Equal Oncological Outcomes Research Articles

Diagnosis of laryngopharyngeal carcinoma through office-based flexible laryngoscopy as a reliable alternative for biopsies under general anesthesia: Faster diagnostics with equal oncological outcome

PurposeDiagnostic endoscopy with biopsy under general anesthesia (DE-GA) is still considered as the established standard to assess laryngopharyngeal cancer patients. Office-based flexible laryngoscopic biopsy (FLB) offers an alternative, but the effect on oncological outcome remains uncertain. Therefore, the diagnostic process and survival of patients undergoing FLB, compared to those undergoing DE-GA were evaluated. MethodsPatients suspected of laryngopharyngeal cancer who underwent FLB were evaluated. Patients with FLB-confirmed squamous cell carcinoma (SCC) were matched with DE-GA patients based on tumor site, T-classification, N-classification, age, and p16 overexpression. Time from first visit to diagnosis (FVD), time to treatment interval (TTI), disease-specific survival (DSS) and overall survival (OS) were analyzed. ResultsFLB yielded a definitive diagnosis in 155/164 (95 %) patients. No complications were observed. Ninety-eight of the 124 patients in which FLB revealed a SCC received curative treatment and were compared with 98 matched patients who underwent DE-GA. Median FVD interval was 6 days after FLB and 15 days after DE-GA (p < 0.001). Median TTI interval (FLB: 28 days, DE-GA: 28 days) was equal (p = 0.91). Oncological outcomes were comparable (p > 0.05) between FLB (OS: 2-yr: 76 %, 5-yr: 42 %; DSS: 2-yr: 86 %, 5-yr: 85 %) and DE-GA groups (OS: 2-yr: 76 %, 5-yr: 50 %; DSS: 2-yr: 81 %, 5-yr: 79 %). ConclusionFLB in the outpatient setting demonstrates a high diagnostic accuracy, is safe, accelerates the diagnostic process and has no negative effects on clinical outcome compared to DE-GA. Therefore, FLB should be considered as the standard diagnostic procedure in patients suspected of laryngopharyngeal cancer.

Anastomotic techniques in minimally invasive esophageal and gastric surgery

In specialized centers minimally invasive surgery has become established as the standard of care for esophageal and gastric surgery. Offering equal oncological outcome, patients benefit with respect to lower postoperative pain and complication rates. The creation of the anastomosis during minimally invasive surgery remains acritical step and the complications are decisive for the immediate postoperative course. So far no clear consensus exists in the literature regarding the recommended techniques for placement of an anastomosis after resections in the upper gastrointestinal tract. This article summarizes and compares the various established anastomotic techniques used in minimally invasive esophageal and gastric surgery.

The effects of method of anaesthesia on the safety and effectiveness of Radical Retropubic Prostatectomy.

The aim of this study is to determine if patients undergoing radical retropubic prostatectomy with localized prostate cancer under combined (epidural-spinal) anaesthesia have any benefit over patients undergoing the procedure under general anaesthesia. Patients with clinically localised prostate cancer, scheduled for radical retropubic prostatectomy, were allocated to undergo the operation under either general anaesthesia (GA) or under combined (epidural-spinal) (CESA) anaesthesia. Several parameters were recorded both preoperatively (medical history, biometric data, PSA, biopsy Gleason score) and postoperatively (blood pressure, heart rate, haemoglobin levels, operation time and total hospital stay). In addition, mean arterial pressure, change in heart rate, total blood loss, blood transfusions, SAS score, intravenous fluid administration and operation time were also noted down intraoperatively. Patient pain levels and total satisfaction were evaluated using appropriate questionnaires. At the 12-month follow-up, biochemical recurrence using PSA levels and urinary continence status were evaluated. A total of 60 patients were included (30 in each group). Intraoperatively, mean MAP and heart rate change was higher in the GA group (MAP+7,46, HR+27) and mean SAS was higher in the CESA group (+0.93). The time needed for patients' recovery was faster (-3.5 min) and hospitalization was shorter for patients in the CESA group (-0.6 days). Intraoperative blood loss, time for induction and duration of operation were not significantly different. Mean postoperative drop of haemoglobin was greater in the GA group (+0.56) while blood transfusions, VAS pain scores and amount of intravenous fluids did not differ significantly between the two groups. No complications were reported. Patient satisfaction and urinary continence were comparable between the groups and there were no cases of biochemical recurrence. Radical retropubic prostatectomy can safely be performed under combined (spinal epidural anaesthesia, with possible benefits of lower blood loss, less post-operative complications and earlier discharge. Both procedures have equal oncological and functional outcomes at the 12-month follow-up.

