Left-sided Cancer Research Articles

HPB O04 - Human Splenic Ex-Vivo Perfusion Model: A Platform for Translational Basic Science Research

Abstract Background The function of the spleen has always been shrouded in mystery and since the Renaissance leading figures have attempted to understand its function. Vesalius questioned Galen and Marcello Malpighi (1628-1694) gave the first accurate description of the histology and the physiology. The spleen still poses unique challenges as invasive approaches may produce intraperitoneal bleeding, differences between human and animal spleens complicates comparative studies, and post-mortem examinations reveal only late-stage disease manifestations and functional studies are impossible. This study describes a human splenic ex-vivo perfusion model for translational research, using microbiological studies as markers of splenic physiological function. Method Patients with left-sided pancreatic cancers scheduled for distal pancreatic and splenic resection were identified from the Hepato-Pancreatic and Biliary MDT at the University Hospitals of Leicester NHS Trust. Patients were informed, consented, and the surgical approach remained standard, with splenic artery ligation deferred until specimen extraction. The artery was cannulated, and residual blood clots were cleared with Custodiol® HTK solution. The perfusion technique employs an extracorporeal circuit incorporateing anoxygenator and a heated water chamber maintaining a 37°C perfusate. The perfused spleen was infected with Streptococcus Pneumoniae strains, with regular biopsies and perfusate gas analysis performed. Results Since February 2023, nine spleens have been successfully perfused, with an average weight of 169.5 grams, cold ischemic time of 116 minutes, and warm ischemic time of 12.2 minutes. Pressure was maintained at 80 mmHg and hourly perfusate gas analysis demonstrated a mean pH of 7.1 and a gradual increase in lactate. Histopathological examination revealed clear distinctions between the lymphoid tissue and splenic red pulp, with intact central arterioles and healthy cell morphology at time 0 and after 6 hours of perfusion. Additionally, the perfused spleens cleared S. pneumoniae strains to below-detection levels. Conclusion Our work demonstrates that a stable human splenic ex-vivoperfusion model which maintains structural and physiological integrity can be achieved from tissue that would otherwise be discarded. The continued physiological function is confirmed by the clearance of S. pneumoniae. While currently employed for microbiological studies, this model has the potential to facilitate a wide range of different translational science studieswhile reducing the need for animal experimentation. The perfusion times employed for the present study were sufficient to demonstrate bacterial clearance which was the aim but there is capacity in the system to significantly prolong the duration.

8621 A Challenging Case of Preoperative Management of Pheochromocytoma Presenting With Recurrent Hypotension

Abstract Disclosure: N. Shripad: None. R. Osman: None. Introduction: Pheochromocytoma is a neuroendocrine tumor that clinically manifests due to the hypersecretion of catecholamines. Preoperative management typically involves alpha- and beta-adrenergic blockade. Patients commonly present with hypertension; however, in rare cases, patients may be hypotensive due to other comorbidities, posing a challenge to preoperative management. The following is a case of management of a pheochromocytoma with recurrent preoperative hypotension before the initiation of blood pressure-lowering agents. Case: A 47-year-old female presented to the hospital with dizziness and hypotension. The patient has a history of bilateral nephrectomy with left-sided adrenalectomy secondary to left-sided renal cell cancer and is hemodialysis-dependent. A right-sided pheochromocytoma was diagnosed a year ago on a follow-up CT scan done for monitoring renal cell cancer. The diagnosis was later confirmed with a DODATE scan and, eventually, a biopsy. Normetanephrine levels were between 581-735 pg/mL (0-88 pg/mL), with normal metanephrine levels. She denies having hyperadrenergic spells. She was started on metoprolol and doxazosin the year prior to presentation; however, she self-discontinued doxazosin after experiencing dizziness and palpitations on hemodialysis days. On admission, she was afebrile with a blood pressure of 103/66 mm Hg and a heart rate of 115 BPM. After an interdisciplinary decision was made for surgical resection, she was restarted on a lower dose of doxazosin (1 mg) and metoprolol was increased to the goal heart rate. Despite fewer hypotensive episodes on a reduced dose of doxazosin, the patient remained hypotensive on hemodialysis days. Salt tablets were started post-dialysis after clearance from nephrology, and an improvement in blood pressure was noted. She underwent a right adrenalectomy without receiving saline infusion before surgery due to concerns about volume overload. She was started on stress dose steroids due to her history of left adrenalectomy. She remained stable during and following surgery and did not require any vasopressor support. Discussion: Perioperative management of pheochromocytoma can be challenging in hypotensive patients and is poorly documented. Midodrine, an alpha-1 agonist that is typically used in dialysis-induced hypotension, is contraindicated in the setting of pheochromocytoma. We opted to manage our patient with a reduced dose of doxazosin and beta-blocker initially; however, with continued hypotensive episodes, the addition of salt tablets preoperatively on dialysis days helped to alleviate the hypotension. Although our patient did not require it, a preoperative overnight albumin infusion is a viable alternative to saline to prevent volume overload. Despite the limited literature, the patient was treated successfully through an interdisciplinary approach. Presentation: 6/3/2024

