Microscopic Positive Resection Research Articles

358. IMPLICATIONS ON OVERALL SURVIVAL FROM POSITIVE CIRCUMFERENTIAL RESECTION MARGINS IN OESOPHAGEAL CANCER PATIENTS AT A TERTIARY REFERRAL CENTRE IN ENGLAND

Abstract Background The oesophagogastric (OG) tertiary referral centre at our Trust was established in March 2009.It caters to a catchment population of approximately 1.6 million. Oesophageal cancer is a morbid disease contributing to 18% of cancer mortalities worldwide. Involvement of circumferential resection margin (CRM) is an indicator of poor prognosis. The aim was to calculate the microscopic positive resection rate in patients undergoing resections for oesophageal cancers, assess disease free survival (DFS) and overall survival (OS) in this cohort. Methods Patients undergoing oesophageal resections for cancer at our OG unit who satisfied the inclusion criteria - age>18, operation with curative intent, adenocarcinoma and squamous cell cancer with a microscopic positive resection margin (R1) were included. Data was collected from the electronic patient record (Quadramed). Retrospective analysis was performed using MS Excel and IBM SPSS statistics Ver 27. Results A total of 640 oesophageal cancer resections performed between April 2009 - March 2023, who satisfied the inclusion criteria were included. Median age at surgery was 66 years. The R1 rate was 40% in our cohort (R0:R1 =380:260). Male to female ratio in the R1 cohort was 4:1. 98% (255 patients) had T3/T4 disease. 47.7% (124 patients developed recurrence. Of these, 83.8% (104 patients) developed distant metastasis and 16.2 %(20 patients) had locoregional metastasis. Median time to recurrence was 12 months and disease-free survival was also12 months. The OS at one year of 81% (140/260) was comparable to national data. Conclusion We conclude that locally advanced tumour staged T3 and above is the most likely cause for higher rate of CRM positivity. Other factors that could contribute is the lack of serosal layer in the oesophagus and the practise of ex situ removal of nodes from the main specimen in theatre which could potentially lead to stripping of the adventitia thus making the CRM falsely R1 during pathological staging. The R1 status however does not seem to affect the overall survival rate.

Clinical Outcome of Patients with Gastric, Duodenal, or Rectal Neuroendocrine Tumors after Incomplete Endoscopic Resection.

Objectives: Our aim was to investigate the clinical outcome of patients with well-differentiated gastric, duodenal, and rectal neuroendocrine tumors after treatment with incomplete endoscopic resection due to the finding of microscopic positive resection margins (R1). Methods: This is a retrospective analysis of consecutive patients with type 1 gastric, non-ampullary non-functioning duodenal, or rectal neuroendocrine neoplasms with positive R1 margins after endoscopic resection. The rate of tumor recurrence and progression-free survival were considered to be the study's main endpoints. Statistical analysis was performed using MedCalc® v.17 software and a p-value of <0.05 was considered significant. A Cox proportional-hazard regression was performed to identify risk factors for disease recurrence/progression. Results: After evaluating 110 patients, a total of 58 patients were included in the final analysis (15 gastric NENs, 12 duodenal NENs, and 31 rectal NENs). After evidence of endoscopic R1 resection had been gathered, 26 patients (44.8%) underwent an endoscopic/surgical extension of the previous resection. Tumor progression (all local recurrences) occurred in five out of fifty-eight patients (8.6%) with a median PFS of 36 months. There were no tumor-related deaths. G2 grading and the gastric primary tumor site were the only features significantly associated with the risk of recurrence of the disease (HR: 11.97 [95% CI: 1.22-116.99], HR: 12.54 [95% CI: 1.28-122.24], respectively). Conclusions: Tumor progression rarely occurs in patients with microscopic positive margin excision (R1) after endoscopic resection and does not seem to affect patients' clinical outcomes.

