Equivalent Oncologic Outcomes Research Articles

Adrenal Metastasectomy in the Era of Immuno- and Targeted Therapy.

Adrenal metastasectomy has an increasing role in multimodality oncologic care for diverse primary cancer types. In this review, we discuss the epidemiology, evaluation, and contemporary best practices in the management of adrenal metastases from various primaries. Initial evaluation of suspected adrenal metastases should include diagnostic imaging to assess the extent of tumor involvement and determine surgical resectability, as well as biochemical evaluation for hormone secretion. Biopsy has a minimal role and should only be performed in tumors that are established to be non-hormone secreting and when the biopsy results would change clinical management. Adrenal metastasectomy is associated with survival benefit in selected patients. We suggest that adrenal metastasectomy has the greatest benefit in four clinical scenarios: (1) disease limited to the adrenal gland in which adrenalectomy renders the patient disease-free; (2) isolated progression in the adrenal gland in the setting of otherwise controlled metastatic extra-adrenal disease; (3) need for palliation of symptoms related to adrenal metastases; or (4) in the context of tissue-based clinical trials. Both minimally invasive and open adrenalectomy techniques are safe and appear to have equivalent oncologic outcomes. Minimally invasive approaches are favored when technically feasible while maintaining oncologic principles. A multidisciplinary evaluation including clinicians with expertise in the primary cancer type is essential to the successful management of adrenal metastases.

MP47-06 CONTEMPORARY NATIONAL TRENDS IN PARTIAL NEPHRECTOMY UTILIZATION FOR RENAL CANCER: A REAL-WORLD STUDY USING THE NATIONAL INPATIENT SAMPLE DATABASE

You have accessJournal of UrologyCME1 Apr 2023MP47-06 CONTEMPORARY NATIONAL TRENDS IN PARTIAL NEPHRECTOMY UTILIZATION FOR RENAL CANCER: A REAL-WORLD STUDY USING THE NATIONAL INPATIENT SAMPLE DATABASE Sanjana Ranganathan, Carlos Riveros, Jiaqiong Xu, Courtney Chang, Michael Geng, Zachary Klaassen, Christopher J. D. Wallis, and Raj Satkunasivam Sanjana RanganathanSanjana Ranganathan More articles by this author , Carlos RiverosCarlos Riveros More articles by this author , Jiaqiong XuJiaqiong Xu More articles by this author , Courtney ChangCourtney Chang More articles by this author , Michael GengMichael Geng More articles by this author , Zachary KlaassenZachary Klaassen More articles by this author , Christopher J. D. WallisChristopher J. D. Wallis More articles by this author , and Raj SatkunasivamRaj Satkunasivam More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003293.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) has become a preferred approach for small renal masses (SRMs) (<T1a) and similarly amenable tumors in recent years. Compared to radical nephrectomy (RN), PN can mitigate the risk of progression to chronic kidney disease (CKD) while yielding equivalent oncologic outcomes in select patients. Though the benefits of PN are known, the extent of diffusion of the technique and real-world factors influencing patient selection remain unclear. We aim to better understand temporal trends in PN utilization and elucidate patient and facility characteristics associated with PN. METHODS: We identified patients in the National Inpatient Sample (NIS) diagnosed with renal cancer and treated with PN or RN from 2014 to 2019. We accounted for a lack of pathologic and staging data in the NIS by excluding patients with concomitant diagnoses and procedures indicative of increased case complexity. We performed multivariable logistic regression modeling to identify factors associated with nephrectomy type and examined trends in proportion of PN use using a Wilcoxon-type test for trend. RESULTS: A total of 39,983 patients were identified; 15,915 (39.8%) treated with PN and 24,068 (60.2%) with RN. Multivariable analysis (Table 1) identified increased age, comorbid CKD, and self-pay status to be associated with increased likelihood of receiving RN. Higher income quartile, private insurance status, treatment at an urban teaching facility, and treatment at a high nephrectomy volume facility were associated with increased likelihood of receiving PN. We found no trend in PN use over the study period (p=0.08). Limitations include lack of granular data on tumor staging and differences in case complexity influencing treatment decisions. CONCLUSIONS: Contemporary adoption of PN has been slow and requires further study, particularly in the context of increasing use of ablative therapy and active surveillance for SRMs. These data suggest that some patients, particularly those not treated at teaching or high nephrectomy volume facilities as well as those without financial means or insurance coverage, may not have the option of receiving PN despite having potentially amenable tumors. Source of Funding: Sanjana Ranganathan is a Burroughs Wellcome Fund Scholar supported by a Burroughs Wellcome Fund Physician Scientist Institutional Award to the Texas A&M University Academy of Physician Scientists © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e645 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sanjana Ranganathan More articles by this author Carlos Riveros More articles by this author Jiaqiong Xu More articles by this author Courtney Chang More articles by this author Michael Geng More articles by this author Zachary Klaassen More articles by this author Christopher J. D. Wallis More articles by this author Raj Satkunasivam More articles by this author Expand All Advertisement PDF downloadLoading ...