Association between tumor deposits and liver and lung metastases at diagnosis of colorectal cancer: A SEER-based analysis

BackgroundTumor deposits are a unique histologic feature of colorectal cancer that is associated with adverse survival outcomes. The present study aimed to assess the association between tumor deposits and liver and lung metastases and to describe the characteristics of colorectal cancer associated with tumor deposits. MethodsThe Surveillance, Epidemiology, End Results (SEER) database was screened between 2010 and 2020 for patients with colorectal adenocarcinoma who underwent radical resection with data on tumor deposits. The primary outcome of the study was liver and lung metastases. The secondary outcome was the characteristics of patients with tumor deposits. ResultsA total of 205,294 patients (52% male, mean age 66.5 years) were included in the study. Tumor deposits were detected in 20,059 (9.7%) patients. Patients with tumor deposits were younger and presented more often with larger tumors, T3/T4 tumors, N+ tumors, stage IV disease, left-sided and rectal cancers, signet-ring cell carcinomas, high-grade adenocarcinomas, and perineural invasion. Multivariable binary regression analyses showed that tumor deposits were associated with 72% higher odds of liver metastases (odds ratio 1.72, 95% confidence interval 1.62–1.82, P < .001) and 68% higher odds of lung metastases (1.68, 1.51–1.86, P < .001). The odds of liver metastases increased by 3% (odds ratio 1.03, 95% confidence interval 1.03–1.04, P < .001) and the odds of lung metastases increased by 2% (1.02, 1.01–1.03, P < .001) for each tumor deposit detected. ConclusionsTumor deposit–positive colorectal cancers were larger, more often on the left side or in the rectum and presented with more advanced disease and unfavorable histology than tumor deposit–negative cancers. Tumor deposits were independently associated with 72% and 68% higher odds of liver and lung metastases, respectively.

Prognostic Implications of Selective Dissection of Left Lower Paratracheal Lymph Nodes in Patients with Left-Sided Non-Small Cell Lung Cancer.

This study aimed to examine the clinical implications of selective station 4L lymph node dissection (S4L-LND) on survival in non-small cell lung cancer (NSCLC) and to evaluate its potential advantages. We enrolled patients with primary left-sided NSCLC who underwent upfront video-assisted thoracoscopic surgery with R0 resection including lobectomy and segmentectomy, with or without S4L-LND, at our institution between January 2007 and December 2021. Following 1:1 propensity score matching (PSM), we compared overall survival (OS) and recurrence-free survival (RFS) between patients with and without S4L-LND. The study included 2,601 patients, of whom 1,126 underwent S4L-LND and 1,475 did not. PSM yielded 1,036 patient pairs. Among those who underwent S4L-LND, 87 (7.7%) exhibited S4L-LN involvement. Neither OS (p=0.12) nor RFS (p=0.24) differed significantly between matched patients with and without S4L-LND. In patients with S4L-LN involvement, metastases were more common in the left upper lobe (LUL) than in the left lower lobe (LLL) (3.6% vs. 2.0%, p=0.061). Metastasis became significantly more frequent with more advanced clinical N (cN) stage (cN0, 2.3%; cN1, 5.8%; cN2, 32.6%; p<0.001). Multivariate logistic regression analysis revealed that cN stage and tumor location were independently associated with S4L-LN involvement (p<0.001 for both). OS and RFS did not differ significantly between matched patients with and without S4L-LND. Among participants with S4L-LN involvement, metastases occurred more frequently in the LUL than the LLL, and their incidence increased significantly with more advanced cN stage. Thus, patients with LUL or advanced cN lung cancers may benefit from S4L-LND.

525. PALLIATIVE MULTIMODALITY-THERAPY, EVEN WITH ABBREVIATED IMMUNOTHERAPY CAN MAKE CURATIVE SURGERY FOR SYNCHRONOUS LUNG AND ESOPHAGEAL CANCER POSSIBLE: A CASE REPORT

