Macroscopic Complete Resection Research Articles

Improving outcomes of surgery in advanced infiltrative thymic tumours: the benefits of multidisciplinary approach.

Background:For stage III or IVa thymic tumours, a multimodality approach is recommended. The role of surgery is to achieve complete resection.Aim:To present the outcomes of patients undergoing surgery for stage III or IVa thymoma.Methods:Retrospective review of patients undergoing open surgery for stage III or IVa thymoma between 2016 and 2020 at a single centre was performed. Preoperative imaging, treatment plan, surgical approach, and postoperative outcomes were analyzed.Results:Forty-seven patients underwent surgery for thymoma. Patients with clinical stage I/II thymoma or minimally invasive thymectomy were excluded. Thirteen patients with clinical stage III or IVa were included. Median sternotomy approach was used in four patients, of which one was redo sternotomy; a hemi-clamshell in four; and a combination of approaches in the remaining five patients. There was no postoperative mortality. Four patients had postoperative complications. Complete resection was achieved in all but two patients. At a median follow-up of 17.9 months, all patients were alive with no evidence of recurrence except one who died 4 months after surgery from coronavirus disease 2019 (COVID-19) pneumonia.Conclusions:Surgery for stage III and IVa thymoma is safe and can be achieved with complete macroscopic resection. To obtain adequate exposure of all structures involved in the tumour, combined surgical approaches can be used with no increased morbidity. The majority of patients, even after extrapleural pneumonectomy, did not receive adjuvant radiotherapy and had no evidence of local relapse.

Surgery for recurrent thymoma during the COVID-19 pandemic: a narrative review.

Patients who have undergone surgical resection of thymoma may present later with recurrence of disease. This is most commonly in the pleural cavity. Surgery for recurrent thymoma has been shown to have a survival advantage. During the COVID-19 pandemic, there has been a reduction in capacity for routine healthcare provision. We present the outcomes of patients undergoing surgery for recurrent thymoma during the COVID-19 pandemic and our protocols to allow surgery to be performed during this time. Retrospective review of patients undergoing surgery for recurrent thymoma between March 2020 and the March 2021 at a single centre was performed. Preoperative demographic data, postoperative outcomes and the incidence of complications or postoperative COVID-19 infection were assessed. Over a 4-year period, and under the care of a single surgeon, 7 operations were performed for recurrent thymoma. Of these, three patients were operated during the COVID-19 pandemic. All patients had a history of myasthenia gravis (MG) and all patients presented with disease recurrence in the pleural cavity. No patients had post-operative complications and no patients tested positive for COVID-19 in the pre or postoperative period. Complete macroscopic resection was achieved in all patients. Surgery for recurrent thymoma can be performed safely and complete macroscopic resection can be achieved. It is possible to offer surgery with low risk of perioperative COVID infection and related morbidity and mortality. Given the benefits seen in survival and disease-free survival, we believe surgery for recurrent thymoma should continue to be advocated even during the current viral pandemic.

Surgical Management and Reconstruction of Diaphragm, Pericardium and Chest Wall in Mesothelioma Surgery: A Review.

Mesothelioma is an aggressive disease arising from parietal pleura. Surgery is a valuable option in the frame of a multimodality treatment. Several surgical approaches have been standardized with the aim of a macroscopic complete resection; these often require homolateral diaphragm and pericardial resection and reconstruction. Extrapleural pneumonectomy (EPP) and extended pleurectomy decortication (EPD) have been recognized as radical surgical procedures. Nevertheless, both operations are technically challenging and associated with a significant rate of peri-operative morbidity and non-negligible mortality. The diaphragmatic and pericardial reconstruction technique is mandatory to avoid respiratory impairment and to reduce post-operative complications like gastric and cardiac herniation. Moreover, in the case of localized chest wall recurrence, surgery might be considered a valuable therapeutical option for highly selected and fit patients. All the technical aspects of the resection and reconstruction of the diaphragm, pericardium, and chest wall are described as well as the possible use of new minimally invasive techniques. In addition, the choice of different prosthetic materials, considering the most recent innovations in the field, are discussed.

Non-incisional pleurectomy/decortication for malignant pleural mesothelioma.