Short-Term and Textbook Surgical Outcomes During the Implementation of a Robotic Gastrectomy Program

BackgroundWhether gastric cancer patients derive greater benefit from robotic gastrectomy (RG), or open gastrectomy (OG) is unknown. We initiated a RG program in 2018, with prospective short-term outcome monitoring to ensure safety. We hypothesized that the RG program for gastric cancer can be safely implemented with equivalent safety and oncological textbook outcomes (TOs) to conventional open gastrectomy (OG). MethodsThe study included patients who underwent curative-intent OG or RG for gastric adenocarcinoma between January 2018 and December 2021. TO metrics were negative surgical margins, ≥ 15 lymph nodes examined, no severe (Clavien–Dindo grade ≥ IIIa) postoperative complications, no reinterventions within 90 days after surgery, no ICU admission, no prolonged length of stay (LOS; > 10 days), no 90-day postoperative mortality, and no readmission within 90 days after surgery. Overall TO was achieved when all these metrics were met. ResultsOf 161 patients, 120 underwent OG, and 41 underwent RG. The two groups’ demographic and disease characteristics did not differ significantly. Compared with OG patients, RG patients had a longer median surgery time (348 vs. 282 min), smaller median blood loss volume (50 vs. 150 mL), lower mean prescribed opioid dose at discharge (12 vs. 45 mg), and shorter median LOS (4 vs. 7 days; all p < 0.001). The groups’ postoperative complication rates (10% vs. 17%) did not differ significantly (p = 0.283). The overall TO rate of the RG group (73%) was higher than that of the OG group (60%), but the difference was not significant (p = 0.131). ConclusionWe were able to implement the RG program safely, without compromising safety or oncological outcomes.

Robotic esophageal surgery

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly becoming established as astandard procedure in surgical centers for esophagectomy in cases of cancer. To date, RAMIE has been shown to have fewer postoperative complications and at least equivalent oncological outcomes compared with open resection. Compared with classical minimally invasive resection, there seem to be fewer cases of postoperative pneumonia after RAMIE. In addition, ahigher number of harvested lymph nodes could lead to better oncological long-term outcomes. The learning curve for this complex surgical procedure is relatively shallow but can be greatly reduced at high-volume centers through special training and proctoring programs. Robotic surgical approaches have also been described for other esophageal diseases; however, no clear superiority compared to laparoscopic surgery has so far been shown.

ASO Visual Abstract: High Risk, High Reward: Frailty in Colorectal Cancer Surgery Associates with Worse Postoperative Outcomes But Equivalent Long-Term Oncologic Outcomes.

ASO Visual Abstract: High Risk, High Reward: Frailty in Colorectal Cancer Surgery Associates with Worse Postoperative Outcomes But Equivalent Long-Term Oncologic Outcomes.

Cytoreductive partial and radical nephrectomies provide equivalent oncologic outcomes in T1-2M1 renal cell carcinoma.