Comparing costs of standard Breast-Conserving Surgery to Oncoplastic Breast-Conserving Surgery and Mastectomy with Immediate two-stage Implant-Based Breast Reconstruction

BackgroundConventional breast-conserving surgery (C-BCS) has equal oncological outcomes and superior cosmetic and patient-reported outcomes compared to mastectomy with immediate two-stage implant-based breast reconstruction (M-IBR). Oncoplastic breast-conserving surgery (OP-BCS) is increasingly being used, as it often has better cosmetic results and it enables larger tumour resection. However, OP-BCS and M-IBR compared to C-BCS lengthens operative time and might lead to more complications and consequently to additional costs. Therefore, this study aimed to compare costs and complication rates of C-BCS, OP-BCS and M-IBR. MethodsThis single-centre, retrospective cohort study, calculated costs for all patients who had undergone breast cancer surgery between January 2014 and December 2016. Patient-, tumour- and surgery-related data of C-BCS, OP-BCS and M-IBR patients were retrieved by medical record review. Treatment costs were calculated using hospital financial data. Differences in costs and complications were analysed. ResultsA total of 220 patients were included: 74 patients in the C-BCS, 78 in the OP-BCS and 68 in the M-IBR group. From most expensive to least expensive, differences in total costs were found between C-BCS vs. OP-BCS and C-BCS vs. M-IBR (p=<0.01 and p=0.04, respectively). Costs of OP-BCS and M-IBR were comparable. Complication rates were 5.5% for C-BCS, followed by 17% for OP-BCS, and 34% for M-IBR (p<0.01). ConclusionConsidering total treatment costs, OP-BCS was financially non-inferior to M-IBR, whereas complication rates were higher following M-IBR. Therefore, when considering other benefits of OP-BCS, such as higher patient-reported outcomes and similar oncological outcomes, a shift from M-IBR to BCS using oncoplastic techniques seems justified.

Insulinoma of Pancreas, Brief Experience at a Dedicated Surgical Oncology Department

Background: Insulinoma of pancreas is a rare neuroendocrine tumor (NET). Mostly insulinomas are benign and solitary. They can have association with multiple endocrine neoplasia 1 (MEN -1). Insulinomas presents with symptoms of hypoglycemia. Most of the times the symptoms are vague and result in delay in the diagnosis and hence management. After appropriate diagnostic and localization investigations along with metastatic workup, surgery is the treatment of choice. Surgery can offer cure. Minimally invasive surgery can offer potential benefits of minimal morbidity and at least equal oncological outcomes.

The impact of surgical learning curve on survival – reopening the door for minimally invasive surgery in the management of cervical cancer?

