Local Recurrence Rate In Patients Research Articles

Does Neoadjuvant Chemoradiotherapy Have an Additional Effect to Lateral Pelvic Lymph Node Dissection for Rectal Cancer?

A total mesenteric excision (TME) with lateral pelvic lymph node dissection (LLND) is the standard treatment for advanced low rectal cancer in Japan. Recently, neoadjuvant (chemo)radiotherapy (n(C)RT) has been used with LLND to improve outcomes at multiple Japanese institutes. This study evaluates the benefits of adding nCRT to TME with LLND. Seventy-two consecutive patients who underwent TME and LLND with or without nCRT between 2006-2019 to treat advanced low rectal cancer were retrospectively reviewed. The clinicopathological data were compared and the risk factors for local recurrence were evaluated. Fifty-seven patients (79.1%) underwent TME and LLND with nCRT, and 15 patients (20.9%) without nCRT. There was no significant difference in the clinicopathological characteristics except the clinical T stage. The occurrence of postoperative complications was statistically insignificant. The 5-year local recurrence rate of patients with nCRT was significantly lower than those without (4.0% versus 26.6%, in all patients, p=0.002). Multivariate analysis revealed that the absence of nCRT was an independent risk factor for local recurrences in patients who underwent TME with LLND (hazard ratio: 6.04, p=0.04). The administration of nCRT prevented local recurrences more effectively in patients with advanced low rectal cancer who underwent TME with LLND.

Comparison of Endoscopic Submucosal Dissection With Endoscopic Mucosal Resection After Circumferential Precutting to Treat Gastric Adenomas ≤15 mm

Objectives: Endoscopic submucosal dissection (ESD) is a widely used approach for the resection of superficial gastric neoplastic lesions. Endoscopic mucosal resection (EMR) is acceptable for lesions <10–15 mm in size. Herein, we compared the clinical outcomes of ESD with those of EMR after circumferential precutting (EMR-P) for gastric adenomas ≤15 mm.Methods: We retrospectively analyzed the data of 213 patients with 228 gastric adenomas ≤15 mm in size who were treated endoscopically at a single tertiary hospital in Korea between November 2018 and October 2022. We evaluated the complete endoscopic resection rate, recurrence rate, procedurer-elated complications, and procedure time according to the procedure used.Results: Among the 228 gastric adenomas, 49 were treated with EMR-P and 179 with ESD. The histological complete resection rate was higher in the ESD group than in the EMR-P group (87% vs. 57%, <i>p</i><0.001). No significant between-group differences were observed in endoscopic en bloc resection rates (ESD vs. EMR-P, 96% vs. 90%; <i>p</i>=0.081). The procedure time was significantly shorter in the EMR-P group than in the ESD group (28.9±19.7 min vs. 8.8±5.9 min, <i>p</i><0.001). The local recurrence rate in patients with histologically incomplete resection did not differ between the two groups (ESD vs. EMR-P, 8.7% vs. 9.5%; <i>p</i>=0.924).Conclusions: For gastric adenomas ≤15 mm, EMR-P may be the preferable treatment method considering the en bloc resection rate, procedure time, and local recurrence rate. However, considering the complete resection rate, ESD is recommended as the treatment of choice for high-grade adenomas and early gastric cancer lesions.