To compare the effectiveness of cytoreductive partial nephrectomy (CPN) and cytoreductive radical nephrectomy (CRN) in the treatment of metastatic T1-T2 renal cell carcinoma (RCC). We obtained the clinical and pathological data of patients with metastatic T1-T2 RCC who underwent CPN or CRN from the Surveillance, Epidemiology, and End Results (SEER) database (https://seer.cancer.gov). Propensity score matching (PSM) was used to balance differences in characteristics between CPN and CRN cases. Kaplan-Meier survival analysis and univariate and multivariate Cox regression were used to assess the effect of partial nephrectomy (PN) versus radical nephrectomy (RN) on overall survival (OS) and cancer-specific survival (CSS). After screening, 866 eligible cases were obtained. During the 1-107 months of follow-up, 500 patients died, 453 (90.6%) of whom died of RCC. The tumor size in the CRN group was significantly greater than that in the CPN group. Kaplan-Meier survival analysis showed that there was no significant difference in OS and CSS between the CPN group and the CRN group before and after matching. Univariate and multivariate Cox regression analysis found that the risk factors for OS were older age at diagnosis [hazard ratio (HR) =1.02, P=0.008], non-clear cell renal cell carcinoma (ccRCC) pathological type (HR =1.69, P=0.002), number of metastases ≥2 (HR =2.13, P<0.001), and regional lymph node involvement (HR =2.22, P=0.004), while the risk factors for CSS were non-ccRCC pathological type (HR =1.51, P=0.021) and the number of metastases ≥2 (HR =2.24, P <0.001). CPN can provide similar oncologic outcomes as can CRN in T1-2M1 cases, and tumor metastatic burden is a major risk factor for survival in these patients with metastatic renal cell carcinoma (mRCC).

High Risk, High Reward: Frailty in Colorectal Cancer Surgery is Associated with Worse Postoperative Outcomes but Equivalent Long-Term Oncologic Outcomes.

Frailty is a physiologic state that affects perioperative outcomes. Studies evaluating the impact of frailty on long-term oncologic outcomes are limited. This study evaluated perioperative and long-term oncologic outcomes for elderly patients undergoing colorectal surgery. Patients older than 65 years at the time of colorectal resection between July 2011 and September 2020 at Roswell Park Comprehensive Cancer Center were identified. Variables from the National Surgical Quality Improvement Program (NSQIP), the tumor registry, and electronic medical records (EMRs) were used to identify frail patients using the revised Risk Analysis Index (RAI-A) score. A score of 38 or higher defined a patient as "frail." Perioperative outcomes were evaluated using logistic regression and chi-square, and oncologic outcomes were evaluated using Kaplan-Meier analysis. The study analyzed 411 patients. The mean age at surgery was 75.1 years. The median RAI-A score was 37, and 29.9 % of the patients were frail. The frail patients had significantly higher rates of overall complications (30.1 % vs 14.6 %; p < 0.001). They also had significantly higher rates of postoperative hospitalization longer than 30 days, postoperative delirium, and discharge to rehabilitation. No mortality differences were observed. The 318 patients with colorectal adenocarcinoma undergoing curative-intent resection were evaluated for oncologic outcomes. No differences with frailty in terms of overall survival, disease-specific survival, or progression-free survival were observed except for frail patients with stage 0 or 1 adenocarcinoma, who had worse overall survival than non-frail patients but equivalent other outcomes. For elderly patients undergoing colorectal surgery, frailty is associated with higher postoperative complications, discharge to rehabitation, and prolonged hospitalization rates. Frailty does not affect long-term oncologic outcomes, so frail elderly patients gain the same oncologic benefit with surgery as non-frail patients.

The usefulness of the endoscopic surgical skill qualification system in laparoscopic right hemicolectomy: a single-center, retrospective analysis with propensity score matching.

Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

LAPAROSCOPIC COLORECTAL SURGERY: ANALYSIS OF THE FIRST OPERATIONS

The aim of the research: to analyze the initial experience of the introduction of laparoscopic technologies in the surgical treatment of patients with colorectal cancer (CRC).&#x0D; Materials and Methods. Our experience in performing laparoscopic operations includes 7 patients (3 men and 4 women) on CRC who underwent laparoscopic operations in the Ternopil Regional Clinical Hospital from December 2021 to July 2022. The mean age of patients was 64,42 ± 10,87 (range 46-75). All patients underwent preoperative 3D-CT angiography and vascular anatomy of the mesentery. 4 patients had previously undergone surgery and had a connective tissue laparoscopic viscerolysis. In 2 patients, the tumor grew into the lateral abdominal wall, pelvic lateral wall and loop of the small intestine, respectively, combined operations were performed. D3 lymphadenectomy was performed in 2 cases and D2 lymphadenectomy was performed in 5 cases. Stapler intracorporeal anastomosis was applied to 3 patients, manual extracorporeal anastomosis was applied to 3 patients. 3 patients receive adjuvant chemotherapy. Statistical analysis was performed using Statistica 64 software. Ordinal data were calculated using the median.&#x0D; Results. The average blood loss was 120±73,7 ml (range 40-250 ml). Intraoperative time was 242,86±45,44 minutes (interval 180-300 minutes). The average number of removed lymph nodes was 16,57 ± 8, (range 12-35). According to the TNM classification, stage T1 was detected in 1 patient, T2 -2, T3 - 3, T4a - 2, T4b – 1. Three patients were diagnosed with a high (G1) degree of adenocarcinoma differentiation, 2 patients were diagnosed with a moderate (G2) degree, while a low (G3) degree was diagnosed in 2 patients. Metastasis to regional lymph nodes were detected in 3 patients. In 3 cases, the macrodrug was removed through a 4-cm Pfanenstiel incision, in 2 cases through a 5-cm incision above the umbilicus, in 1 case through access in the left mesogastric area, where a sigmoid was later formed, and in 1 case through the perineum. We did not observe any cases of anastomosis leakage or 30-day mortality. In 1 patient the postoperative period was complicated by the development of pseudomembranous colitis. R0 resection was achieved in all patients. During the laparoscopic resection of the sigmoid colon in a patient with a T1 tumor, there were difficulties in locating the tumor, the situation was resolved by intraoperative colonoscopy. In the future, we plan to use the technique of endoscopic marking with the help of special stewed paints. The treatment of 3 patients at the pre- and postoperative stages was carried out according to the fast-track protocol, respectively, the patients were discharged from the hospital 3-4 days after the operation&#x0D; Conclusions. Laparoscopic surgery is safe and feasible for colorectal cancer and has resulted in improved short-term outcomes and equivalent oncological outcomes compared with open surgery, even in the setting of colon obstruction. Good selection of patients, preoperative 3D CT-angiography and management of patients according to the program of accelerated rehabilitation are the keys to reducing postoperative complications and faster recovery of patients.

VATS versus Open Lobectomy following Induction Therapy for Stage III NSCLC: A Propensity Score-Matched Analysis.

This study aims to evaluate the perioperative and oncologic outcomes of thoracoscopic lobectomy for advanced stage III NSCLC. We retrospectively reviewed 205 consecutive patients who underwent VATS or open lobectomy for clinical stage III lung cancer between January 2013 and December 2020. The perioperative and oncologic outcomes of the two approaches were compared. Long-term survival was assessed using the Kaplan-Meier estimator. Propensity score-matched (PSM) comparisons were used to obtain a well-balanced cohort of patients undergoing VATS and open lobectomy. VATS lobectomy was performed in 77 (37.6%) patients and open lobectomy in 128 (62.4%) patients. Twelve patients (15.6%) converted from VATS to the open approach. PSM resulted in 64 cases in each group, which were well matched according to twelve potential prognostic factors, including tumor size, histology, and pTNM stage. Between the VATS and the open group, there were no significant differences in unmatched and matched analyses, respectively, of the overall postoperative complications (p = 0.138 vs. p = 0.109), chest tube duration (p = 0.311 vs. p = 0.106), or 30-day mortality (p = 1 vs. p = 1). However, VATS was associated with shorter hospital stays (p &lt; 0.0001). The five-year overall survival (OS) and five-year Recurrence-free survival (RFS) were comparable between the VATS and the open groups. There was no significant difference in the recurrence pattern between the two groups in both the unmatched and matched analyses. For the advanced stage III NSCLC, VATS lobectomy achieved equivalent postoperative and oncologic outcomes when compared with open lobectomy without increasing the risk of procedure-related locoregional recurrence.

Outcome comparisons of laparoscopic distal pancreatectomy vs open in pancreas cancer

Background: As minimally invasive (MIS) approaches continue to advance within the field of hepato-pancreato-biliary (HPB) surgery, it is imperative to ensure that equivalent oncologic outcomes can be achieved as compared to open surgery. In the setting of left sided pancreatic adenocarcinoma (PDAC), limited long-term data is available regarding the oncologic outcomes of patients undergoing laparoscopic resection, particularly in patients necessitating multivisceral or vascular resection. The purpose of this study was to compare the oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP for PDAC.