Pleurectomy/decortication has been preferably employed as a curative-intent surgery for malignant pleural mesothelioma. However, visceral pleurectomy during pleurectomy/decortication provides technical challenges. For visceral pleurectomy, pleural incisions are commonly made to create a dissection plane between the visceral pleura and the lung parenchyma, which may cause tumor dissemination and may not allow en bloc complete resection of the entire pleura. To overcome such potential disadvantages, we have developed a novel surgical technique without any pleural incision (non-incisional pleurectomy/decortication) to achieve en bloc removal of the entire pleura. A total of 36 consecutive patients who underwent non-incisional pleurectomy/decortication for malignant pleural mesothelioma from January 2017 through December 2020 in our institute were retrospectively reviewed to assess the feasibility. Macroscopic complete resection was achieved in 31 patients (86.1%) with non-incisional pleurectomy/decortication. In the majority of patients (n = 29), en bloc complete resection of the entire pleura was achieved (without pleural laceration in 10 and with some pleural laceration in 19 patients). The total operation time and the duration of visceral pleurectomy were significantly shorter as compared with those for conventional pleurectomy/decortication (median, 350 versus 506min [P = 0.011], and 43 versus 97 min [P < 0.001], respectively). Among 36 patients who underwent non-incisional pleurectomy/decortication, postoperative complications developed in 13 patients (36.1%), and one patient died on the postoperative day 95 caused by aggressive tumor progression of residual tumor. Non-incisional pleurectomy/decortication is a fast and feasible technique to achieve en bloc macroscopic complete resection for malignant pleural mesothelioma.

Extrapleural Pneumonectomy Versus Pleurectomy/Decortication for Malignant Pleural Mesothelioma

BackgroundWhether extrapleural pneumonectomy (EPP) or extended pleurectomy/decortication (P/D) is the optimal resection for malignant pleural mesothelioma remains controversial. We therefore compared perioperative outcomes and long-term survival of patients who underwent EPP versus P/D. MethodsPatients with the diagnosis of malignant pleural mesothelioma who underwent either EPP or P/D from 2000 to 2019 were identified from our departmental database. Propensity score matching was performed to minimize potential confounders for EPP or P/D. Survival analysis was performed by the Kaplan-Meier method and Cox multivariable analysis. ResultsOf 282 patients, 187 (66%) underwent EPP and 95 (34%) P/D. Even with propensity score matching, perioperative mortality was significantly higher for EPP than for P/D (11% vs 0%; P = .031); when adjusted for perioperative mortality, median overall survival between EPP and P/D was 15 versus 22 months, respectively (P = .276). Cox multivariable analysis for the matched cohort identified epithelioid histology (hazard ratio [HR], 0.56; P = .029), macroscopic complete resection (HR, 0.41; P = .004), adjuvant radiation therapy (HR, 0.57; P = .019), and more recent operative years (HR, 0.93; P = .011)—but not P/D—to be associated with better survival. Asbestos exposure (HR, 2.35; P = .003) and pathologic nodal disease (HR, 1.61; P = .048) were associated with worse survival. ConclusionsIn a multimodality treatment setting, P/D and EPP had comparable long-term oncologic outcomes, although P/D had much lower perioperative mortality. The goal of surgical cytoreduction should be macroscopic complete resection achieved by the safest operation a patient can tolerate.

Relapse Patterns and Tailored Treatment Strategies for Malignant Pleural Mesothelioma Recurrence after Multimodality Therapy.

To date, there have been no established therapies for recurrent malignant pleural mesothelioma (MPM) after multimodality treatment. Aims of this retrospective study are to analyze the recurrence pattern, its treatment and to identify the predictors of best oncological outcomes for relapsed MPM, comparing extrapleural pneumonectomy (EPP) vs. pleurectomy/decortication (PD). Study population: 94 patients with recurrence of MPM after multimodality treatment underwent macroscopic complete resection (52.1% with EPP and 47.9% with PD) between July 1994 and February 2020. Distant spread was the most frequent pattern of recurrence (71.3%), mostly in the EPP group, while the PD group showed a higher local-only failure rate. Post-recurrence treatment was administered in 86.2%, whereas best supportive care was administered in 13.8%. Median post-recurrence survival (PRS) was 12 months (EPP 14 vs. PD 8 months, p = 0.4338). At multivariate analysis, predictors of best PRS were epithelial histology (p = 0.026, HR 0.491, IC95% 0.263–0.916), local failure (p = 0.027, HR 0.707, IC95% 0.521–0.961), DFS ≥ 12 months (p = 0.006, HR 0.298, IC95% 0.137–0.812) and post-recurrence medical treatment (p = 0.046, HR 0.101, IC95% 0.897–0.936). The type of surgical intervention seems not to influence the PRS if patients are fit enough to face post-recurrence treatments. In patients with a prolonged disease-free interval, in the case of recurrence the most appropriate treatment seems to be the systemic medical therapy, even in the case of local-only relapse.