Analysis of clinical factors impacting recurrence in myxofibrosarcoma

Myxofibrosarcoma (MFS) is a malignant fibroblastic/myofibroblastic neoplasm with a prominent myxoid area. It has the clinical features of frequent local recurrence (LR) and occasional distant metastasis. Robust epidemiological data on MFS in China are lacking. The aim of this retrospective analysis was to determine the natural history of MFS, identify prognostic factors for recurrence and describe the real-life outcomes of MFS. We reviewed 52 patients with primary MFS from the First Affiliated Hospital of Nanjing Medical University diagnosed between 2016 and 2020. All tumors were subjected to retrospective univariate analysis for prognostic factors of the disease, including tumor size, grade, location and sex; patient age; planned operation; surgical margin; and laboratory results. The significant factors identified by univariate analysis were subsequently analyzed via multivariate analysis. Overall survival (OS), post-treatment LR and metastatic-free survival were assessed as outcomes. The median age was 61 years (range, 13–93). Fourteen (26.92%) patients exhibited low grade disease, and 38 (73.08%) exhibited high grade disease. Among the 29 males, and 23 females, 15 (28.85%) had tumors in the trunk, 37 (71.15%) had tumors in the extremities, 26 had undergone planned surgery, and 26 had unexpected unplanned operation. The margin was negative in 39 (75%) patients and positive in 13 patients (25%). The serum creatine kinase (CK) concentration was high level in 33 (63.46%) patients and low level in 19 (36.54%) patients. The serum lactate dehydrogenase (LDH) levels were low in 23 (44.23%) patients and high in 29 (55.77%) patients. LR was observed in 25 patients (48.08%), and 4 patients developed metastasis. A worse LR rate was found for patients with a low CK level (84.21%) than for those with a high CK level (27.27%) at 5 years (p < 0.05). The LR rate of patients who underwent planned surgery was lower than that of patients who underwent unplanned surgery (p < 0.05). There were significantly more patients with positive margins than patients with negative margins (92.30%, and 33.33%, respectively; p < 0.05). Moreover, superficial tumors were also associated with greater recurrence rate (2/20 [10%]) than deep tumors, (23/32 [71.86%]) [p < 0.05]. The probability of LR in patients with MFS was significantly greater in association with unplanned operations, positive margins, low serum CK levels or superficial tumor depth. These data could help identify high-risk patients; thus, more careful follow-up should be performed for higher-risk patients. Diagnosis and treatment at qualified regular medical centers can reduce the local recurrence rate of MFS.

Comparison of En Bloc Resection and Intralesional Excision for Re-resection of Giant Cell Tumors of the Spine.

Re-resection of spinal giant cell tumors is an exceedingly difficult procedure. Moreover, the prognosis of patients with en bloc resection or intralesional excision for re-resection has rarely been reported. This study aimed to compare the prognostic value of en bloc resection with that of intralesional excision in patients undergoing re-resection for giant cell tumors of the spine. This retrospective analysis evaluated patients who underwent revision surgeries for relapse of giant cell tumors of the spine at our center between January 2005 and January 2021. Local progression-free survival represents the duration between en bloc resection or intralesional excision and tumor recurrence. Neurological recovery, survival rates, local control, and complications were evaluated. The Kaplan-Meier estimator was used for survival analysis. A total of 22 patients (nine men and 13 women) with a mean age of 34.1 (range 19-63) years were included. Significant statistical differences were found in the local tumor recurrence rate between patients treated with en bloc resection and those treated with intralesional excision (p < 0.05). The 5- and 10-year local progression-free survival rates were both 90% in the en bloc resection group, while in the intralesional excision group, the 5-year local progression-free survival rate was 80% with a 10-year rate of 45.7%. The en bloc resection group had a lower local tumor recurrence rate than that of the intralesional excision group (p < 0.05), but the former had a higher rate of complications (p = 0.015). This study revealed a low local recurrence rate in patients who underwent en bloc resection for giant cell tumors, while the perioperative complication rate was high.

Oncologic Safety of Close Margins in Patients With Low- to Intermediate-Grade Major Salivary Gland Carcinoma

Postoperative radiation therapy for close surgical margins in low- to intermediate-grade salivary carcinomas lacks multi-institutional supportive evidence. To evaluate the oncologic outcomes for low- and intermediate-grade salivary carcinomas with close and positive margins. The American Head and Neck Society Salivary Gland Section conducted a retrospective cohort study from 2010 to 2019 at 41 centers. Margins were classified as R0 (negative), R1 (microscopically positive), or R2 (macroscopically positive). R0 margins were subclassified into clear (>1 mm) or close (≤1 mm). Data analysis was performed from June to October 2023. Main outcomes were risk factors for local recurrence. A total of 865 patients (median [IQR] age at surgery, 56 [43-66] years; 553 female individuals [64%] and 312 male individuals [36%]) were included. Of these, 801 (93%) had parotid carcinoma and 64 (7%) had submandibular gland carcinoma, and 748 (86%) had low-grade tumors and 117 (14%) had intermediate-grade tumors, with the following surgical margins: R0 in 673 (78%), R1 in 168 (19%), and R2 in 24 (3%). Close margins were found in 395 of 499 patients with R0 margins (79%), for whom margin distances were measured. A total of 305 patients (35%) underwent postoperative radiation therapy. Of all 865 patients, 35 (4%) had local recurrence with a median (IQR) follow-up of 35.3 (13.9-59.1) months. In patients with close margins as the sole risk factor for recurrence, the local recurrence rates were similar between those who underwent postoperative radiation therapy (0 of 46) or observation (4 of 165 [2%]). Patients with clear margins (n = 104) had no recurrences. The local recurrence rate in patients with R1 or R2 margins was better in those irradiated (2 of 128 [2%]) compared to observed (13 of 64 [20%]) (hazard ratio [HR], 0.05; 95% CI, 0.01-0.24). Multivariable analysis for local recurrence found the following independent factors: age at diagnosis (HR for a 10-year increase in age, 1.33; 95% CI, 1.06-1.67), R1 vs R0 (HR, 5.21; 95% CI, 2.58-10.54), lymphovascular invasion (HR, 4.47; 95% CI, 1.43-13.99), and postoperative radiation therapy (HR, 0.10; 95% CI, 0.04-0.29). The 3-year local recurrence-free survivals for the study population were 96% vs 97% in the close margin group. In this cohort study of patients with low- and intermediate-grade major salivary gland carcinoma, postoperative radiation therapy for positive margins was associated with decreased risk of local recurrence. In isolation from other risk factors for local recurrence, select patients with close surgical margins (≤1 mm) may safely be considered for observation.