Abstract Background Synchronous lung and esophageal carcinomas are problematic. When both cancers are locally advanced, combined surgical treatment is rarely possible because of high-risk or insufficient respiratory reserve. Palliative treatment including immunotherapy can sometimes offer significant tumor response and potentially prolong survival in patients with PDL-1 tumor expression. However the place of immunotherapy for potentially rendering inoperable patients operable is still unknown. Methods Case report: A 78-year-old male with smoking history was diagnosed with synchronous locally advanced adenocarcinoma of the Gastroesophageal Junction (GEJ) cT3cN1cM0 and bilateral lung adenocarcinomas stage 4a, cT2cN1cM1a (right lower lobe 43mm confirmed by CT-guided biopsy, left upper lobe 32mm and additional S6 left lower lobe nodule). The patient was considered incurable by MDT and palliative treatment was offered as both cancers had significant PDL-1 expression (GEJ: CPS score &amp;gt;1, Lung: PDL-1 expression 90%). Pembrolizumab immunotherapy was started but poorly tolerated (severe myositis) and stopped again after only 6 weeks. The left-sided lung cancer had by then already regressed and stereotactic irradiation (SBRT 5x12Gy) of the right-side lung cancer was administered resulting in further local tumor control (figure). Endoscopic tumor re-evalution showed a Siewert type 2 tumor (uT3N1) similar to the initial endoscopy 15 months before. Both side lung adenocarcinomas remained regressed and the left lower lobe nodule was unchanged (6mm). Mediastinal lymph node staging by EBUS was negative. Thirteen months after initial diagnosis, 4 cycles of neo-adjuvant chemotherapy (FLOT) were administered. Combined synchronous surgery was finally done 16 months after initial diagnosis. A minimally invasive combined resection included a laparoscopic &amp; thoracoscopic Ivor-Lewis MIE, left thoracoscopic wedge of the lower lobe nodule and a right lower lobectomy with radical lymph node dissection. Post-operative course was smooth: Clavien-Dindo score 1, hospital stay 18 days. Final pathology Distal third adenocarcinoma (1.5x1.2cm above Z-line) with major partial response ypT2N0M0, R0, 0/43 lymph nodes (subcarinal signs of nodal response), right lower lobe tumor of 60x55mm with residual 1.2mm focus of residual viable adenocarcinoma (ypTisN0M0, R0) and left lower lobe hamartoma (6mm). Follow-up showed no recurrence 9 months after surgery (25 months from initial diagnosis). Conclusions: 1) Despite much abbreviated palliative immunotherapy (6 weeks), SBRT and FLOT our patient was down-staged within 16 months from an initially palliative situation to a potential cure with complete resection of all tumors. 2) Synchronous combined radical laparoscopic &amp; thoracoscopic Ivor-Lewis esophagectomy with lung lobectomy can be feasible after immuno-, chemo- and radiotherapy even in elderly patients.

The Prognostic and Predictive Utility of CDX2 in Colorectal Cancer.

Caudal type homeobox transcription factor 2 (CDX2) is a gastrointestinal cancer biomarker that regulates epithelial development and differentiation. Absence or low levels of CDX2 have been associated with poor prognosis and proposed as a chemotherapy response predictor. Tumour tissue samples from 668 patients with stage I-IV colorectal cancer were stained for CDX2 and stratified into two subgroups according to expression levels. Statistical tests were used to evaluate CDX2's relationship with survival and chemotherapy response. Of 646 samples successfully stained, 51 (7.9%) had low CDX2 levels, and 595 (92.1%) had high levels. Low CDX2 staining was associated with poor differentiation and the presence of lymphovascular or perineural invasion and was more common in colon and right-sided tumours. Overall survival (p < 0.001) and disease-free survival (p = 0.009) were reduced in patients with low CDX2 expression. Multivariable analysis validated CDX2 as an independent poor prognostic factor after excluding confounding variables. There was no statistically significant improvement in survival with adjuvant chemotherapy in stage II colon cancer (p = 0.11). In the rectal cohort, there was no relationship between CDX2 levels and therapy response. While confirming the prognostic utility of CDX2 in colorectal cancer, our study highlights that larger studies are required to confirm its utility as a predictive chemotherapy biomarker, especially in left-sided and rectal cancers.

Right vs. Left colorectal cancer – Where do we draw the line?

PurposeNo consensus on the definition of right and left colorectal cancer (CRC) exists, nor studies offering histological or molecular basis for such categorisation. This study investigated the regional variations in the histological and molecular characteristics of CRCs, with the objective of determining an optimal division point between right and left CRCs. Materials and methodsAn observational study of consecutive patients who underwent CRC resection (1995–2022) at Concord Hospital, Sydney was performed. Clinicopathological data were extracted from a prospective database and seven permutations of right-left divisions considered. Logistic regression tested association between the right-left divisions and pathological characteristics. Receiver operating characteristic and area under the curve (AUC) analyses determined the discriminative ability of each division to predict 18 pathology characteristics. Results3753 patients underwent a CRC resection (2120 male; mean 69.5yrs [SD12.6]). There was regional variation in tumours with respect to tumour infiltrating lymphocytes (TILs), mismatch repair deficiency (dMMR), and mutant BRAF (mBRAF). Left-sided tumours were less likely to demonstrate TILs (P < 0.001), be dMMR (P < 0.001), and express mBRAF (P < 0.001). Division at the descending-sigmoid junction yielded highest discriminative abilities: TILs – AUC 0.66, dMMR – AUC 0.76, and mBRAF – AUC 0.73. ConclusionThis is the first study to provide a pathological basis on which right- and left-sided cancers may be defined, and found the optimal division point between the right and left colorectum to be at the descending-sigmoid junction. Further research is needed to determine whether this can facilitate individualised patient management.