P25.02 Lymph Node Metastasis of Malignant Pleural Mesothelioma

Lymph node dissections and its efficacy are not well defined in malignant pleural mesothelioma (MPM) to date. To evaluate the progression of the disease, an appropriate mapping/zoning of lymph nodes is essential. We analyzed the frequency of lymph node metastases and prognosis of the patients with or without lymph node metastasis in MPM. We retrospectively retrieved the clinicopathological characteristics and medical courses of consecutive patients who had undergone surgery for MPM for curative intent. The lymph node was categorized according to lung cancer nodal chart: from zone 1 to zone 5. The cases with lymph nodes dissected only from one zone, with an incomplete evaluation of lymph nodes, a histological diagnosis other than epithelioid type, or cases without macroscopic complete resection were excluded in this analysis. From January 2007 and March 2019, a total of 241 patients received surgery for MPM. Of which 78 (32.4%) cases had a pathological evaluation of lymph node retrieved. There were 50 patients with no lymph node metastasis while 28 had metastases in lymph node resected. The median number of lymph node dissected was 6 (range 2-26). The five-year overall survival rate of patients without lymph node metastasis after diagnosis of MPM was 34.9% (C.I.19.6-50.1) and patient with positive lymph node metastasis was 10.7% (C.I. 0-22.1) (p<0.001). The limitation of this study is that lymph node dissection is not systematic and cannot be analyzed for each zone. There was a significant difference in the overall survival of the patients with or without lymph node metastases, which is compatible with the 8th ed of TNM classification for MPM. Prospective and planned lymph node dissection is most desired for MPM specific lymph node mapping.

P24.02 Rick Factors for the Occurence of Postoperative Empyema in Malignant Pleural Mesothelioma Patients Undergoing Macroscopic Complete Resection

P24.02 Rick Factors for the Occurence of Postoperative Empyema in Malignant Pleural Mesothelioma Patients Undergoing Macroscopic Complete Resection

Prognostic Role of PD-L1 in Malignant Pleural Mesothelioma: Unraveling the Complexity of the Tumor Microenvironment in Mesothelioma

In this issue of The Annals of Thoracic Surgery, Lee and colleagues1 observed that high programmed death-ligand 1 (PD-L1) expression characterized by PD-L1 expression in 50% or more of tumor cells in malignant pleural mesothelioma (MPM) was associated with worse survival both in epithelial and nonepithelial histology. This high level of PD-L1 expression was seen in 50% of sarcomatoid mesothelioma and in 14% of epithelial mesothelioma treated with complete macroscopic resection. Ingenuity pathway analysis demonstrated that high PD-L1 expression was associated with genes expression related to T cell exhaustion, dendritic cell maturation, interferon signaling, and JAK/Stat signaling, suggesting that high expression of PD-L1 is associated with the presence of reactive, but exhausted tumor-specific T cells.

Recurrence of mesothelioma after a macroscopic complete resection procedure: is a second radical surgery justified?

A best evidence topic was written according to a structured protocol. The question addressed was: In patients with mesothelioma who develop a local recurrence after macroscopic complete resection (MCR) surgery, does performing a second radical surgery lead to improvement in survival? A total of 2076 papers were identified using the reported search, of which 3 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. The 2 largest studies included 16 patients each who underwent a second surgery for radical resection of recurrence after MCR for mesothelioma. One study (with 16 chest wall resections) had no in-hospital mortality, whereas the other study showed 2/16 (12.5%) patients dying in the hospital, both of whom had a contralateral pleurectomy. One study correlated the median survival after the second surgery with the time to recurrence and epithelioid pathology. The other study showed better post-recurrence survival after a second surgery, with patients having a significantly longer median post-recurrence survival (16 months) compared with those who received other types of second-line therapy (9 months) and those who received no therapy at all (2 months) (P < 0.0005), although selection bias is a possibility. The last study included 8 patients who underwent a second surgery for radical intent after MCR for mesothelioma. The median time to recurrence was 29 months and the survival after second surgery was 14.5 months with no correlation to disease-free interval (expected due to the small number of patients). In patients presenting with recurrence of mesothelioma after an MCR procedure, radical surgery to resect the recurrent tumour could have a role in improvement of survival in selected patients. Positive prognostic factors include epithelioid pathology and a longer disease-free interval after the first procedure.