Minimally invasive surgery has been widely adopted in gynaecological oncology with a significant surge since 2010 associated with the introduction of robot-assisted surgery. Up until 2018, virtually all testimonials of minimally invasive surgery for cervical cancer indicated equal oncological outcomes compared with laparotomy. The unexpected results from the only randomised controlled trial (Ramirez et al. N Engl J Med 2018;379:1895–904) seriously challenge the use of minimally invasive surgery for cervical cancer. However, the lack of plausible explanations for the inferior survival has made it hard for many gynaecological oncologists to accept the results at face value. Suggested causes such as the use of intrauterine manipulators and intracorporeal colpotomy may to some extent account for the detrimental outcomes but as practice differs widely worldwide, none of these factors seem convincing. In the current paper by Baeten et al., a different aspect of novel surgical technologies has been explored (BJOG 2020; https://doi.org/10.1111/1471-0528.16399). The adoption of any new modality/technology is clearly associated with a learning curve and it is well known from surgery that procedural outcomes, such as operative time, improve with increasing case numbers. However, the potential impact of learning curve on hard outcomes such as survival has scarcely been reported. Baeten et al. convincingly demonstrate that a substantial number of robot-assisted radical hysterectomies are required to overcome an initial harm. The authors point out that the learning curve should be considered institutional; suggesting that an individual learning curve may benefit from previous experiences at the specific institution. Intriguingly, similar data have not been presented for endometrial cancer, which may be related to the higher complexity of radical hysterectomy for cervical cancer. Although no specific changes were made over time in the current study, a learning curve may include modifications of surgical routines based on early experiences. Which specific improvements during the learning curve account for the increased survival are unclear but reduction of complications that could delay adjuvant treatment may be one. The data presented by Baeten et al. signify a solid effort to elucidate the underlying cause of the outcomes from the LACC trial, especially as the trial was launched at a time when most surgeons had limited experience from laparoscopic/robotic radical hysterectomy. The study should raise the awareness of surgical learning curve in the context of survival in oncological surgery. It also brings us to the most important question – how do we avoid harming our patients when novel technologies are adopted? The authors suggest that centralisation and structured training represent two of the most important strategies to mitigate the effects of early errors. Interestingly, recent population-based studies from countries with high levels of centralisation do not corroborate the findings from the LACC trial (Alfonzo et al. Eur J Cancer 2019;29:1072–6; Jensen et al. Eur J Cancer 2020;128:47–56). Although the current study may reopen the door for robotic surgery in the management of cervical cancer, prospective randomised trials are needed to ensure its safety. The impact of surgical learning curve should be considered in any future trial exploring oncological safety for procedural interventions. HF is a proctor for Intuitive Surgical Inc. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Insulinoma of Pancreas, Brief Experience at a Dedicated Surgical Oncology Department

Introduction: Insulinoma of pancreas is a rare neuroendocrine tumor (NET). Mostly insulinomas are benign and solitary. They can have association with multiple endocrine neoplasia 1 (MEN -1). Insulinomas presents with symptoms of hypoglycemia. Most of the times the symptoms are vague and result in delay in the diagnosis and hence management. After appropriate diagnostic and localization investigations along with metastatic workup, surgery is the treatment of choice. Surgery can offer cure. Minimally invasive surgery can offer potential benefits of minimal morbidity and at least equal oncological outcomes. Study Design: Case series. Place and Duration of Study: Department of Surgical Oncology, Shaukat Khanam Memorial Cancer Hospital &amp; Research Center (SKMCH&amp;RC), from January 2011 to March 2020. Methodology: We studied a total of five patients that presented to SKMCH&amp;RC in the above-mentioned period. Detailed clinical information of these five patients, including sociodemographic variables, symptomatology, diagnostic and localization investigations, clinical and pathological staging, comprehensive details of surgery, postoperative course, oncological outcomes, postoperative resolution of symptoms, postoperative diabetes, prognosis and follow up duration were analysed. The record was being retrospectively retrieved from Hospital Information System (HIS) that is prospectively maintained. We are a paperless hospital and all data and record of the patient is maintained through HIS. Results: A total of five patients presented to SKMCH&amp;RC with a mean age of 41 (18 -80) years. The median duration of symptoms was 24 (6-60) months. Symptomatic hypoglycemia was present in all 5 (100%) of the patients. Tumor distribution in the pancreas was as follows; uncinate 1 (20%), body 1 (20%) and tail 3 (60%). All five patients (100%) were treated by surgery. Resolution of symptoms occurred in all five (100%) of the patients. Conclusion: Insulinoma of pancreas is a rare disease with varied symptomatology, physicians shall have an index of suspicion for this disorder to aid early diagnosis that is pivotal for the management and prevention of possible fatal complications of hypoglycemia. Appropriate diagnostic and localizing investigations are required. Adequate surgery can offer cure. Minimally invasive surgery can be safely offered with equal oncological outcomes.