Process and outcome differences in the care of patients undergoing elective and emergency right hemicolectomy.

Up to 30% of patients with colorectal cancer present as an emergency and have worse outcomes than elective patients. Compared with left-sided cancers, malignancies arising in the right colon are significantly under-researched. We sought to compare cancer care quality and clinical outcomes between emergency and elective presentations of right-sided colon cancer (RCC). This multicentre, retrospective study included all patients who underwent operative management for a RCC, from 1 April 2017 to 31 March 2022. Data were collected from electronic patient records, and host and tumour factors as well as outcomes between emergency and elective cohorts were compared. Overall, 806 patients (median age 72 years) were included. Some 175 patients (22%) presented as an emergency: 140 in obstruction and 35 with tumour perforation, compared with 1 patient with tumour perforation in the elective group (p < 0.001). The emergency group had higher rates of postoperative complications (59.1% vs 20.0%, p < 0.001), increased 90-day mortality (13.7% vs 1.3%, p < 0.001) and a longer hospital stay (5 vs 10 days, p < 0.001). From the emergency cohort only 29.2% of eligible patients received adjuvant chemotherapy and in multivariate regression analysis emergency presentation was associated with a decreased likelihood of receiving adjuvant chemotherapy (odds ratio 0.26 [0.14-0.47], p < 0.001). Both short- and long-term outcomes after emergency presentation of RCC are poor, with inadequate access to subsequent chemotherapy. Strategies addressing emergency presentations of left-sided tumours have moved towards temporisation and elective surgery. Delaying major resectional surgery for optimisation may improve outcomes and access to adjuvant therapies for RCC.

Effect of Different Radiotherapy Techniques on the Left Anterior Descending Coronary Artery Dose in Left-Sided Lung Cancer

Effect of Different Radiotherapy Techniques on the Left Anterior Descending Coronary Artery Dose in Left-Sided Lung Cancer

An artificial intelligence-designed predictive calculator of conversion from minimally invasive to open colectomy in colon cancer

Minimally invasive surgery is safe and effective in colorectal cancer. Conversion to open surgery may be associated with adverse effects on treatment outcomes. This study aimed to assess risk factors of conversion from minimally invasive to open colectomy for colon cancer and impact of conversion on short-term and survival outcomes. This case–control study included colon cancer patients undergoing minimally invasive colectomy from the National Cancer Database (2015–2019). Logistic regression analyses were conducted to determine independent predictors of conversion from laparoscopic and robotic colectomy to open surgery. 26,546 patients (mean age: 66.9 ± 13.1 years) were included. Laparoscopic and robotic colectomies were performed in 79.1% and 20.9% of patients, respectively, with a 10.6% conversion rate. Independent predictors of conversion were male sex (OR: 1.19, p = 0.014), left-sided cancer (OR: 1.35, p < 0.001), tumor size (OR: 1, p = 0.047), stage II (OR: 1.25, p = 0.007) and stage III (OR: 1.47, p < 0.001) disease, undifferentiated carcinomas (OR: 1.93, p = 0.002), subtotal (OR: 1.25, p = 0.011) and total (OR: 2.06, p < 0.001) colectomy, resection of contiguous organs (OR: 1.9, p < 0.001), and robotic colectomy (OR: 0.501, p < 0.001). Conversion was associated with higher 30- and 90-day mortality and unplanned readmission, longer hospital stay, and shorter overall survival (59.8 vs 65.3 months, p < 0.001). Male patients, patients with bulky, high-grade, advanced-stage, and left-sided colon cancers, and patients undergoing extended resections are at increased risk of conversion from minimally invasive to open colectomy. The robotic platform was associated with reduced odds of conversion. However, surgeons’ technical skills and criteria for conversion could not be assessed.

Primary Tumor Sidedness Associated with Clinical Characteristics and Postoperative Outcomes in Colon Cancer Patients: A Propensity Score Matching Analysis.

Background: Recent investigations have suggested that-sidedness is associated with the prognosis of colon cancer patients. However, the role of sidedness in surgical outcome is unclear. In this study, we tried to demonstrate the real role of sidedness in postoperative results for colon cancer patients receiving surgical intervention. Methods: This is a propensity score matching study using the database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2009 to 2013. Sidedness groups including right-sided and left-sided colon cancer were created according to the associated diagnosis and procedure codes. Postoperative 30-day mortality, morbidity, overall complications, and total length of hospital stay were analyzed after performing propensity score matching. Results: Out of a total of 24,436 colon cancer patients who received associated operations, 15,945 patients had right-sided cancer and 8941 patients had left-sided cancer. Right-sided colon cancer patients were accompanied by more preoperative comorbidities including old age, female sex, hypertension, dyspnea, anemia, hypoalbuminemia, and a high American Society of Anesthesiologists grade (SMD > 0.1). Postoperative mortality, morbidities including re-intubation, bleeding, urinary tract infection and deep vein thrombosis, postoperative overall complications, and total length of hospital stay were significantly associated with right-sided cancer (p < 0.05). After 1:1 propensity score matching, postoperative mortality was not significantly different between right-sided cancer (2.3%) and left-sided cancer (2.4%) patients. The patients with left-sided colon cancer had significantly more postoperative morbidities, more overall complications, and longer total length of hospital stay. Conclusions: Poor clinical characteristics and postoperative outcomes were noted in right-sided cancer patients. After propensity score matching, left-sided cancer patients had worse postoperative outcomes than those with right-sided cancer.