Multidisciplinary Surgical Approach to Increase Complete Cytoreduction Rates for Advanced Ovarian Cancer in a Tertiary Gynecologic Oncology Center.

Surgical resection remains the cornerstone of ovarian cancer management. In 2017, the authors implemented a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper gastrointestinal (GI) surgeons to increase gross macroscopic resection rates. This report aims to describe changes in complete cytoreduction rates and morbidity after the implementation of a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper GI surgeons in a tertiary gynecologic oncology unit. The study used two cohorts. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients initiated in 2017. A multidisciplinary approach to preoperative medical optimization, intraoperative management, and postoperative care was implemented in 2017. The patients in cohort B with upper abdominal disease were offered primary cytoreduction with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Before 2017, the patients with upper abdominal disease received neoadjuvant chemotherapy (cohort A). This study included 146 patients in cohort A (2006-2015) and 93 patients in cohort B (2017-2019) with stages 3 or 4 ovarian cancer. The overall complete macroscopic resection rate (CC0) increased from 58.9 in cohort A to 67.7% in cohort B. The rate of primary cytoreductive surgery (CRS) increased from 38 (55/146) in cohort A to 42% (39/93) in cohort B. The CC0 rate for the patients who underwent primary CRS increased from 49 in cohort A to 77% in cohort B. Major morbidity remained stable throughout both study periods (2006-2019). The study data demonstrate that implementation of a multidisciplinary team intraoperative approach and a meticulous approach to preoperative optimization resulted in significantly improved complete resection rates, particularly for women offered primary CRS.

A Prospective, Phase I/II, Open-Label Pilot Trial to Assess the Safety of Hyperthermic Intraperitoneal Chemotherapy After Oncological Resection of Pancreatic Adenocarcinoma

BackgroundPancreatic ductal adenocarcinoma (PDAC) is a common fatal disease with unfavorable prognosis, even after oncological resection. To improve survival, adding hyperthermic intraperitoneal chemotherapy (HIPEC) has been suggested. Whether HIPEC entails disproportional short-term mortality is unknown and a prospectively determined adverse events profile is lacking. Since both pancreatic resection and HIPEC may relevantly influence morbidity and mortality, this uncontrolled single-arm, open-label, phase I/II pilot trial was designed to assess the 30-day mortality rate, treatment feasibility, and adverse events connected with HIPEC after oncological pancreatic surgery.MethodsThis trial recruited patients scheduled for PDAC resection. A sample size of 16 patients receiving study interventions was estimated to establish a predefined margin of treatment-associated short-term mortality with a power of > 80%. Patients achieving complete macroscopic resection received HIPEC with gemcitabine administered at 1000 mg/m2 body surface area heated to 42 °C for 1 hour.ResultsWithin 30 days after intervention, no patient died or experienced any adverse events higher than grade 3 that were related to HIPEC. Furthermore, treatment-related adverse events were prospectively documented and categorized as expected or unexpected. This trial supports that the actual mortality rate after PDAC resection and HIPEC is below 10%. HIPEC treatment proved feasible in 89% of patients allocated to intervention. Pancreatic fistulas, as key complications after pancreas surgery, occurred in 3/13 patients under risk.ConclusionCombined pancreas resection and gemcitabine HIPEC proved feasible and safe, with acceptable morbidity and mortality. Based on these results, further clinical evaluation can be justified.Registration NumberNCT02863471 (http://www.clinicaltrials.gov).