Laparoscopic surgery reduces the incidence of surgical site infections compared to the open approach for colorectal procedures: a meta-analysis.

BackgroundSurgical site infections (SSI) are the commonest healthcare associated infections. They severely compromise patient safety, are a significant burden on healthcare resources and have an adverse impact on patient quality of life. The incidence of SSIs can be as high as 10% after colorectal procedures. The laparoscopic approach is being increasingly used to undertake colorectal procedures. It provides advantages over the traditional open approach with smaller incisions, shorter hospital stay and equal oncological outcomes. The aim of this meta-analysis was to evaluate whether the laparoscopic approach for colorectal procedures reduces the incidence of SSI compared to the open approach.MethodsRandomised controlled trials (RCTs) comparing the two approaches published since 2000 were included in the review. Revman 5.3 software was used to carry out the review. Data were pooled and the results were shown as risk ratios with 95% confidence intervals using the fixed effects model.ResultsSixteen RCT’s were included in the analysis comprising 5797 patients. These covered a range of colorectal pathologies including colon cancer, rectal cancer, inflammatory bowel disease and familial adenomatous polyposis syndrome. Analysis showed significantly lower wound infection rates (RR: 0.72, 95% confidence interval: 0.60–0.88, p = 0.001) and lower abdominal abscess rates (RR: 0.88, 95% CI 0.62–1.27, p = 0.51). The combined SSI rate was significantly lower in laparoscopic compared to open surgery (RR: 0.76, 95% CI 0.64–0.90, p = 0.001).ConclusionsLaparoscopic colorectal surgery significantly lowers the incidence of SSI compared to open surgery.Electronic supplementary materialThe online version of this article (10.1007/s10151-020-02293-8) contains supplementary material, which is available to authorized users.

Survival of patients with early-stage cervical cancer after abdominal or laparoscopic radical hysterectomy: a nationwide cohort study and literature review

AimRecently, the safety of laparoscopic radical hysterectomy (LRH) has been called into question in early-stage cervical cancer. This study aimed to evaluate overall survival (OS) and disease-free survival (DFS) in patients treated with abdominal radical hysterectomy (ARH) and LRH for early-stage cervical cancer and to provide a literature review. MethodsPatients diagnosed between 2010 and 2017 with International Federation of Gynaecology and Obstetrics (2009) stage IA2 with lymphovascular space invasion, IB1 and IIA1, were identified from the Netherlands Cancer Registry. Cox regression with propensity score, based on inverse probability treatment weighting, was applied to examine the effect of surgical approach on 5-year survival and calculate hazard ratios (HR) and 95% confidence intervals (CIs). Literature review included observational studies with (i) analysis on tumours ≤4 cm (ii) median follow-up ≥30 months (iii) ≥5 events per predictor parameter in multivariable analysis or a propensity score. ResultsOf the 1109 patients, LRH was performed in 33%. Higher mortality (9.4% vs. 4.6%) and recurrence (13.1% vs. 7.3%) were observed in ARH than LRH. However, adjusted analyses showed similar DFS (89.4% vs. 90.2%), HR 0.92 [95% CI: 0.52–1.60]) and OS (95.2% vs. 95.5%), HR 0.94 [95% CI: 0.43–2.04]). Analyses on tumour size (<2/≥2 cm) also gave similar survival rates. Review of nine studies showed no distinct advantage of ARH, especially in tumours <2 cm. ConclusionAfter adjustment, our retrospective study showed equal oncological outcomes between ARH and LRH for early-stage cervical cancer – also in tumours <2 cm. This is in correspondence with results from our literature review.

Minimally Invasive Three Stage Esophagectomy for squamous cell carcinoma esophagus; Our Technique with reference to a case report.