Minimally invasive radical hysterectomy and the importance of avoiding cancer cell spillage for early-stage cervical cancer: a narrative review.

Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons' skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons' inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.

Robotic Pancreatoduodenectomy - how I do it: tips, tricks and pitfalls to standardize the technique to reduce postoperative morbidity and mortality

benefits of minimally invasive surgery and equivalent oncological outcomes compared with conventional open PD (OPD). When LPD and RPD are compared, RPD offers better precision with 3D vision and advanced instrumentation. Although the learning curve for RPD is long with a longer operating time compared with OPD, this can be reduced to a duration similar to that for OPD through standardization of techniques and case numbers.Perioperative outcomes such as length of stay, blood loss, and transfusion requirement are significantly improved compared to OPD and fewer cases require conversion to open than LPD. In this article, we describe our approach to RPD through standardizing PD techniques along with tips and tricks for the benefit of surgeons interested in learning robotic pancreatic surgery.

Kidney-sparing surgery for distal high-risk ureteral carcinoma: Clinical efficacy and preliminary experiences in 22 patients.

Several groups proved kidney-sparing surgery (KSS) had equivalent oncological outcomes compared with radical nephroureterectomy (RNU) for the low-risk upper urinary tract urothelial carcinoma (UTUC) patients. Whereas, the clinical efficacy of KSS for high-risk UTUC, especially for distal high-risk ureteral carcinoma, remains unclear. To evaluate the feasibility of KSS for patients with distal high-risk ureter cancer. Our study included 22 patients who diagnose the distal high-risk ureter cancer and underwent KSS between May 2012 and July 2021 in the First Affiliated Hospital of Chongqing Medical University. Overall survival (OS), confirmed as the primary endpoint of present study, was assessed by a blinded independent review committee (BIRC). The secondary endpoints included the postoperative SF-36 (the short form 36 health survey questionnaire) score, progression-free survival (PFS), postoperative complications, and so on. Overall, 17 (77.3%) and 5 (22.7%) patients underwent segmental ureterectomy (SU) and endoscopic ablation (EA), respectively. By the cut-off date, the mean OS was 76.3months (95% Cl: 51.3-101.1months) and the mean PFS was 47.0months (95% Cl: 31.1-62.8months), respectively. And the SF-36 score in a majority of patients was >300 (90.9%). This is a daring endeavor to explore the clinical efficacy of KSS in distal high-risk ureter cancer based on the high-risk UTUC criteria, which shows satisfactory results in the long-term prognosis and operation-associated outcomes. However, future randomized or prospective multicenter studies are necessary to validate our conclusions.

Current Considerations in Surgical Treatment for Adolescents and Young Women with Breast Cancer.

Adolescents and young women (AYA) with breast cancer represent a unique patient population, compared to the general population with breast cancer. We performed a literature review to evaluate the factors that influenced the surgical outcomes in this patient population. Fifty-two studies were identified, which evaluated breast surgery type, axillary surgery, contralateral prophylactic mastectomy (CPM), surgical timing, psychological factors, disparities, and imaging use. AYA patients had equivalent oncologic outcomes with breast conserving surgery (BCS) or mastectomy. CPM did not improve survival. There are limited data on axillary management in the AYA population, and while more data would be beneficial, this is currently extrapolated from the general breast cancer population. A shorter time to initiate treatment correlated to better outcomes, and disparities need to be overcome for optimal outcomes. AYA patients appreciated involvement in clinical decisions, and shared decision making should be considered whenever possible. Providers must keep these factors in mind when counseling AYA patients, regarding the surgical management of breast cancer.