Are Pathologic Fractures in Patients With Osteosarcoma Associated With Worse Survival Outcomes? A Systematic Review and Meta-analysis.

Pathologic fractures occur in 5% to 10% of patients with osteosarcoma, and prior studies have suggested they are prognostically important. However, because they represent an uncommon event in the setting of an already rare disease, most studies fail to reach conclusive findings, and there is no agreement about how best to treat pathologic fractures. (1) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer overall survivorship? (2) Is the occurrence of a pathologic fracture in patients with osteosarcoma associated with poorer local recurrence-free survival or metastasis-free survival? (3) Is the surgical approach (amputation or limb salvage) associated with differences in local recurrence rates in patients with osteosarcoma with pathologic fractures? This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our study was registered in PROSPERO (ID: 380459). A search of the PubMed and Embase databases resulted in 625 and 747 titles, respectively. After application of the inclusion and exclusion criteria, 21 articles were finally included. Quality assessment of all studies was performed using the Newcastle-Ottawa Quality Assessment Scale. The Risk of Bias In Non-Randomized Studies of Interventions tool was used in the 11 articles that evaluated the effect of an intervention (amputation or limb salvage) on local recurrence rates. The relative risk (RR) was calculated to compare outcomes in patients with osteosarcoma with pathologic fractures and those without. Heterogeneity among studies was calculated using the I 2 statistic. The pooled RR was calculated using the fixed-effects or random-effects model depending on study heterogeneity. The fragility index and the ratio between the fragility index and the total number of participants for each outcome was additionally calculated to assess the robustness of our results. A total of 7604 patients with osteosarcoma, 12% of whom (885) had pathologic fractures, were included in our analysis. Pathologic fractures in patients with osteosarcoma were associated with lower 3-year (RR 1.53 [95% CI 1.29 to 1.82]; p < 0.001) and 5-year overall survival (RR 1.27 [95% CI 1.16 to 1.40]; p < 0.001). No difference in recurrence rates was found between patients with osteosarcoma with pathologic fractures and those without (RR 1.22 [95% CI 0.91 to 1.64]; p = 0.18). However, having a pathologic fracture was associated with an increased risk of developing metastasis (RR 1.33 [95% CI 1.08 to 1.63]; p = 0.01). Treatment with limb salvage surgery was not associated with a higher rate of local recurrence (RR 1.58 [95% CI 0.88 to 2.85]; p = 0.13). In light of these findings, surgeons should be aware that after appropriate case selection, patients with osteosarcoma and pathologic fractures undergoing limb salvage surgery may have similar rates of local recurrence to those undergoing amputation. Therefore, a pathologic fracture may no longer be an absolute contraindication for limb salvage surgery. Future studies adjusting for potential confounders such as tumor size, tumor location, and response to neoadjuvant therapy would provide further insight into the effect of pathologic fractures on our assessed outcomes. Level III, therapeutic study.

Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance).