Introduction: Esophageal cancer ranks 8th among the most common malignancies. Management of esophageal cancer is complex and involves multidisciplinary team approach. Esophagectomy is a complex procedure with significant morbidity. The surgical approach to the oesophagus depends on a lot of factors like the anatomical location of the disease in the oesophagus, histopathology, desired lymphadenectomy and surgeon preferences. Historically the approach to esophageal resection was via open surgery. Minimally invasive surgery has revolutionized the management of esophageal surgery. The concept of Minimally invasive esophagectomy (MIE) was introduced to lessen the morbidity associated with open surgery. Less surgical trauma and hence less injury and inflammation are thought to play a vital part in reducing surgical stress and associated morbidity. Minimally invasive three-stage esophagectomy is carried out for tumours of the upper and middle oesophagus, hence mostly for squamous cell carcinomas as they predominate in this region. Methods: We report a case of carcinoma oesophagus that was managed by minimally invasive three-stage esophagectomy. At our institute, Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMH&RC) we routinely perform minimally invasive esophagectomy. We perform the thoracic part first in the left lateral position via the Video Assisted Thoracoscopic Surgery (VATS) approach, then the patient is placed in a modified Lloyd Davis position and the abdominal part is performed via laparoscopic approach and simultaneously neck is dissected and later anastomosis is fashioned in the neck. Results: The patient underwent the procedure safely and was discharged on day five after surgery. It was an adequate oncological resection. Conclusion: Minimally invasive three-stage esophagectomy is a safe procedure with less morbidity and equal oncological outcomes in high volume centres.

A case report of Insulinoma Pancreas in an 80 old lady with long standing history: managed by 3 -D Laparoscopic resection

Introduction: Insulinomas are a rare group of neuroendocrine tumors. Ninety percent are benign and most are solitary. They can have varied presentations and long-standing history of symptoms. Mostly people are affected in fourth to sixth decades of life. Insulinomas can have association with multiple endocrine neoplasia type 1 (MEN) however typically they are sporadic. Most are solitary and benign. Most common presentation is symptomatic hypoglycemia. After investigations, surgery is the treatment of choice and can offer cure. Laparoscopic surgery can offer all the benefits of minimally invasive surgery and equal oncological outcomes in high volume and dedicated centers. 3D laparoscopy further improves outcomes. Case Presentation: This case presentation is about an 80-year-old female who presented with long standing symptoms. After biochemical and radiological investigation, she was treated with 3-D laparoscopic distal pancreatectomy. Histopathology was consistent with insulinoma and she had resolution of symptoms. Conclusion: Insulinoma is a rare tumor and proper management is multidisciplinary. Proper management leads to rapid cure and resolution of the symptoms.

Partial breast irradiation with the 1.5 T MR-Linac: First patient treatment and analysis of electron return and stream effects

IntroductionExternal beam partial breast irradiation (PBI) provides equal oncological outcomes compared to whole breast irradiation when applied to patients with low risk tumours. Recently, linacs with an integrated magnetic resonance image-guidance system have become clinically available. Here we report the first-in-human PBI performed at the 1.5 T MR-Linac, with a focus on clinical feasibility and investigation of the air electron stream effect (ESE) and the electron return effect (ERE) in the presence of the 1.5 T magnetic field, which might influence the dose on the chin (out-of-field dose, due to the ESE), the skin and the lung/chest wall interface (in-field dose, ERE). MethodsA 59 years old patient affected by a 15 mm unifocal grade 1 carcinoma not special type of the right breast staged pT1c pN0 cM0 was planned and treated at Unity 1.5 T MR-Linac. To investigate the ERE and the ESE, an MR-Linac treatment plan was simulated without considering the 1.5 T B field using a research version of Monaco (V. 5.19.03). In vivo dosimetry was performed using Gafchromic® EBT3 films placed on top and underneath a 1 cm bolus which was placed on the patient’s chin. The plans with and without 1.5 T magnetic field were compared in terms of dose to the chin, to the skin and to the interface lung/chest wall. Finally, the dose on the chin measured with the in vivo dosimetry was compared with the dose calculated by Monaco. ResultsPBI using the 1.5 T MR-Linac was successfully performed with a 7 MV photon 7-beams IMRT step-and-shoot plan. The treatment was well tolerated, the patient developed a slight acute toxicity, i.e. breast skin erythema and breast oedema CTC V.4 grade 1. The plan with 1.5 T magnetic field documented a fractional dose of 0.17 Gy in the chin area (2.6 Gy in 15 fractions), which was reduced to 0.05 Gy (0.75 in 15 fractions) by the presence of 1 cm bolus. The simulated plan without magnetic field showed a dose reduced by 2.3 Gy in the chin area. With the in vivo dosimetry a fractional dose of, respectively, 0.12 Gy and 0.034 Gy on top and underneath the bolus were measured (1.8 and 0.51 Gy in 15 fractions). The plan with 1.5 T magnetic field showed a skin D2 of 40 Gy and a skin V35 of 40.2%, which were reduced to, respectively, 39.7 Gy and 24.9% in the simulation without magnetic field. At the interface lung/chest there were no differences in DVH statistics. ConclusionPBI with the 1.5 T MR-Linac was performed for the first time. ESE is accurately calculated by the treatment planning system, can be effectively reduced with a 1 cm bolus and is comparable to dose of cone beam-CT based position verification. The additional dose caused by ERE is not associated with an increased risk of acute toxicity.