Nab-paclitaxel plus gemcitabine versus nab-paclitaxel plus gemcitabine followed by FOLFIRINOX induction chemotherapy in locally advanced pancreatic cancer (NEOLAP-AIO-PAK-0113): a multicentre, randomised, phase 2 trial

The optimal preoperative treatment for locally advanced pancreatic cancer is unknown. We aimed to compare the efficacy and safety of nab-paclitaxel plus gemcitabine with nab-paclitaxel plus gemcitabine followed by fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) as multidrug induction chemotherapy regimens in locally advanced pancreatic cancer. In this open-label, multicentre, randomised phase 2 study, done at 28 centres in Germany, eligible patients were adults (aged 18-75 years) with an Eastern Cooperative Oncology Group performance status of 0 or 1 and histologically or cytologically confirmed, treatment-naive locally advanced pancreatic adenocarcinoma, as determined by local multidisciplinary team review. After two cycles of nab-paclitaxel 125 mg/m2 plus gemcitabine 1000 mg/m2 (administered intravenously on days 1, 8, and 15 of each 28-day cycle), patients without progressive disease or unacceptable adverse events were randomly assigned (1:1) to receive either two additional cycles of nab-paclitaxel plus gemcitabine (nab-paclitaxel plus gemcitabine group) or four cycles of sequential FOLFIRINOX (oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 180 mg/m2, fluorouracil 400 mg/m2 by intravenous bolus followed by a continuous intravenous infusion of 2400 mg/m2 for 46 h on day 1 of each 14-day cycle; sequential FOLFIRINOX group). Randomisation was done by the clinical research organisation on request of the trial centre using a permuted block design (block size 2 and 4). Patients, investigators, and study team members were not masked to treatment allocation. The primary endpoint was surgical conversion rate (complete macroscopic tumour resection) in the randomised population by intention-to-treat analysis, which was assessed by surgical exploration in all patients with at least stable disease after completion of induction chemotherapy. This trial is registered with ClinicalTrials.gov, NCT02125136. Between Nov 18, 2014, and April 27, 2018, 168 patients were registered and 130 were randomly assigned to either the nab-paclitaxel plus gemcitabine group (64 patients) or the sequential FOLFIRINOX group (66 patients). Surgical exploration after completed induction chemotherapy was done in 40 (63%) of 64 patients in the nab-paclitaxel plus gemcitabine group and 42 (64%) of 66 patients in the sequential FOLFIRINOX group. 23 patients in the nab-paclitaxel plus gemcitabine group and 29 in the sequential FOLFIRINOX group had complete macroscopic tumour resection, yielding a surgical conversion rate of 35·9% (95% CI 24·3-48·9) in the nab-paclitaxel plus gemcitabine group and 43·9% (31·7-56·7) in the sequential FOLFIRINOX group (odds ratio 0·72 [95% CI 0·35-1·45]; p=0·38). At a median follow-up of 24·9 months (95% CI 21·8-27·6), median overall survival was 18·5 months (95% CI 14·4-21·5) in the nab-paclitaxel plus gemcitabine group and 20·7 months (13·9-28·7) in the sequential FOLFIRINOX group (hazard ratio 0·86 [95% CI 0·55-1·36]; p=0·53). All other secondary efficacy endpoints, such as investigator-assessed progression-free survival, radiographic response rate, CA 19-9 response rate, and R0 resection rate, were not significantly different between the two treatment groups except for improved histopathological downstaging in evaluable resection specimens from the sequential FOLFIRINOX group (ypT1/2 stage: 20 [69%] of 29 patients in the sequential FOLFIRINOX group vs four [17%] of 23 patients in the nab-paclitaxel plus gemcitabine group, p=0·0003; ypN0 stage: 15 [52%] of 29 patients in the sequential FOLFIRINOX group vs four [17%] of 23 patients in the nab-paclitaxel plus gemcitabine group, p=0·02). Grade 3 or higher treatment-emergent adverse events during induction chemotherapy occurred in 35 (55%) of 64 patients in nab-paclitaxel plus gemcitabine group and in 35 (53%) of 66 patients in the sequential FOLFIRINOX group. The most common of which were neutropenia (18 [28%] in nab-paclitaxel plus gemcitabine group, 16 [24%] in the sequential FOLFIRINOX group), nausea and vomiting (two [3%] in nab-paclitaxel plus gemcitabine group, eight [12%] in the sequential FOLFIRINOX group), and bile duct obstruction with cholangitis (six [9%] in nab-paclitaxel plus gemcitabine group, seven [11%] in the sequential FOLFIRINOX group). No deaths were caused by treatment-related adverse events during the induction chemotherapy phase. Our findings suggest that nab-paclitaxel plus gemcitabine is similarly active and safe as nab-paclitaxel plus gemcitabine followed by FOLFIRINOX as multidrug induction chemotherapy regimens for locally advanced pancreatic cancer. Although conversion to resectability was achieved in about a third of patients, additional evidence is required to determine whether this translates into improved overall survival. Celgene.