Radiofrequency Ablation Provides Equivalent Oncologic Outcomes as Compared with Surgical Lobectomy in Small Papillary Thyroid Cancers

Clinical ThyroidologyVol. 34, No. 11 Thyroid CancerRadiofrequency Ablation Provides Equivalent Oncologic Outcomes as Compared with Surgical Lobectomy in Small Papillary Thyroid CancersSamantha A. Wolfe and Jesse D. PasternakSamantha A. WolfeSection of Endocrine Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, CanadaSearch for more papers by this author and Jesse D. PasternakSection of Endocrine Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, CanadaSearch for more papers by this authorPublished Online:11 Oct 2022https://doi.org/10.1089/ct.2022;34.492-495AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 34Issue 11Nov 2022 Information© Copyright 2022, Mary Ann Liebert, Inc.To cite this article:Samantha A. Wolfe and Jesse D. Pasternak.Radiofrequency Ablation Provides Equivalent Oncologic Outcomes as Compared with Surgical Lobectomy in Small Papillary Thyroid Cancers.Clinical Thyroidology.Nov 2022.492-495.http://doi.org/10.1089/ct.2022;34.492-495Published in Volume: 34 Issue 11: October 11, 2022PDF download

Focal MR-Guided High-Dose-Rate Brachytherapy for Localized Prostate Cancer: A Prospective Clinical Trial

<h3>Purpose/Objective(s)</h3> Focal therapy has gained traction in the management of localized prostate cancer (PCa) based on the promise of equivalent oncologic outcomes with minimal toxicity compared to whole gland therapy. However, 20-45% of patients have persistent/recurrent disease within the first 2-5 years after most commonly-used ablative methods (e.g., HIFU, cryotherapy). Based on brachytherapy's (BT) well-established and long track-record of efficacy for PCa, we sought to test the focal therapy hypothesis in a prospective clinical trial of MR-guided HDR for men with localized PCa. <h3>Materials/Methods</h3> This prospective trial was approved in 2016 (UHN IRB# 16-5490; NCT02918253) for patients with clinically low- and favorable intermediate-risk prostate cancer, and a conspicuous lesion on mpMRI consistent with the area of pathological involvement. The CTV was derived from the mpMRI-defined GTV plus a 7 mm isotropic expansion, with 2 mm sup/inf added for the PTV. Implant and planning were performed with an MR-only workflow, and delivery with HDR BT. Treatment consisted of two separate implants within 14 days, to a prescription dose of 33-36 Gy in 2 sessions (BED ≥ 200 Gy). Biochemical recurrence (BCR), defined as > 2ng/mL above nadir was calculated using the Kaplan Meier method. Local failure, distant metastasis (DM) and toxicity events are reported as absolute rates. <h3>Results</h3> Nineteen patients have been treated, with a median age of 73 years (range 48-84), and median follow-up of 24 months (8-63). Median PSA was 6.1 ng/mL and 17/19 patients had Grade Group 2 disease. On average, the GTV and PTV corresponded to 3.56% (1.58-12.07) and 23.16% (13.71-40.75) of the median prostatic volume (40.49 cc [25.57-97.6]). Median number of catheters was 7 (4-11). Median GTV D₉₉ and PTV D₉₅ per fraction were 23.82 Gy (18.50-31.89) and 18.71 Gy (16.01-20.64), respectively. Nine patients have undergone the 2-yr local control ascertainment; 7 with mpMRI plus biopsies, and 2 with mpMRI only. At 2-years, local control and BCR-free survival were 100%; a single BCR event has been recorded 34 months after treatment. No DM or death events have occurred. The rate of treatment-related acute and late toxicities that were graded ≥ 2 was 0%. <h3>Conclusion</h3> Focal MRI-guided HDR brachytherapy as monotherapy appears to have a high therapeutic ratio and is a promising technique for localized PCa. Further follow-up will determine the durability of outcomes with this approach and the need for collaborative randomized studies.

Surgical management of T1/T2 node-negative papillary thyroid cancer with tall cell histology: Is lobectomy enough?