Totally Laparoscopic Strategies for the Management of Colorectal Cancer with Synchronous Liver Metastasis

AbstractBackground: The purpose of this study is to compare the laparoscopic techniques for the management of colorectal cancer with synchronous liver metastases:Simultaneous laparoscopic liver and colon cancer resec-tion.Simultaneous colon resection and Radiofrequency Ablation (RFA) of liver metastases.Methods: Convenient sample of about 30 patients expected to attend the Oncology Center, Mansoura University (OCMU) Gastro-Enterology Center (GEC) during study period of 3 years (2014-2017) with adenocarcinoma of the colon and rectum with Synchronous Colorectal Liver Metastases (SCRLM) will be considered.Results: Mean operative time was 205 minutes for LLR, in comparison with the resection group, mean operative time for RFA was 185 minutes. Though shorter in time, this did not appear to be statistically significant (p-value=4.41). Mean blood loss for the resection group was 350ml, and mean blood transfusion was 0.89L. On the other hand, mean blood loss for the RFA group was 90ml and mean blood transfusion was 0.76L. This difference between the two groups appeared to be statistically different (p-value=0.01). For the LLA group mean hospital stay 8.4 days and mean recovery time per case was 4.1 days. This was a bit shorter for the RFA group were mean hospital was 8.3 days while mean recovery time per case was 3.6 days. Although shorter, this difference appear to be insignificant statistically. (p-value=0.95/p-value=0.79 respectively).Conclusions: Treatment of hepatic metastasis especially in colorectal hepatic lesion could prolong survival in selected cases, all the results of the systemic reviews and meta-analysis suggested an inferior outcome of non resectional treatment compared to hepatic resection.Minimal invasive approach for treatment of CRLM offers more advantages such as early recovery, less pain, better cosmosis, less blood loss, and reduced morbidity and mortality with equal oncological outcome compared to classic open surgery.

Robotic assisted lobectomy and lymphadenectomy “different approaches”

Robot-assisted thoracic surgery (RATS) is a relatively new technique for minimally invasive lung lobectomy. During the last decade, different robotic approaches have been described on performing a lung resection ranging from the use of three or four robotic arms, utility incision or CO 2 insufflation, and different port placement. So far, a not-completely portal lobectomy (with utility incision) or completely portal robotic lobectomy (CPRL) is the mostly used robotic approaches to perform lung resection. RATS for lung lobectomy resulted feasible and safe with low rate of conversion, and associated with reduced mortality, shorter hospital stay, and fewer overall complications compare to open surgery. Besides, the 3D vision and the wide range of high-precision movements of the robotic system, even greater than the human wrist, are crucial in performing lymphadenectomy, allowing an excellent hilar and mediastinal lymph node dissection. Thus, RATS allowed an adequate lymphadenectomy with detection of occult lymph node metastatic disease, with significant overall pathological lymph node upstaging and equal oncologic outcomes compare to open radical lymphadenectomy. However, robotic surgery has still some limitations, including increased costs, absence of a tactile feedback, and the need for specialized equipment and training; beside, longer follow-up is still needed to have a correct vision of the long-term outcome.