The Association of Mismatch Repair Status with Microscopically Positive (R1) Margins in Stage III Colorectal Cancer: A Retrospective Cohort Study

BackgroundThere is mounting evidence that microscopically positive (R1) margins in patients with colorectal cancer (CRC) may represent a surrogate for aggressive cancer biology rather than technical failure during surgery. However, whether detectable biological differences exist between CRC with R0 and R1 margins is unknown. We sought to investigate whether mismatch repair (MMR) status differs between Stage III CRC with R0 or R1 margins.MethodsPatients treated for Stage III CRC from January 1, 2016 to December 31, 2019 were identified by using the Danish Colorectal Cancer Group database. Patients were stratified according to MMR status (proficient [pMMR] vs. deficient [dMMR]) and margin status. Outcomes of interest included the R1 rate according to MMR and overall survival.ResultsA total of 3636 patients were included, of whom 473 (13.0%) had dMMR colorectal cancers. Patients with dMMR cancers were more likely to be elderly, female, and have right-sided cancers. R1 margins were significantly more common in patients with dMMR cancers (20.5% vs. 15.2%, p < 0.001), with the greatest difference seen in the rate of R1 margins related to the primary tumour (8.9% vs. 4.7%) rather than to lymph node metastases (11.6% vs. 10.5%). This association was seen in both right- and left-sided cancers. On multivariable analyses, R1 margins, but not MMR status, were associated with poorer survival, alongside age, pN stage, perineural invasion, and extramural venous invasion.ConclusionsIn patients with Stage III CRC, dMMR status is associated with increased risks of R1 margins following potentially curative surgery, supporting the use of neoadjuvant immunotherapy in this patient group.

Prognosis and predictive factors of conversion surgery for initially unresectable advanced colorectal cancer

PurposeThe aim of this study was to report the outcomes of conversion surgery for initially unresectable advanced colorectal cancer and to identify factors that enable successful conversion surgery.MethodsWe compared the outcomes of patients with colorectal cancer with distant metastases, including extrahepatic metastases, who underwent upfront surgery, neoadjuvant chemotherapy, conversion surgery, and chemotherapy only at our department from 2007 to 2020. In addition, factors influencing the achievement of conversion surgery in patients who were initially unresectable were examined in univariate and multivariate analyses.ResultsOf 342 colorectal cancer patients with distant metastases treated during the study period, 239 were judged to be initially unresectable, and 17 (conversion rate: 7.1%) underwent conversion surgery. The prognosis for the conversion surgery group was better than that of the chemotherapy only group but worse than that of the upfront surgery group. In the conversion surgery group, the recurrence-free survival after resection was significantly shorter than that upfront surgery group and neoadjuvant chemotherapy group, and no patients have been cured. Among patients who were initially unresectable, left-sided primary cancer and normal CA19-9 level were identified as independent factors contributing to the achievement of conversion surgery in a multivariate analysis.ConclusionsAlthough relapse after conversion surgery is common, and no patients have been cured thus far, overall survival was better in comparison to patients who received chemotherapy only. Among unresectable cases, patients with left-sided primary cancer and normal CA19-9 levels are likely to be candidates for conversion surgery.

Evaluating the efficacy of laparoscopic radical antegrade modular pancreatosplenectomy in selected early-stage left-sided pancreatic cancer: a propensity score matching study

BackgroundLaparoscopic radical pancreatectomy is safe and beneficial for recectable pancreatic cancer, but the extent of resection for early-stage tumors remains controversial.MethodsConsecutive patients with left-sided pancreatic cancer who underwent either laparoscopic radical antegrade modular pancreatosplenectomy (LRAMPS, n = 54) or laparoscopic distal pancreatosplecnectomy (LDP, n = 131) between October 2020 and December 2022 were reviewed. The preoperative radiological selection criteria were as follows: (1) tumor diameter ≤ 4 cm; (2) located ≥ 1 cm from the celiac trunk; (3) didn’t invade the fascial layer behind the pancreas.ResultsAfter 1:1 propensity score matching (LRAMPS, n = 54; LDP, n = 54), baseline data were well-balanced with no differences. LRAMPS resulted in longer operation time (240.5 vs. 219.0 min, P = 0.020) and higher intraoperative bleeding volume (200 vs. 150 mL, P = 0.001) compared to LDP. Although LRAMPS harvested more lymph nodes (16 vs. 13, P = 0.008), there were no statistically significant differences in lymph node positivity rate (35.2% vs. 33.3%), R0 pancreatic transection margin (94.4% vs. 96.3%), and retroperitoneal margin (83.3% vs. 87.0%) rate. Postoperative complications did not significantly differ between the two groups. However, LRAMPS was associated with increased drainage volume (85.0 vs. 40.0 mL, P = 0.001), longer time to recover semi-liquid diet compared to LDP (5 vs. 4 days, P < 0.001) and increased daily bowel movement frequency. Tumor recurrence pattern and recurrence-free survival were comparable between the two groups, but the adjuvant chemotherapy regimens varied, and the completion rate of the 6-month intravenous chemotherapy was lower in the LRAMPS group compared to the LDP group (51.9% vs. 75.9%, P = 0.016).ConclusionsLRAMPS did not provide oncological benefits over LDP for left-sided pancreatic cancer within the selection criteria, but it increased operation time, intraoperative bleeding, and postoperative bowel movement frequency. These factors impacted the regimen selection and completion of adjuvant chemotherapy, consequently compromising the potential benefits of LRAMPS in achieving better local control.Graphical