BackgroundThe tall cell variant of papillary thyroid carcinoma has traditionally been treated more aggressively than classic papillary thyroid carcinoma. However, this may not be justified in patients with T1/T2 tall cell variant node-negative tumors. MethodsWe evaluated well-differentiated thyroid cancers treated surgically between 1985 and 2015 at our institution. We compared patients undergoing lobectomy for node-negative T1/T2 tall cell variant tumors with the same cohort with classic papillary thyroid carcinoma. Patients who underwent early planned completion thyroidectomy were excluded. Tall cell variant tumors were defined as those with ≥30% tall cells. Survival and recurrence outcomes were determined by the Kaplan-Meier method and groups compared using the log-rank test. ResultsThyroid lobectomy was performed for T1/T2 N0X disease in 70 (15%) tall cell cases and 429 (23%) classic papillary thyroid carcinoma cases. There was no significant difference in 10-year overall survival (P = .56) or locoregional recurrence-free probability (P = .52). Disease-specific survival and local or central nodal recurrence-free probability were 100% in both groups. In 9 papillary thyroid carcinoma cases, subsequent contralateral lobe tumors developed, and in 5, lateral neck metastases developed. No recurrences were seen in the tall cell group. ConclusionT1 node-negative tumors with tall cell histology can be satisfactorily managed with thyroid lobectomy, with equivalent oncological outcomes to classic papillary thyroid carcinoma.

Surgical considerations and outcomes of minimally invasive approaches for gastric cancer resection.

Despite high mortality rates from gastric cancer, surgical management remains critical for curative potential. Optimal outcomes of gastric cancer resection depend on a multitude of variables, including the extent of resection, scope of lymphadenectomy, method of reconstruction, and potential for a minimally invasive approach. Laparoscopic gastrectomy, compared with open gastrectomy, has been analyzed in numerous randomized control trials. Generally, those trials demonstrated statistically similar postoperative complication rates, mortality, and oncologic outcomes between the two approaches. Although laparoscopic gastrectomy requires longer operative times, significant improvements in estimated blood loss, postoperative length of stay, and return of bowel function have been noted in patients who undergo laparoscopic gastrectomy. These short-term benefits, along with equivalent oncologic results, have influenced national guidelines in both Eastern and Western countries to recommend laparoscopy, especially for early stage disease. Although robotic gastrectomy has not been as widely validated in effective trials, studies have reported equivalent oncologic outcomes and similar or improved postoperative complication and recovery rates after robotic gastrectomy compared with open gastrectomy. Comparing the two minimally invasive gastrectomy approaches, robotic surgery was associated with improved estimated blood loss, incidence of pancreatic sequela, and lymph node harvests in some studies, whereas laparoscopy resulted in lower operative times and hospital costs. Ultimately, when applying outcomes from the literature to clinical patient care decisions, it is imperative to recognize these studies' range of inclusion criteria, delineating between patients originating from Eastern or Western countries, the use of neoadjuvant chemotherapy, the volume of surgeon experience, and the extent of gastrectomy, among others.

Comparison of the Oncological and Functional Outcomes of Brachytherapy and Radical Prostatectomy for Localized Prostate Cancer.

Background and Objectives: To compare the oncological and functional outcomes of brachytherapy (BT) and radical prostatectomy (RP) in patients with localized prostate cancer (PCa). Materials and Methods: We retrospectively analyzed data from 557 patients with localized PCa who were treated with BT (n = 245) or RP (n = 312) at Northern Jiangsu People’s Hospital between January 2012 and December 2017. Biochemical relapse-free survival (bRFS) and cancer-specific survival (CSS) were compared by treatment modality. Multivariate Cox regression analysis was used to evaluate bRFS. Health-related quality of life (HRQoL) was measured using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Results: The BT group was older and had a higher initial PSA (iPSA). The 5-year bRFS was 82.9% in the BT group versus 80.1% in the RP group (p = 0.570). The 5-year CSS was 96.4% in the BT group versus 96.8% in the RP group (p = 0.967). Based on multivariate Cox regression analysis, Gleason score ≥ 8 was the main independent prognostic factor for bRFS. Regarding the HRQoL, compared with the baseline, both treatments produced a significant decrease in different aspects of HRQoL at 3, 6, and 12 months after treatment. Patients in the BT group had lower HRQoL with regard to urinary irritation/obstruction and bowel function or bother, while patients in the RP group had lower HRQoL concerning urinary incontinence and sexual function or bother. There was no significant difference in HRQoL aspects between the two groups after follow-up for 2 years compared with the baseline. Conclusions: BT provides equivalent oncological control outcomes in terms of bRFS and CSS for patients with localized PCa compared with RP. Gleason score ≥ 8 was the main independent prognostic factor for bRFS. BT had better HRQoL compared with RP, except for urinary irritation/obstruction and bowel function or bother, but returned to baseline after 2 years.