Development of an online, patient-centred decision aid for patients with oropharyngeal cancer in the transoral robotic surgery era.

Radiotherapy (rt) has been the standard treatment for early oropharyngeal cancer, achieving excellent outcomes, but with significant toxicities. Transoral robotic surgery (tors) has emerged as a promising alternative. A decision aid (da) can help to establish patient treatment preferences. A da was developed and piloted in 40 healthy adult volunteers. Assuming equal oncologic outcomes of the treatments, participants indicated their preference. The treatment trade-off point was then established, and participant perceptions were elicited. More than 80% of participants initially selected tors for treatment, regardless of facilitator background. For all participants, the treatment trade-off point changed after an average 15% cure benefit. Treatment toxicities, duration, novelty, and perceptions all influenced treatment selection. All subjects valued the da. A da developed for early oropharyngeal cancer treatment holds promise in the era of shared decision-making. Assuming equal cure rates, tors was preferred over rt by healthy volunteers.

Clinical outcomes of video-assisted thoracoscopic surgery esophagectomy for esophageal cancer: a propensity score-matched analysis.

Minimally invasive esophagectomy theoretically offers advantages compared with open esophagectomy (OE). The aim of this study was to compare the early- and mid-term outcomes between video-assisted thoracoscopic surgery (VATS) esophagectomy (VE) and OE in patients with esophageal cancer. Between November 2011 and July 2015, a total of 172 patients were divided into two groups depending on the method of esophagectomy: the VE group (n=42) and the OE group (n=130). A propensity analysis that incorporated perioperative variables, such as age, sex, preoperative pulmonary function, Charlson comorbidity index, tumor location, histologic grade of the tumor, pathologic stage and operative procedure (Ivor Lewis or McKeown) was performed, and postoperative outcomes were compared. Matching based on propensity scores produced 42 patients in each group for the analysis. After propensity matching, there were only two operative mortalities in the OE group, and both died of postoperative pneumonia. The overall incidence of postoperative complications was 38.1% (16 of 42) and 57.1% (24 of 42) in the VE group and in the OE group, respectively (P=0.088). The incidence of pulmonary complications was lower in the VE group than in the OE group (9.5% vs. 40.5%, P=0.004). The 2-year overall survival and disease-free survival were not different between the two groups (74.4% and 69.5% in the VE group, 69.5% and 69.8% in the OE group, P=0.865 and P=0.513, respectively). In select patients, superior short-term surgical results and equal oncological outcomes were achieved with VE compared with OE.

Preoperative Chemoradiotherapy Versus Perioperative Chemotherapy for Patients With Resectable Esophageal or Gastroesophageal Junction Adenocarcinoma

BackgroundThis study compares neoadjuvant chemoradiotherapy (nCRT) with perioperative chemotherapy (pCT) for patients with resectable esophageal or gastroesophageal junction (GEJ) adenocarcinoma in terms of toxicity, postoperative complications, pathologic response, and survival.MethodsThis study retrospectively analyzed and compared 313 patients with resectable esophageal or GEJ adenocarcinoma treated with either nCRT (carboplatin/paclitaxel 41.4 Gy, n = 176) or pCT (epirubicin, cisplatin and capecitabine, n = 137).ResultsThe baseline and tumor characteristics were similar in both groups. The ability to deliver all planned preoperative cycles was greater in the nCRT group (92.0 vs. 76.6%). Whereas nCRT was associated with a higher rate of grades 3 and 4 esophagitis, pCT was associated with a higher rate of grades 3 and 4 thromboembolic events, febrile neutropenia, nausea, vomiting, diarrhea, hand–foot syndrome, mucositis, cardiac complications, and electrolyte imbalances. Two patients in the pCT group died during neoadjuvant treatment due to febrile neutropenia. More postoperative cardiac complications occurred in the nCRT group. All other postoperative complications and the in-hospital mortality rate (nCRT, 4.7%; pCT, 2.3%) were comparable. The pathologic complete response (pCR) rate was 15.1% after nCRT and 6.9% after pCT. Radicality of surgery was comparable (R0: 93.0 vs. 91.6%). The median overall survival was 35 months after nCRT versus 36 months after pCT.ConclusionFor patients with esophageal or GEJ adenocarcinoma, chemoradiotherapy with paclitaxel, carboplatin and concurrent radiotherapy, and perioperative chemotherapy with epirubicin, cisplatin, and capecitabin lead to equal oncologic outcomes in terms of radical resection rates, lymphadenectomy, patterns of recurrent disease, and (disease-free) survival. However, neoadjuvant chemoradiotherapy is associated with a considerably lower level of severe adverse events and should therefore be the preferred protocol until a well-powered randomized controlled trial provides different insights.

