabilities between the two groups. All surgeries were performed with a single-stage anastomosis, and no anastomotic leakage was observed. There was one patient with abdominal morbidity in the open group (Open) and none in the Lap group. There was no mortality in either group. Time to flatus (3.4 ± 1.8 days, Lap; 2.6 ± 1.1 days, Open) and time to oral intake (7.9 ± 2.5 days, Lap; 7.7±1.9 days, Open) were similar between the groups. Postoperative hospitalization times for the Lap group were shorter, but the difference was not statistically significant (15.2 ± 3.9 days, Lap; 21 ± 11.7 days, Open, p = 0.21). Conclusion Our findings indicate that laparoscopic surgery combined with preoperative stent placement is feasible as well as safe compared with open surgery for obstructive CRC.

Radiotherapy for gastric cancer: a systematic review and meta-analysis

There have been many trials trying to prove the benefit of radiotherapy for gastric cancer; however, the results were either inclusive or controversial. The purpose of the study was to elucidate the effect of radiotherapy on gastric cancer delivered as perioperative or palliative treatment. We conducted systematic searches for trials exploring the effect of radiotherapy on gastric cancer. In the subgroup of patients receiving preoperative radiotherapy for gastric cancer, a significant benefit was found on 10-year overall survival with a hazard ratio (HR) of 0.75 (95% confidence interval (CI), 0.61 to 0.91); however, the benefit on 5-year overall survival was not proven (HR, 0.68; 95%CI, 0.45 to 1.01). There are also no significant differences in resection rate and radical resection rate between group of patients receiving radiotherapy and control group with a relative risk (RR) of 1.06 (95%CI, 0.99 to 1.13) and 1.12 (95%CI 0.93 to 1.36), respectively. In the subgroup of patients receiving postoperative radiotherapy for gastric cancer, survival benefits were found on 3- and 5-year progression-free survival with HR of 0.69 (95%CI, 0.53 to 0.90) and HR of 0.70 (95%CI, 0.61 to 0.80), respectively. Survival benefits of adjuvant radiotherapy on 3- and 5-year progression-free survival were also found; nonetheless, there was no evidence of significant difference in 3-year overall survival (HR, 0.70; 95%CI, 0.61 to 1.01). The effect of radiotherapy on 5-year overall survival was also quite controversial. In short, gastric cancer patients could benefit from radiotherapy both in the form of preoperative radiotherapy and postoperative radiotherapy.

Racial Disparities in Surgical Resection and Survival among Elderly Patients with Poor Prognosis Cancer

Reports indicate that black patients have lower survival after the diagnosis of a poor prognosis cancer, compared with white patients. We explored the extent to which this disparity is attributable to the underuse of surgery. Using the Surveillance, Epidemiology, and End Results program and Medicare database, we identified 57,364 patients, ages 65 years and older, with a new diagnosis of nonmetastatic liver, lung, pancreatic, and esophageal cancer, from 2000 to 2005. We evaluated racial differences in resection rates after adjustment for patient, tumor, and hospital characteristics using hierarchical logistic regression. Cox proportional hazards regression was used to assess racial differences in survival after adjusting for patient, tumor, and hospital characteristics, and receipt of surgery. Compared with white patients, black patients were less likely to undergo surgery for liver (adjusted odds ratio [aOR] = 0.49; 95% CI, 0.29-0.83), lung (aOR = 0.62; 95% CI, 0.56-0.69), pancreas (aOR = 0.53; 95% CI, 0.41-0.70), and esophagus cancers (aOR = 0.64; 95% CI, 0.42-0.99). Hospitals varied in their surgery rates among patients with potentially resectable disease. However, resection rates were consistently lower for black patients, regardless of the resection rate of the treating hospital. Although there were no racial differences in overall survival with liver and esophageal cancer, black patients experienced poorer survival for lung (adjusted hazard ratio = 1.05; 95% CI, 1.00-1.10) and pancreas cancer (adjusted hazard ratio = 1.15; 95% CI, 1.03-1.30). In both instances, there were no residual racial disparities in overall survival after adjusting for use of surgery. Black patients are less likely to undergo surgery after diagnosis of a poor prognosis cancer. Our findings suggest that surgery is an important predictor of overall mortality, and that efforts to reduce racial disparities will require stakeholders to gain a better understanding of why elderly black patients are less likely to get to the operating room.

Differences in outcomes of oesophageal and gastric cancer surgery across Europe

In several European countries, centralization of oesophagogastric cancer surgery has been realized and clinical audits initiated. The present study was designed to evaluate differences in resection rates, outcomes and annual hospital volumes between these countries, and to analyse the relationship between hospital volume and outcomes. National data were obtained from cancer registries or clinical audits in the Netherlands, Sweden, Denmark and England. Differences in outcomes were analysed between countries and between hospital volume categories, adjusting for available case-mix factors. Between 2004 and 2009, 10 854 oesophagectomies and 9010 gastrectomies were registered. Resection rates in England were 18·2 and 21·6 per cent for oesophageal and gastric cancer respectively, compared with 28·5-29·9 and 41·4-41·9 per cent in the Netherlands and Denmark (P < 0·001). The adjusted 30-day mortality rate after oesophagectomy was lowest in Sweden (1·9 per cent). After gastrectomy, the adjusted 30-day mortality rate was significantly higher in the Netherlands (6·9 per cent) than in Sweden (3·5 per cent; P = 0·017) and Denmark (4·3 per cent; P = 0·029). Increasing hospital volume was associated with a lower 30-day mortality rate after oesophagectomy (odds ratio 0·55 (95 per cent confidence interval 0·42 to 0·72) for at least 41 versus 1-10 procedures per year) and gastrectomy (odds ratio 0·64 (0·41 to 0·99) for at least 21 versus 1-10 procedures per year). Hospitals performing larger numbers of oesophagogastric cancer resections had a lower 30-day mortality rate. Differences in outcomes between several European countries could not be explained by differences in hospital volumes. To understand these differences in outcomes and resection rates, with reliable case-mix adjustments, a uniform European upper gastrointestinal cancer audit with recording of standardized data is warranted.