Breast-conserving therapy (BCT) is the preferred treatment for unifocal breast cancer (BC). The oncologic safety of BCT for multiple ipsilateral breast cancer (MIBC) has not been demonstrated in a prospective study. ACOSOG Z11102 (Alliance) is a phase II, single-arm, prospective trial designed to evaluate oncologic outcomes in patients undergoing BCT for MIBC. Women age 40 years and older with two to three foci of biopsy-proven cN0-1 BC were eligible. Patients underwent lumpectomies with negative margins followed by whole breast radiation with boost to all lumpectomy beds. The primary end point was cumulative incidence of local recurrence (LR) at 5 years with an a priori rate of clinical acceptability of <8%. Among 270 women enrolled between November 2012 and August 2016, there were 204 eligible patients who underwent protocol-directed BCT. The median age was 61 years (range, 40-87 years). At a median follow-up of 66.4 months (range, 1.3-90.6 months), six patients developed LR for an estimated 5-year cumulative incidence of LR of 3.1% (95% CI, 1.3 to 6.4). Patient age, number of sites of preoperative biopsy-proven BC, estrogen receptor status and human epidermal growth factor receptor 2 status, and pathologic T and N categories were not associated with LR risk. Exploratory analysis showed that the 5-year LR rate in patients without preoperative magnetic resonance imaging (MRI; n = 15) was 22.6% compared with 1.7% in patients with a preoperative MRI (n = 189; P = .002). The Z11102 clinical trial demonstrates that breast-conserving surgery with adjuvant radiation that includes lumpectomy site boosts yields an acceptably low 5-year LR rate for MIBC. This evidence supports BCT as a reasonable surgical option for women with two to three ipsilateral foci, particularly among patients with disease evaluated with preoperative breast MRI.

Wide margin vs. narrow margin in post-neoadjuvant lumpectomy

Background: Primary systemic (neoadjuvant) therapy (NAT) is a widely practiced curative treatment for invasive breast cancer. Neoadjuvant chemotherapy (before surgery) and adjuvant chemotherapy (after surgery) had equivalent survival rates in major randomized trials. In these studies, preoperative systemic therapy increased the patient's chance to achieve breast conservation. The downside was a clear trend towards increased ipsilateral breast tumor recurrence. Preoperative chemotherapy leads to patchy, irregular cell death known as the honeycomb effect and thus may lead to a misleading false-negative resection margin of a tumorectomy operation. Even with the advent of oncoplastic techniques which allowed larger resection volumes with satisfactory cosmetic results, rates of re-excision, mastectomy, and local relapse did not differ from those after traditional lumpectomy operations. As of today, there is no consensus -based on evidence- on the optimal width of margin in patients who are offered breast conservative surgery (BCS) after systemic therapy. In view of the current uncertainty and lack of evidence, The present trial is designed to answer the following question (Specific aim): Does planning the resection margin according to the pre-treatment tumor extent improve the local recurrence rate in patients receiving breast conservative surgery after systemic therapy?.

Robotic pelvic side-wall dissection and en-bloc excision for locally advanced and recurrent rectal cancer: outcomes on feasibility and safety.

Global differences exist in managing lateral pelvic nodes in rectal cancer. Recent studies demonstrate improved local recurrence rates in patients undergoing lateral pelvic lymph node dissections (LPND) in addition to total mesorectal excision (TME) for advanced lower rectal cancer. This study aims to report on the safety and feasibility of the robotic approach in patients undergoing pelvic sidewall lymph node dissection or en-bloc sidewall resection for advanced lower rectal cancer. Patients who underwent an elective robotic pelvic sidewall lymph node dissection or en-bloc sidewall resection for locally advanced rectal cancer with suspicious lateral lymph nodes or pelvic side wall involvement between January 2018 and March 2021 were included. Demographic, clinical, perioperative and histopathological variables were recorded and analysed. Eight patients (3 males) with a mean age of 55 (33-73) years and mean body mass index of 26.3 (20.7-30.0) kg/m2 were included. The median operative time and blood loss were 458.75 (360-540) min and 143.75 (100-300) mL, respectively. There were no conversions or intra-operative complications. There were three post-operative complications recorded (two ileus and one anastomotic leak which required an endoscopic washout in theatre and intravenous antibiotics thereafter). Median length of stay was 12.75 (7-23) days. All patients had an R0 resection, and the median lateral pelvic lymph node yield was 9.1 (6-14). This series demonstrates the practicality and the safety of the robotic approach in the introduction of this technique for en-bloc resection or LPND in patients with locally advanced rectal cancer.