Prognostic Role of Programmed Cell Death 1 Ligand 1 in Resectable Pleural Mesothelioma

The prognostic role of programmed cell death 1 ligand 1 (PD-L1) in malignant pleural mesothelioma (MPM) is incompletely understood. Our objectives were to evaluate the evidence for tumor PD-L1 as a prognostic biomarker in MPM through meta-analysis and to determine whether tumor PD-L1 expression is associated with survival in MPM patients undergoing macroscopic complete resection. Meta-analysis was performed to determine the association of PD-L1 with overall survival in MPM (n= 1655) from 14 studies containing overall survival and tumor PD-L1 expression. Univariable and multivariable analyses tested the relationship of tumor PD-L1 with overall survival and recurrence-free survival in an institutional cohort of MPM patients treated by macroscopic complete resection (n= 75). To validate the association of PD-L1 with overall survival, we utilized two independent MPM cohorts (n= 284). Meta-analysis demonstrated that high tumor PD-L1 expression was associated with poor overall survival. Among 75 patients undergoing macroscopic complete resection, 49 tumors (65%) expressed PD-L1 (1% or more), and high PD-L1 (50% or greater) was more commonly expressed on nonepithelial (29%) compared with epithelial tumors (14%). High tumor PD-L1 expression was independently associated with poor overall survival (P < .001, hazard ratio 5.67) and recurrence-free survival (P= .003, hazard ratio 3.28). The association of PD-L1 overexpression with unfavorable survival was more significant in epithelial MPMs than nonepithelial MPMs. These findings were validated in RNA sequencing analyses in two independent cohorts. Exploratory transcriptome analysis revealed that MPM tumors with PD-L1 overexpression displayed coexpression of other immune regulatory molecules, programmed cell death 1 ligand 2 and T-cell immunoglobulin mucin receptor3. Tumor PD-L1 expression is a prognostic biomarker in patients undergoing surgical resection for MPM and may be useful in perioperative decision making.

The Impact on Outcome by Adding Bevacizumab to Standard Induction Chemotherapy Prior to Mesothelioma Surgery: A Retrospective Single Center Analysis.

ObjectivesAdding bevacizumab, an anti-Vascular Endothelial Growth Factor (VEGF), to platinum-based chemotherapy/pemetrexed in 1st line treatment of advanced malignant pleural mesothelioma (MPM), significantly improved overall survival. However, increased high grade bleeding after operation was reported in patients with colorectal cancer who previously received bevacizumab. In the present analysis, we assessed for the first time the impact of adding bevacizumab to induction chemotherapy prior to surgery for mesothelioma patients.MethodsTwo hundred twenty-seven MPM patients, intended to be treated with induction chemotherapy followed by surgery at the University Hospital of Zurich between 2002 and December 2018, were included in the present analysis. After propensity score matching for gender, histology and age (1:3 ratio), data from 88 patients were analyzed. Sixty-six patients underwent induction chemotherapy (with cis-/carboplatin and pemetrexed: control group) alone and 22 patients underwent induction chemotherapy with the addition of bevacizumab (bevacizumab group) prior macroscopic complete resection (MCR). Perioperative and long-term outcome variables were analyzed.ResultsPatients undergoing combination treatment with bevacizumab had a significantly better response than with chemotherapy alone as assessed by modified RECIST (p=0.046). Intraoperative complications in the bevacizumab group (one patient), or in the control group (three patients) were not related to intraoperative bleeding. Postoperative transfusion of blood products occurred in a larger amount in the control group than in the bevacizumab group (p=0.047). Overall survival was not statistically different between both groups.ConclusionThese initial data demonstrate that MCR can be performed safely after triple induction chemotherapy with bevacizumab without increased intra- and postoperative bleeding complications. Response rates were significantly improved by the addition of bevacizumab.