Endoscopic full-thickness resection for gastric stromal tumor

Objective To evaluate the therapeutic effect of endoscopic full-thickness resection （EFTR） for gastric stromal tumors. Methods A total of 33 patients with gastric stromal tumor origination from deep muscularis propria layer received EFTR from January 2010 to July 2011. The effectiveness and safety of EFTR were compared with those of other 34 patients with gastric stromal tumor origination from mus- calaris propria layer who underwent endoscopic submucosal dissection （ESD）. Results Except in 2 patients with lesions larger than 3.0 × 3.0 cm, EFTR was successful in others 31 patients, who recovered well and had no recurrence during the follow-up within 12 months. There were no significant differences in resection rate, incidence of complications, body temperature, white blood cell counts or recovery time between 2 procedures （P〉0.05）. However, the number of clips used in EFTR （7.0 ±3.5 vs. 4.9 ±3.1, P = 0. 013） and postoperative fasting days （3.4 ±1.5 vs. 2. 0 ± 1.0, P =0. 001 ） were significantly higher than those of ESD procedures. Conclusion EFTR is effective and safe for gastric stromal tumors with no higher risk than ESD, but it is more complex technically. EFTR can be used as an expanding method of ESD in en- doscopic treatment of gastric stromal tumors. Key words: Gastrointestinal stromal tumors ; Therapy ; Endoscopic full-thickness resection ; Endoscopic submucosal dissection

Survival impact of malignant pancreatic neuroendocrine and islet cell neoplasm phenotypes

The low incidence of malignant "functional" (F) or "nonfunctional" (NF) neuroendocrine islet cell tumors (ICTs) of the pancreas represents a challenge to precise post-therapeutic survival prediction. This study examined the survival impact of malignant pancreatic ICT morphologic subtypes. A pancreatic ICT data set was created from a US-based population database from 1980-2004. Prognostic factors with survival impact and relationships between surgical therapy and overall survival (OS) were analyzed. There were 2,350 individuals with malignant ICTs. Histologic subtypes included carcinoid tumors, islet cell carcinomas, neuroendocrine carcinomas, and malignant gastrinomas, insulinomas, glucagonomas, or VIPomas. There was no difference in resection rates between FICTs and NFICTs (23% vs. 20%, P = ns). Median OS was 30 months, with group differences ranging from NE carcinomas (21) to VIPomas (96; P < 0.0001). Median OS of resected versus unresected FICTs was 172 versus 37 months, while that of NFICTs was 113 versus 18 months (P < 0.0001). Compared to neuroendocrine carcinomas, hazard ratios were: VIPomas 0.48, gastrinomas 0.65, carcinoid tumors 0.76, insulinomas 0.84, glucagonomas 0.93, and islet cell carcinomas 1.0. When controlled for other established prognostic parameters, histopathologic subtype assignment of pancreatic ICTs affects survival prediction. Resection is associated with superior survival for all tumor types.

Surgery with curative-intent in patients treated with first-line chemotherapy plus bevacizumab for metastatic colorectal cancer First BEAT and the randomised phase-III NO16966 trial

Background:Complete resection of metastases can result in cure for selected patients with metastatic colorectal cancer.Methods:First BEAT evaluated the safety of bevacizumab with first-line chemotherapy in 1914 patients. Prospectively collected data from 225 patients who underwent curative-intent surgery were analysed, including an exploratory comparison of resection rate in patients treated with different regimens. NO16966 compared efficacy of oxaliplatin-based chemotherapy plus bevacizumab or placebo in 1400 patients. A retrospective analysis of resection rate was undertaken.Results:In First BEAT, 225 out of 1914 patients (11.8%) underwent curative-intent surgery at median 64 days (range 42–100) after the last dose of bevacizumab. R0 resection was achieved in 173 out of 225 patients (76.9%). There were no surgery-related deaths and serious post-operative complications were uncommon, with grade 3/4 bleeding and wound-healing events reported in 0.4% and 1.8%, respectively. Resection rates were highest in patients receiving oxaliplatin-based combination chemotherapy (P=0.002), possibly confounded by patient selection. In NO16966, 44 out of 699 patients treated with bevacizumab (6.3%) and 34 out of 701 patients treated with placebo (4.9%) underwent R0 metastasectomy (P=0.24).Conclusions:The rate of serious post-operative complications in First BEAT was comparable to historical controls without bevacizumab. In NO16966, there were no statistically significant differences in resection rates or overall survival in patients treated with bevacizumab vs placebo.