Local recurrence rate in women with breast cancer submitted to conservative surgery and adjuvant radiotherapy / Taxa de recidiva local em mulheres com cancro da mama submetidas a cirurgia conservadora e radioterapia adjuvante

ABSTRACTTo evaluate the local recurrence rate in women treated with conservative surgery followed by breast irradiation. Methodology: Retrospectively selected female patients between 20 and 80 years old, who performed chemotherapy and or/radiotherapy as adjuvant treatment for breast-sparing surgery (quadrantectomy) for initial clinical stages until IIa. Result: Of the 58 patients selected 31 women were subjected to chemotherapy followed by radiotherapy, 25 women were subjected to exclusive radiotherapy, 1 women subjected to exclusive chemotherapy and 1 women subjected to radiotherapy followed by chemotherapy. The recurrence rate independent of the therapeutic modality used was 12.06%. 71.4% of relapses were at a distance and 28.6% local. Two women presented a local relapse. The local recurrence rate independent of the therapeutic modality used was 3.4%. 1 women subjected to exclusive radiotherapy presented local recurrence. 1 women subjected to radiotherapy followed by chemotherapy presented local recurrence. The local recurrence rate for patients subjected to exclusive radiotherapy was 4%. No women subjected to chemotherapy followed by radiotherapy presented local recurrence. Discussion: The patient who presented recurrence has a death risk 7.93 (IC95% 1,98-31,75; p = 0.003) times greater than the patient who did not present. The global survival in 5 years for patients subjected to isolated radiotherapy versus chemotherapy followed by radiotherapy was 96% x 90.3% (p = ns).

Prognostic significance of lateral pelvic lymph node dissection for middle-low rectal cancer patients with lateral pelvic lymph node metastasis: a propensity score matching study

BackgroundThere is still controversy regarding the clinical value and significance of lateral pelvic lymph node (LPN) dissection (LPND). The present study aimed to investigate whether the addition of LPND to total mesorectal excision (TME) confers survival benefits in rectal cancer patients with clinical lateral pelvic node metastasis (LPNM).MethodsFrom January 2015 to January 2021, a total of 141 rectal cancer patients with clinical evidence of LPNM who underwent TME + LPND were retrospectively analysed and divided into the LPNM group (n = 29) and the non-LPNM group (n = 112). The LPNM group was further subdivided into a high-risk LPNM group (n = 14) and a low-risk LPNM group (n = 15). Propensity score matching (PSM) was performed to minimize selection bias. The primary outcomes of this study were 3-year overall survival (OS) and disease-free survival (DFS).ResultsOf the 141 patients undergoing LPND, the local recurrence rate of patients with LPNM was significantly higher than that of patients without LPNM both before (27.6% vs. 4.5%, P = 0.001) and after (27.6% vs. 3.4%, P = 0.025) PSM. Multivariate analysis revealed that LPNM was an independent risk factor for not only OS (HR: 3.06; 95% CI, 1.15–8.17; P = 0.025) but also DFS (HR: 2.39; 95% CI, 1.18–4.87; P = 0.016) in patients with LPNM after TME + LPND. When the LPNM group was further subdivided, multivariate logistic regression analysis showed that OS and DFS were significantly better in the low-risk group (obturator/internal iliac artery region and < 2 positive LPNs).ConclusionEven after LPND, LPNM patients have a poor prognosis. Moreover, LPNM is an independent poor prognostic factor affecting OS and DFS after TME + LPND. However, LPND appears to confer survival benefits to specific patients with single LPN involvement in the obturator region or internal iliac vessel region. Furthermore, LPND may have no indication in stage IV patients and should be selected carefully.