Adjuvant Chemoradiotherapy Associated with Improved Overall Survival in Resected Esophageal Squamous Cell Carcinoma after Neoadjuvant Chemoradiotherapy in Intensity-Modulated Radiotherapy Era.

The prognosis of patients with resected esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy is particularly poor in those who were staged as ypT3/T4 and/or ypN+. This study investigated whether adjuvant chemoradiotherapy was associated with improved clinical outcomes in these patients. we identified patients with esophageal squamous cell carcinoma who were staged as ypT3/T4 and/or ypN+ after being treated with neoadjuvant chemoradiotherapy followed by esophagectomy between the years 2013 and 2019. Patients were divided into two groups based on whether they received adjuvant chemoradiotherapy. The Kaplan-Meier method and Cox regression modeling were performed for survival analyses and multivariable analysis, respectively. 76 eligible patients were included in the analyses. The median follow-up for the study cohort was 43.4 months. On Kaplan-Meier analyses of the overall population, adjuvant chemoradiotherapy was associated with significantly improved median overall survival (31.7 months vs. 16.3 months, p = 0.036). On Kaplan-Meier analyses of the 35 matched pairs generated by propensity score matching, adjuvant chemoradiotherapy was associated with significantly longer median overall survival (31.7 months vs. 14.3 months; p = 0.004) and median recurrence-free survival (18.9 months vs. 11.7 months; p = 0.020). In multivariable analysis, adjuvant chemoradiotherapy was independently associated with a 60% reduction in mortality (p = 0.003) and a 48% reduction in risk of recurrence (p = 0.035) after adjusting for putative confounders. In addition, microscopic positive resection margin and Mandard tumor regression grade 3-4 were independently associated with increased mortality and risk of recurrence. While a greater number of lymph nodes dissected was independently associated with significantly improved overall survival, the number of positive lymph nodes was independently associated with significantly worse overall survival and a trend (p = 0.058) towards worse recurrence-free survival. This study demonstrated that adjuvant CRT was independently associated with a significantly improved survival and lower risk of recurrence than observation in esophageal squamous cell carcinoma patients staged as ypT3 and/or ypN+ after receiving neoadjuvant chemoradiotherapy and radical surgery. The results of this study have implications for the design of future clinical trials and may improve treatment outcomes of patients in this setting who cannot afford or are without access to adjuvant nivolumab.

222. ARE GASTRIC MAPPING BIOPSIES NECESSARY TO DETERMINE THE DISTAL RESECTION MARGIN FOR SIGNET RING ADENOCARCINOMAS OF THE OESOPHAGO-GASTRIC JUNCTION?

Abstract In our department patients with oesophago-gastric junctional adenocarcinomas with signet ring differentiation undergo a second endoscopy for gastric mapping biopsies to investigate the extent of tumour extension into the proximal stomach. This is due to the perceived aggressive morphology and to avoid a R1 (microscopic positive) resection at the distal margin. Our aim was to elucidate whether gastric mapping endoscopic biopsies are necessary prior to resection in signet ring adenocarcinomas of the oesophago-gastric junction (OGJ). Patients with operable OGJ adenocarcinomas with signet ring morphology were retrospectively analysed from 2011–2021 from our databank of completed oesophagectomies at our upper gastrointestinal cancer surgical department. From 2014–2021, OGJ adenocarcinomas identified with signet ring differentiation were subjected to a second invasive endoscopy with gastric mapping biopsies to determine the distal ex-tent of microscopic invasion into the cardia and beyond. These were analysed to determine the histopathological yield from gastric mapping biopsies and the number of cases with a positive (R1) distal resection margin. From 2014, 322 oesophagectomy cases were completed and these were analysed further. Of these, 21.7% (n = 70) were found pre-operatively to have signet ring differentiation and thus underwent a second gastric mapping endoscopy. Within the signet ring morphology cohort, only one patient (1.4%) was found to involve a R1 resection margin which necessitated a second operation involving gastric resection and colonic interposition. Our results suggest that patients with signet ring adenocarcinoma of the OGJ do not need gastric mapping biopsies to determine the distal margin prior to resection. Although considered a more aggressive subtype of adenocarcinoma, radial infiltration from the tumour does not seem to affect conventional surgical oncological margins.