Comparison of Survival Outcomes between Radical Antegrade Modular Pancreatosplenectomy and Conventional Distal Pancreatosplenectomy for Pancreatic Body and Tail Cancer: Korean Multicenter Propensity Score Match Analysis.

(1) Background: The aim of this study was to compare the survival benefit of radical antegrade modular pancreatosplenectomy (RAMPS) with conventional distal pancreatosplenectomy (cDPS) in left-sided pancreatic cancer. (2) Methods: A retrospective propensity score matching (PSM) analysis was conducted on 333 patients who underwent RAMPS or cDPS for left-sided pancreatic cancer at four tertiary cancer centers. The study assessed prognostic factors and compared survival and operative outcomes. (3) Results: After PSM, 99 patients were matched in each group. RAMPS resulted in a higher retrieved lymph node count than cDPS (15.0 vs. 10.0, p < 0.001). No significant differences were observed between the two groups in terms of R0 resection rate, blood loss, hospital stay, or morbidity. The 5-year overall survival rate was similar in both groups (cDPS vs. RAMPS, 44.4% vs. 45.2%, p = 0.853), and disease-free survival was also comparable. Multivariate analysis revealed that ASA score, preoperative CA19-9, histologic differentiation, R1 resection, adjuvant treatment, and lymphovascular invasion were significant prognostic factors for overall survival. Preoperative CA19-9, histologic differentiation, T-stage, adjuvant treatment, and lymphovascular invasion were independent significant prognostic factors for disease-free survival. (4) Conclusions: Although RAMPS resulted in a higher retrieved lymph node count, survival outcomes were not different between the two groups. RAMPS was a surgical option to achieve R0 resection rather than a standard procedure.

The Factors Impacting Decision-Making for Breast Reconstruction in Women Following Mastectomy: A Cross-Sectional Study

OBJECTIVES This study aimed to assess the Factors Impacting Decision-Making for Breast Reconstruction in Women Following Mastectomy in Combined Military Hospital, Rawalpindi METHODOLOGY This prospective cross-sectional study was conducted at a specialized Breast Clinic in the Combined Military Hospital Rawalpindi from January to June 2023. The sampling technique was non-probability sampling. A total of 56 female patients between the ages of 20-70 years with a histological diagnosis of carcinoma breast and undergoing mastectomy as part of their breast cancer therapy were included in the study. Patients who had metastatic cancer or connective tissue disorder were excluded from the study. After getting informed written consent, data was collected from patients. A semi-structured questionnaire was used as a study tool. Data was presented in the form of tables. RESULTSThe surgical preference of 56 patients was studied. Only 11(19.6%) patients opted for breast reconstruction. A total of 45(80.4%) patients refused to undergo BR. Several factors affecting the decision not to have BR were identified. They included fear of recurrence in 07 (15.5%) patients, long surgical procedures in 06 (13.3%), lack of concern regarding body image in 11(24.4%), financial issues in 13 (28.8%) patients, unsatisfactory results of breast reconstruction in 8 (17.7%) patients who had lack of trust in plastic surgeon regarding their post reconstruction breast shape. CONCLUSION This study laid the conceptual groundwork that factors like fear of recurrence, long surgical procedures, disregard for body image, poverty, and plastic surgeon distrust negatively influence the likelihood of having post-mastectomy breast reconstruction (PMBR). Methods: From January 2023 to June 2023, this cross-sectional study, carried out at a specialized Breast Clinic in the Combined Military Hospital Rawalpindi, sought to explore surgical preferences for breast reconstruction (BR) among breast carcinoma patients undergoing mastectomy and to identify factors influencing these decisions. 42 patients in all were enrolled, 8 of them selected breast reconstruction while 34 did not. The decision-making process was influenced by a number of issues, such as worry about recurrence, worries about time-consuming surgical procedures, and disregard for body image, financial limitations, and previous unsuccessful reconstructive results. Results: 28 patients had right-sided disease, 13 had left-sided cancer, and 1 had bilateral involvement, according to disease features. Furthermore, 25 individuals had N0 disease, while 17 had N1 disease, according to nodal staging. Six patients had sentinel lymph node biopsy (SLNB), two underwent axillary lymph node dissection (ALND), five chose upfront surgery, and three underwent neoadjuvant therapy before surgery, demonstrating the range of the surgical methods used. Conclusion: This study provides insightful information about the complex decision-making process involving breast reconstruction in individuals with breast cancer. The identified characteristics give healthcare professionals a framework on which to build strategies that guarantee patients receive educated and individualized care, thereby improving patient happiness and quality of life in general. Key words: breast, tumor, surgery, lymph node, reconstruction, aesthetic