The survival impact of preoperative FOLFOX for resectable locally advanced rectal cancer: the R-NAC-01 study

In this follow-up of the R-NAC-01 study, we assessed the long-term oncological benefit of four courses of modified leucovorin, 5-fluorouracil (FU), and oxaliplatin (mFOLFOX6) chemotherapy before rectal surgery. In this prospective, multicenter study (UMIN 000012559) involving 11 hospitals in Japan, patients with lower rectal cancer underwent four cycles of mFOLFOX6 chemotherapy and subsequent surgery within four to six weeks. The 3-year recurrence-free survival and local recurrence rates were then reported. Of 41 patients (36 males, 5 females; mean age: 60.8years old) who received 4 courses of chemotherapy, 40 underwent total mesorectal excision, and 1 underwent total pelvic exenteration. R0 resection was achieved in 40 patients, but none showed a pathological complete response. Twenty-nine patients received adjuvant chemotherapy for an average of 4months. The 3year recurrence-free survival and local recurrence rates in patients undergoing curable resection were 72.8% and 8.5%, respectively. cStage III patients with adjuvant chemotherapy had a significantly higher 3year recurrence-free survival than those without adjuvant chemotherapy (76.6 vs. 40.0%, log-rank p = 0.03). Four courses of mFOLFOX6 chemotherapy before surgery may be a promising treatment strategy for locally advanced rectal cancer. Adjuvant chemotherapy might be needed for cStage III patients, even after four courses of neoadjuvant mFOLFOX6.

Preoperative Decision to Perform Portal Vein Resection Improves Survival in Patients with Resectable Pancreatic Head Cancer Adjacent to Portal Vein

Introduction: We hypothesized that preoperatively planned portal vein resection (PVR), which prevents from approaching tumors, improves survival in patients with resectable pancreatic head cancer adjacent to the portal vein (PhC-PV). The decision to perform PVR is difficult in patients with resectable PhC-PV. Methods: This is a retrospective, bi-institutional study of patients undergoing pancreatoduodenectomy (PD) for resectable PhC-PV from 2009 to 2018. We compared clinical data of patients who underwent PD with preoperatively planned PVR (planned PVR group) and those who underwent conventional PD (cPD) in which decision to perform PVR was made intraoperatively (cPD group). Results: Among the study population of 176 patients, 53 patients (30.1 %) underwent PD with planned PVR. The remaining 123 patients (69.9%) underwent cPD. Tumor characteristics were similar between the two groups. Operation time and major complication rates did not differ between the two groups. The local recurrence rate of patients in the planned PVR group (28.3%) was lower than that of the cPD group (44.7 %, p = 0.041). Median overall survival (OS) was longer in the planned PVR group than in the cPD group (32 months vs. 27 months, p = 0.011). Multivariate analysis revealed that having undergone planned PVR was an independent factor for favorable OS (hazard ratio 1.65; 95% confidence interval 1.08–2.61; p = 0.021). Conclusions: The preoperative decision to perform PVR improves survival by enhancing local control of resectable pancreatic head cancer adjacent to the PV.

Impact of the distal resection margin on local recurrence after neoadjuvant chemoradiation and rectal excision for locally advanced rectal cancer

We aimed to evaluate whether a short distal resection margin (< 1 cm) was associated with local recurrence in patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy. Patients with rectal cancer who underwent preoperative chemoradiotherapy followed by curative surgery were divided into two groups based on the distal resection margin (≥ 1 cm and < 1 cm). In total, 507 patients were analyzed. The median follow-up duration was 48.9 months. The 3-year local recurrence rates were 2% and 8% in the ≥ 1 cm and < 1 cm groups, respectively (P < 0.001). Multivariable analysis revealed that a distal resection margin of < 1 cm was a significant risk factor for local recurrence (P = 0.008). Subgroup analysis revealed that a distal resection margin of < 1 cm was not an independent risk factor for local recurrence in the ypT0–1 group. However, among patients with tumor stages ypT2–4, the cumulative 3-year incidences of local recurrence were 2.3% and 9.8% in the ≥ 1 cm and < 1 cm groups, respectively (P = 0.01). A distal resection margin of < 1 cm might influence local recurrence rates in patients with locally advanced rectal cancer undergoing preoperative chemoradiotherapy, especially in patients with tumor stages ypT2–4.