Hand-assisted laparoscopic versus open partial nephrectomy in patients with T1 renal tumor: Comparative perioperative, functional and oncological outcome

Objective: Studies comparing hand-assisted laparoscopic partial nephrectomy (HALPN) and open partial nephrectomy (OPN) for T1 kidney tumors are scarce. This study investigated the perioperative, functional and oncological outcomes of these methods. Materials and methods: A prospective institutional kidney tumor register was used to identify patients between January 2006 and May 2014 undergoing HALPN (n = 139) or OPN (n = 165) for tumors 7 cm or smaller with non-absolute indication for nephron-sparing surgery. The outcomes were compared using univariate and multivariate statistical methods. Results: HALPN and OPN groups were similar with regard to tumor characteristics but HALPN patients were 2 years younger (p = 0.001) and had less comorbidity. Fewer intraoperative complications were encountered in HALPN than in OPN patients (7.2% vs 12.7%, p = 0.043). HALPN patients had less all-grade postoperative 30 day complications than OPN patients (27% vs 41%, p = 0.037), but there was no significant difference in Clavien 3–5 complications. Glomerular filtration rate 3 months after operation was lower in the HALPN than in the OPN group (7.1 ± 12.7% vs 10.0 ± 12.4%, p = 0.054). There was no difference in overall survival or recurrence-free survival during the median follow-up of 35 months. Conclusions: HALPN is a feasible method to achieve equal perioperative, functional and oncological outcomes compared to OPN in patients with tumors 7 cm or smaller in diameter.

Oncological outcomes after partial vs radical nephrectomy in renal cell carcinomas of ≤7 cm with presumed renal sinus fat invasion on preoperative imaging

ObjectivesTo compare oncological outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for renal tumours of ≤7 cm in which preoperative imaging reveals potential renal sinus fat invasion (cT3a), as RN is preferred for these tumours due to concerns about high tumour stage.Patients and MethodsAmong 1137 nephrectomies performed for renal tumours of ≤7 cm from January 2005 to August 2012, 401 solitary cT3a renal cell carcinomas (RCCs) without metastases were analysed. Classification as cT3a included only renal sinus fat invasion, as there were no tumours with suspected perinephric fat invasion. Multivariate models were used to evaluate predictors of recurrence‐free survival (RFS) and cancer‐specific survival (CSS).ResultsThere were 34 RCCs (8.5%) with unexpected perinephric fat invasion, but only 77 RCCs (19.2%) were staged as pT3a. During the median follow‐up of 43.0 months, recurrence occurred in seven (6.7%) PN cases and 25 (8.4%) RN cases. Six recurred PN cases had positive surgical margins (PSMs). The two cohorts showed equal oncological outcomes for 5‐year RFS and CSS. Multivariate analyses showed PSM, pathological T stage, sarcomatoid dedifferentiation, and type of surgery as significant predictors of recurrence. Older age, pathological T stage, and sarcomatoid dedifferentiation were significant predictors of cancer‐specific mortality.ConclusionsRenal tumours of ≤7 cm with presumed renal sinus fat invasion were mostly pT1. PN conferred equivalent oncological outcomes to RN. If clear surgical margins can be obtained, PN should be considered for these tumours, as patients may benefit from renal function preservation.

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes.

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.