Abstract 6683: The abundance of Fusobacteria nucleatum in tumor tissue is a prognostic factor in patients of right-sided colorectal cancer

Abstract Background: A significant association between the gut microbiome and colorectal carcinogenesis, as well as cancer progression. It has been reported that Fusobacteria nucleatum (F. nucleatum) is one of the most famous bacteria associated with colorectal cancer (CRC). It has been reported that the abundance of F. nucleatum is associated with colorectal cancer-specific survival (CSS), however it remains unclear for association with F. nulceatum and relapse-free survival (RFS). If F. nucleatum has a significant involvement in tumor progression of colorectal cancer, the abundance of F. nucleatum should be associated with not only CSS but also RFS in colorectal cancer. In this study, we measured the bacterial mass of F. nucleatum in tumor tissue of CRC patients in Stage II-III to explore the differences in prognosis. Methods: We included patients with CRC in stage II-III who underwent surgical treatment at Nippon Medical School Hospital between January 2017 and December 2020 except patients who received preoperative chemoradiotherapy and had multiple cancers. We measured the absolute of F. nucleatum copy number of the DNA exacted tumor tissues using droplet digital PCR. Results: 253 patients with CRC were included. 128 patients had pathological stage II and 125 patients had pathological stage III. Among 253 patients, 104 patients had right-sided CRC, 89 patients had left-sided, and 60 patients had rectal cancer. F. nucleatum was detected in 166 patients (65.6%), and the median of F. nucleatum copy number was 1.08 (range; 0.00 -2791.3). F. nucleatum copy number was more abundant in right-sided CRC than in left-sided and rectal cancer (p= 0.02, p=0.01). There was no significant difference between stage II CRC and stage III. We categorized patients into two groups based on the median cut point of F. nucleatum copy number: the F. nucleatum-high group and the F. nucleatum-low group for comparison with clinicopathological features and prognosis. Patients with high abundance of F. nucleatum exhibited T4 of tumor depth (p=0.03), right-sided CRC (p=0.01), longer tumor circumference (p &amp;lt;0.001), longer tumor length (p &amp;lt;0.001), and no lymph node metastasis (p=0.024). There was no significant difference in relapse-free survival between the F. nucleatum-high group and F. nucleatum-low group among whole patients (p=0.53). Analyzing divided tumor location, in right-sided CRC high abundance of F. nucleatum was significantly associated with shorter relapse-free survival than low abundance (p=0.02), while in left-sided and rectal cancer there was no significant difference (p=0.61). Conclusion: F. nucleatum was more abundant in right-sided CRC and associated with relapse-free survival only in right-sided CRC. F. nucleatum may make a greater impact on right-sided CRC than on left-sided and rectal cancer. Citation Format: Toshimitsu Miyasaka, Takeshi Yamada, Sho Kuriyama, Akihisa Matsuda, Kay Uehara, Seiichi Shinji, Yasuyuki Yokoyama, Goro Takahashi, Takuma Iwai, Kohki Takeda, Shintaro Kanaka, Hiroshi Yoshida. The abundance of Fusobacteria nucleatum in tumor tissue is a prognostic factor in patients of right-sided colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6683.

Robotic-assisted surgery for left-sided colon and rectal resections is associated with reduction in the postoperative surgical stress response and improved short-term outcomes: a cohort study.