The importance of clear margins in myxofibrosarcoma: Improving local control by means of staged resection and reconstruction

IntroductionMyxofibrosarcomas are associated with a locally infiltrative growth pattern, making a clear-margin resection margin challenging. This leads to high local recurrence rates. While immediate wound closure and adjuvant radiotherapy has been proposed to mitigate incomplete excisions, we present our experience treating myxofibrosarcomas with staged excisions until clear margins are obtained, prior to reconstruction. MethodsAll patients with myxofibrosarcomas treated with a curative intent at our centre between 2009 and 2019 were identified. Patient demographics, tumour characteristics, number of resections, method of reconstruction, adjuvant therapy, complications, local recurrence rates, length of hospital stay and overall survival were assessed. Results97 consecutive eligible patients were identified. Forty-six (47%) had positive margins reported following a first resection. The median number of resections required to obtain clear margins was two and the median time from first excision to definitive wound closure was 15 days. Local recurrence rate for the whole cohort was 14%. Patients who had staged resection until clear margins were obtained had a significantly lower rate of local recurrence compared to those who had positive margins at time of reconstruction (p-value = 0.001). The estimated 5-year disease-specific survival for the whole cohort was 93%. DiscussionObtaining clear margins in myxofibrosarcoma via staged resections was associated with lower local recurrence rates for patients who had an initial resection with positive margins. The outcomes of performing staged resections are equivalent to patients for whom a clear margin were obtained in the first instance.

Influence of surgical site infection on oncological prognosis after curative resection for colorectal cancer: An observational single-institution study.

An exacerbated inflammatory response to post-operative infection could favor an environment in which residual viable tumor cells present in the surgical bed, bloodstream, or occult micrometastases can survive and progress to produce local or distant recurrence. In this regard, a surgical site infection (SSI) could be an important risk factor for disease progression. This study aimed to investigate the impact of SSI on long-term survival and recurrence of colorectal cancer. Patients who underwent curative-intent resection for colorectal carcinoma between 2011 and 2013 were retrospectively analyzed. Overall and disease-free survival (DFS) and local recurrence rate for patients with and without SSI were analyzed. One hundred and thirty-eight patients were included in the study. Fifty-one (37%) patients showed SSI but revealed no differences in recurrence rate and overall survival compared with non-infected patients. However, the stratified analysis revealed that patients with an intra-abdominal abscess or an organ-space-infection showed a higher recurrence rate and a decreased 5-year overall and DFS. SSI may have an influence on the oncological prognosis and, therefore, could be considered a recurrence factor. Further multi-institutional studies are necessary to conclude a causal association.

Preoperative Decision to Perform Portal Vein Resection Improves Survival in Patients With Resectable Pancreatic Head Cancer Adjacent to Portal Vein.

We hypothesized that preoperatively planned portal vein resection (PVR), which prevents from approaching tumors, improves survival in patients with resectable pancreatic head cancer adjacent to the portal vein (PhC-PV). The decision to perform PVR is difficult in patients with resectable PhC-PV. This is a retrospective, bi-institutional study of patients undergoing pancreatoduodenectomy (PD) for resectable PhC-PV from 2009 to 2018. We compared clinical data of patients who underwent PD with preoperatively planned PVR (planned PVR group) and those who underwent conventional PD (cPD) in which decision to perform PVR was made intraoperatively (cPD group). Among the study population of 176 patients, 53 patients (30.1%) underwent PD with planned PVR. The remaining 123 patients (69.9%) underwent cPD. Tumor characteristics were similar between the 2 groups. Operation time and major complication rates did not differ between the 2 groups. The local recurrence rate of patients in the planned PVR group (28.3%) was lower than that of the cPD group (44.7%; P = 0.041). Median overall survival (OS) was longer in the planned PVR group than in the cPD group (32 vs 27 months; P = 0.011). Multivariate analysis revealed that having undergone planned PVR was an independent factor for favorable OS (hazard ratio = 1.65; 95% confidence interval = 1.08-2.61; P = 0.021). The preoperative decision to perform PVR improves survival by enhancing local control of resectable PhC-PV.

A Modified Technique of Laparoscopic Lateral Lymph Node Dissection Combining Fascia-Oriented Dissection and Routine Upfront Distal Visceral Vessels Ligation for Mid- to Low-Lying Rectal Cancer.