Survival outcomes after delayed cytoreduction surgery following neoadjuvant chemotherapy in advanced epithelial ovarian cancer

ObjectiveInterval cytoreduction following neoadjuvant chemotherapy is a well-recognized treatment alternative to primary debulking surgery in the treatment of advanced epithelial ovarian cancer where patient and/or disease factors prevent complete macroscopic...

The role of extrapleural pneumonectomy for malignant pleural mesothelioma: reviewing 20-years of experience

Background: For patients with malignant pleural mesothelioma (MPM), a multimodality treatment concept including neoadjuvant chemotherapy and radical surgery offers improved overall survival. While the lung-sparing extended pleurectomy and decortication (EPD) has become the preferential surgical approach, the more aggressive extrapleural pneumonectomy (EPP) remains reserved for a selected group of patients. Based on our experience from the past two decades, we aim to discuss and assess today’s role of EPP. Methods: Out of 523 MPM patients intended to be treated by induction chemotherapy followed by macroscopic complete resection between January 1999 and December 2019, we identified 151 consecutive patients who underwent EPP at our center. All patients were treated within a multimodality concept including neoadjuvant chemotherapy with platinum-based agents plus gemcitabine or pemetrexed. Clinical data were collected in an online database and analyzed retrospectively. Results: Of all patients, 57.6% were of IMIG stage IA or IB (n=87), 39.0% of all patients IMIG stage IIIA or IIIB (n=59). Mean tumor volume after induction chemotherapy was 294.6±315.0 cm3. Most patients were operated in the first decade between 1999 and 2009 [112 patients (74.2%)]. The overall 30- and 90-day mortality was 4.6% and 10.6%, respectively. The median overall survival was 18.5 months. Major postoperative morbidity was assessed as a composite outcome and occurred in 38.4% of all patients. Conclusions: Although EPD became the procedure of first choice, EPP is a reasonable approach in selected patients with high tumor burden and extensive involvement of the lung parenchyma, where parenchyma-sparing resection is technically not feasible or functionally not rational. All patients should be preoperatively assessed and informed about the eventuality of EPP, depending on intraoperative findings. Keywords: Extrapleural pneumonectomy (EPP); malignant pleural mesothelioma (MPM); surgical treatment; multimodality treatment; macroscopic complete resection

Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis.

Background Recently, underwater endoscopic mucosal resection (UEMR) has shown promising results in the management of colorectal polyps. Some studies have shown better outcomes compared to conventional endoscopic mucosal resection (EMR). We conducted this systematic review and meta-analysis to compare UEMR and EMR in the management of colorectal polyps. Methods We searched several databases from inception to November 2019 to identify studies comparing UEMR and EMR. Outcomes assessed included rates of en bloc resection, complete macroscopic resection, recurrent/residual polyps on follow-up colonoscopy, complete resection confirmed by histology and adverse events. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a fixed effect model. Heterogeneity was assessed by I 2 statistic. Funnel plots and Egger’s test were used to assess publication bias. We used the Newcastle-Ottawa scale (NOS) for assessment of quality of observational studies, and the Cochrane tool for assessing risk of bias for RCTs Results Seven studies with 1291 patients were included; two were randomized controlled trials and five were observational. UEMR demonstrated statistically significantly better efficacy in rates of en bloc resection, pooled RR 1.16 (1.08, 1.26), complete macroscopic resection, pooled RR 1.28 (1.18, 1.39), recurrent/residual polyps; pooled RR 0.26 (0.12, 0.56) and complete resection confirmed by histology; pooled RR 0.75 (0.57, 0.98). There was no significant difference in adverse events (AEs); pooled RR 0.68 (0.44, 1.05). Conclusions This meta-analysis found statistically significantly better rates of en bloc resection, complete macroscopic resection, and lower risk of recurrent/residual polyps with UEMR compared to EMR. We found no significant difference in AEs between the two techniques.