There is growing evidence that the use of robotic-assisted surgery (RAS) in colorectal cancer resections is associated with improved short-term outcomes when compared to laparoscopic surgery (LS) or open surgery (OS), possibly through a reduced systemic inflammatory response (SIR). Serum C-reactive protein (CRP) is a sensitive SIR biomarker and its utility in the early identification of post-operative complications has been validated in a variety of surgical procedures. There remains a paucity of studies characterising post-operative SIR in RAS. Retrospective study of a prospectively collected database of consecutive patients undergoing OS, LS and RAS for left-sided and rectal cancer in a single high-volume unit. Patient and disease characteristics, post-operative CRP levels, and clinical outcomes were reviewed, and their relationships explored within binary logistic regression and propensity scores matched models. A total of 1031 patients were included (483 OS, 376 LS, and 172 RAS). RAS and LS were associated with lower CRP levels across the first 4 post-operative days (p < 0.001) as well as reduced complications and length of stay compared to OS in unadjusted analyses. In binary logistic regression models, RAS was independently associated with lower CRP levels at Day 3 post-operatively (OR 0.35, 95% CI 0.21-0.59, p < 0.001) and a reduction in the rate of all complications (OR 0.39, 95% CI 0.26-0.56, p < 0.001) and major complications (OR 0.5, 95% CI 0.26-0.95, p = 0.036). Within a propensity scores matched model comparing LS versus RAS specifically, RAS was associated with lower post-operative CRP levels in the first two post-operative days, a lower proportion of patients with a CRP ≥ 150 mg/L at Day 3 (20.9% versus30.5%, p = 0.036) and a lower rate of all complications (34.7% versus 46.7%, p = 0.033). The present observational study shows that an RAS approach was associated with lower postoperative SIR, and a better postoperative complications profile.

Differences in Patterns of Care and Referral Between Proton and Photon Therapy

PurposeTo report demographic and clinical characteristics of patients who were more likely to receive proton beam therapy (PBT) than photon therapy from facilities with access to proton centers. Materials and MethodsWe utilized the national cancer database to identify the facilities with access to PBT between 2004 and 2015 and compared the relative usage of photons and PBT for demographic and clinical scenarios in breast, prostate, and nonsmall cell cancer. ResultsIn total, 231 facilities with access to proton centers accounted for 168 323 breast, 39 975 lung, and 77 297 prostate cancer patients treated definitively. Proton beam therapy was used in 0.5%, 1.5%, and 8.9% of breast, lung, and prostate cases. Proton beam therapy was correlated with a farther distance traveled and longer start time from diagnosis for each site (P < .05).For breast, demographic correlates of PBT were treatment in the west coast (odds ratio [OR] = 4.81), age <60 (OR = 1.25), white race (OR = 1.94), and metropolitan area (OR = 1.58). Left-sided cancers (OR = 1.28), N2 (OR = 1.71), non-ER+/PR+/Her2Neu− cancers (OR = 1.24), accelerated partial breast irradiation (OR = 1.98), and hypofractionation (OR = 2.35) were predictors of PBT.For nonsmall cell cancer, demographic correlates of PBT were treatment in the south (OR = 2.6), metropolitan area (OR = 1.72), and Medicare insurance (OR = 1.64). Higher comorbid score (OR = 1.36), later year treated (OR = 3.16), and hypofractionation (not SBRT) (OR = 3.7) were predictors of PBT.For prostate, correlates of PBT were treatment in the west coast (OR = 2.48), age <70 (OR = 1.19), white race (OR = 1.41), metropolitan area (OR = 1.25), higher income/education (OR = 1.25), and treatment at an academic center (OR = 33.94). Lower comorbidity score (OR = 1.42), later year treated (OR = 1.37), low-risk disease (OR = 1.45), definitive compared to postoperative (OR = 6.10), and conventional fractionation (OR = 1.64) were predictors of PBT. ConclusionEven for facilities with established referrals to proton centers, PBT utilization was low; socioeconomic status was potentially a factor. Proton beam therapy was more often used with left-sided breast and low-risk prostate cancers, without a clear clinical pattern in lung cancer.

Sidedness is not a prognostic factor in an unselected cohort of patients with colon cancer but prognosis for caecal carcinoma is worse – A multivariate analysis of a large single institution database

PurposeSidedness has emerged as a prognostic factor for metastatic colorectal cancer treated with modern systemic therapies. This study investigates whether it is also relevant for an unselected patient cohort including all stages.MethodsAll consecutive patients admitted with colon cancer between 1995 and 2018 were retrieved from an institution-held database. Patients were divided into two cohorts. The first cohort included patients without distant metastases who were able to undergo curative resection. The second cohort presented with distant metastases (stage IV). Potentially prognostic factors were subjected to multivariate Cox Regression analysis.ResultsOverall, 1,606 patients met the inclusion and exclusion criteria. An R0-resection was achieved in 1,222 patients without distant metastases. Five-year cause-specific survival rate was 89.3% for this group. There was no difference between right- and left-sided cancers (88.2% vs. 90.1%, p = 0.220). However, prognosis of caecal carcinoma was significantly worse than that of all other sites combined (83.5% vs. 90.2%, p = 0.007). In multivariate analysis, pT-category, pN-category, grading, vascular invasion, emergency operation, adjuvant chemotherapy, and caecal carcinoma remained as independent prognostic factors. In the 384 patients with stage IV-disease, 3-year overall survival for right- vs. left-sided cancers differed only in univariate analysis (17.7% vs. 28.6%, p = 0.013).ConclusionIn non-metastatic colon cancer, location in the caecum is an independent prognostic factor. In unselected patients with stage IV colon cancer, sidedness was not found to be a prognostic factor. Differentiation into right- and left-sided tumors may be simplistic, and further studies on the biological behavior of different colonic sites are warranted.