Lateral pelvic recurrence can be a cause of local failure after surgery for low rectal cancer. Lateral lymph node dissection is often performed in East Asia for patients with enlarged lateral lymph nodes or because of the presence of risk factors. However, the outcomes of the conventional lateral lymph node dissection are unsatisfactory, with a considerably high local recurrence rate for patients with positive lateral nodes. Here, we introduce a modified technique to improve lateral nodes clearance. This modified technique has 4 key steps: 1) separation of the ureterohypogastric nerve fascia medially, 2) identification of the visceral pelvic fascia and dissection along the inferior vesical or vaginal veins down to the pelvic floor, 3) division of the distal ends of visceral vessels according to the orientation of ureterohypogastric nerve fascia and visceral pelvic fascia for better nerve preservation, and 4) en bloc dissection through a lateral approach over the surfaces of the sacral plexus and piriformis muscle to reveal the course of distal internal iliac vessels before the division of visceral veins. Twenty-nine patients underwent laparoscopic lateral lymph node dissection successively with no conversion. The median blood loss for each lateral procedure was 37.5 mL (range, 0-300.0 mL). Eleven lateral nodes (median; range, 1-22 lateral nodes) were harvested for each lateral side. There was no perioperative mortality, and 4 patients developed major complications (Clavien-Dindo III-IV). This modified technique characterized by the routine division of visceral vessels based on ureterohypogastric nerve fascia and visceral pelvic fascia is feasible and safe. It provides good lymph node harvest, autonomic nerve preservation, and improved bleeding control. Additional investigation is warranted to evaluate the safety, functional outcomes, and oncologic outcomes.

Preoperative Denosumab may increase the Risk of Local Recurrence of Giant-cell Tumor of Bone Treated with Curettage: A Systematic Review and Meta-analysis.

Objective: This systematic review and meta-analysis aimed to determine the effect of preoperative denosumab on the local recurrence of giant-cell tumor of bone (GCTB) treated with curettage.Methods: PubMed, Embase, Cochrane Library, and Web of Science were comprehensively searched. The following data were analyzed using meta-analysis: local recurrence rate of patients receiving denosumab followed by curettage (denosumab group), local recurrence rate of patients receiving curettage only (control group), and a comparison of the local recurrence rates of the two groups.Results: Nine studies that contained 672 patients with GCTB were included in this review. Patients in the denosumab group (preoperative denosumab followed by curettage) had a higher risk of local recurrence compared with those in the control group (curettage only) (odds ratio = 3.04, 95% confidence interval = 1.48-6.22, P < 0.01). The association between preoperative denosumab and local recurrence remained significant in most of the subgroup analyses, except for those with sample sizes < 59 (P = 0.09), sacral GCTB (P = 0.42), and usage of postoperative denosumab (P = 0.38).Conclusions: Preoperative denosumab may increase the risk of local recurrence of GCTB treated with curettage and should be used with caution in the management of GCTB.

Lateral lymph node dissection reduces local recurrence of locally advanced lower rectal cancer in the absence of preoperative neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

BackgroundThe impact of lateral lymph node dissection (LLND) in locally advanced lower rectal cancer remains controversial. This study is to compare total mesorectal excision (TME) with or without LLND in lower rectal cancer cases of stage II/III.MethodsThe electronic databases were systematically searched that compared TME with or without LLND among patients with lower rectal cancer in clinical stage II/III. Subgroup analysis was performed considering neoadjuvant chemoradiotherapy (nCRT). The hazard ratios (HR), relative risk (RR), and weighted mean difference (WMD) were pooled.ResultsTwelve studies of 4458 patients of this meta-analysis demonstrate, LLND alone significantly reduced the local recurrence rate of patients who did not receive nCRT (RR 0.71, P = 0.004), while the difference was not significant when combined with nCRT (RR 0.70, P = 0.36). The analysis shows TME with LLND was associated with significantly longer operation time (WMD 90.73 min, P < 0.001), more intraoperative blood loss (WMD 303.20 mL, P < 0.001), and postoperative complications (RR = 1.35, P =0.02). Whereas urinary dysfunction (RR 1.44, P = 0.38), sexual dysfunction (RR 1.41, P = 0.17), and postoperative mortality (RR = 1.52, P = 0.70), were similar between these two groups. Statistically, no significant differences were observed in OS (HR 0.93, P = 0.62), DFS (HR 0.99, P = 0.96), total recurrence (RR 0.98, P = 0.83), lateral recurrence (RR 0.49, P = 0.14), or distal recurrence (RR 0.95, P = 0.78) between these two groups regardless of whether nCRT was performed or not.ConclusionsThe study shows LLND alone decreases the local recurrence without using nCRT irrespective of the survival advantage in locally advanced lower rectal cancer. The benefit of controlling local recurrence by LLND alone makes us reconsider the usage of nCRT with LLND.Trial registrationThe protocol for this meta-analysis was registered prospectively with PROSPERO (CRD42020135575) on 16 May 2019.