Abstract LB-138: Adjuvant pembrolizumab or placebo in patients with high-risk, locally advanced cutaneous squamous cell carcinoma: Phase 3 KEYNOTE-630

Abstract Background: Local recurrence occurs within 5 years in ~20% of patients with high-risk locally advanced cutaneous squamous cell carcinoma treated with current standard-of-care surgical resection and adjuvant radiotherapy. Recent data with programmed death 1 inhibitors have demonstrated antitumor activity and an acceptable safety profile in patients with locally advanced or metastatic disease. The randomized, double-blind, placebo-controlled phase 3 KEYNOTE-630 trial (NCT03833167) will evaluate the efficacy and safety of adjuvant pembrolizumab monotherapy in patients with high-risk locally advanced cutaneous squamous cell carcinoma. Trial design: Patients with resectable high-risk locally advanced cutaneous squamous cell carcinoma who have undergone surgical resection and radiotherapy will be randomly assigned 1:1 to intravenous pembrolizumab (400 mg every 6 weeks) or placebo for up to 9 cycles (~1 year) or until disease recurrence, unacceptable toxicity, or withdrawal by the investigator or the patient. Randomization will be stratified by extracapsular extension (yes vs no), cortical bone invasion (yes vs no), and prior systemic therapy (yes vs no). Key eligibility criteria include histologically confirmed locally advanced cutaneous squamous cell carcinoma with ≥1 high-risk feature as the primary site of malignancy and complete macroscopic resection of all known cutaneous squamous cell carcinoma disease, with or without microscopic positive margins, who completed ≥45 Gy adjuvant radiotherapy, were disease free ≤28 days from randomization, and have Eastern Cooperative Oncology Group performance status 0 or 1. The primary end point is recurrence-free survival based on investigator assessment with biopsy confirmation. Secondary end points are overall survival, health-related quality of life, and safety. Radiographic imaging will be performed at least every 12 weeks in years 1 and 2, then every 6 months until the end of year 5 to assess treatment response. Patients who are ineligible for surgical resection following documented disease recurrence may cross over to receive re-treatment with open-label intravenous pembrolizumab 400 mg every 6 weeks for up to 18 cycles (~2 years). Adverse events will be recorded until 30 days (90 days for serious adverse events) after study end and will be graded per NCI CTCAE v4.0. Enrollment of ~570 patients is planned, and recruitment is ongoing in 20 countries. Citation Format: Anne Lynne S. Chang, Gregory A. Daniels, Ezra E. Cohen, Joy Yang Ge, Burak Gumuscu, Ramona F. Swaby, Jessica L. Geiger. Adjuvant pembrolizumab or placebo in patients with high-risk, locally advanced cutaneous squamous cell carcinoma: Phase 3 KEYNOTE-630 [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-138.

Neurological outcome after resection of spinal schwannoma

IntroductionSpinal schwannoma (SS) is the most frequently diagnosed benign spinal tumor, constituting approximately 25 % of all intradural tumors. Aim of our study was to identify factors that potentially affect immediate postoperative neurological outcome, and the rate of functional recovery within 12 months. MethodsScreening of our institutional database yielded 90 consecutive patients (mean age 57.1 years, 39 women [43.3 %]) with newly diagnosed SS between March 1997 and October 2018. We pre- and postoperatively reviewed patient charts, surgical reports, radiographic data, use of IOM, duration of symptoms, histopathology, co-morbidities, radiographic extension, surgical strategy, neurological performance (Japanese Orthopedic Association Score [JOA score] and Frankel Grade Classification). ResultsMean duration of preoperative symptoms was 3.6 ± 1.6 months. Most common symptoms were local pain (n = 77, 85.6 %). Macroscopic complete resection was achieved in 84 patients (93.3 %). During follow-up, complete recovery from local pain was documented for 41 patients (59.7 %), from radiating pain for 41 (69.5 %; p < 0.001).Postoperatively, 25 (27.7 %) patients developed a new neurological deficit (motor deficits n = 3 and sensory deficits n = 23; one patient developed both); after 12 months, however, motor deficits had abated in all patients, and 16 (69.5 %) patients had completely recovered from sensory deficits.Use of intraoperative monitoring (IOM) was a significant predictor for good functional outcome (p < 0.001). ConclusionResection of SS accompanied by IOM whenever feasible should be advocated. We achieved a high number of complete resections with a low rate of morbidity. New postoperative motor or sensory deficits had a very high rate of complete recovery within 12 months.