Proposal of novel staging system CNM (Crohn's primary site, nodes, mesentery) to predict postoperative recurrence of Crohn's disease.

After oncologic resection, histological grading and staging of the tumor give important prognostic information about the future risk of recurrence and hence influence the subsequent management plan. Several studies and their meta-analysis have shown that various histological features (e.g., microscopic positive resection margins, plexitis, granuloma, mesenteric inflammatory activity) can predict postoperative clinical/endoscopic/surgical recurrence after resection in Crohn's disease (CD). Inclusion of mesentery in surgical resection specimens has been shown to reduce surgical recurrence after ileocolonic resection in CD. However, there is no uniform histopathological staging system for risk stratification in postoperative CD to systematically predict postoperative recurrence. This is because the prediction to date is based on clinical characteristics (smoking status, disease phenotype, surgical history). Histopathological predictors are still not adopted in routine clinical practice due to the lack of a uniform staging system, heterogeneity of published studies and lack of standardized definition of histological features. In this article, we attempted to incorporate all such histological features in a single histological staging system CNM (Crohn's primary site [resection margin positivity, plexitis, granuloma, depth of infiltration], nodes [presence of granuloma], mesentery [involved or not]) in surgical resection specimen in CD. The proposed CNM classification would help to enable systematic reporting, design future clinical trials, stratify postoperative recurrence risk and choose appropriate postoperative prophylaxis.

Malignant salivary gland tumours: Single-centre experience of 108 patients.

●A functioning facial nerve is a critical structure that limits the margin of resection in parotid malignancies. There was no difference in disease-free survival with close or negative resection margins. ●Microscopic positive (R1) resection margins were associated with poorer disease free survival, but this was not statistically significant, implying that more functional and less radical surgery may be acceptable when followed by adjuvant therapy. ●Perineural invasion was found in 37% of tumours ●Five-year overall and disease-free survival were 82% and 71%. ●Age >50, pT classification 3-4, higher tumour grade, perineural invasion, and advanced TNM stage were all associated with worse overall and disease-free survival.

Single-incision laparoscopic surgery compared to conventional laparoscopic surgery for appendiceal mucocele: a series of 116 patients.

Although the safety and feasibility of conventional laparoscopic surgery (CLS) for appendiceal mucocele (AM) has been reported, studies on single-incision laparoscopic surgery (SILS) for AM have not been reported. Here, we aimed to compare the perioperative and short-term outcomes between SILS and CLS for AM and to evaluate the oncological safety of SILS. We retrospectively analyzed the medical records of patients, diagnosed based on computed tomography findings, who underwent laparoscopic surgery for AM between 2010 and 2018 at one institution. We excluded patients strongly suspected of having malignant lesions and those with preoperative appendiceal perforation. Patients were divided into two groups-CLS and SILS. Pathological outcomes and long-term results were investigated. The median follow-up period was 43.7 (range: 12.3-118.5) months. Ultimately, 116 patients (CLS = 68, SILS = 48) were enrolled. Patient demographic characteristics did not differ between the groups. The preoperative mucocele diameter was greater in the CLS than in the SILS group (3.2 ± 2.9cm vs. 2.3 ± 1.4cm, P = 0.029). More extensive surgery (right hemicolectomies and ileocecectomies) was performed in the CLS than in the SILS group (P = 0.014). Intraoperative perforation developed in only one patient per group. For appendectomies and cecectomies, the CLS group exhibited a longer operation time than the SILS group (63.3 ± 24.5min vs. 52.4 ± 17.3min, P = 0.014); the same was noted for length of postoperative hospital stay (2.9 ± 1.8days vs. 1.7 ± 0.6days, P < 0.001). The most common AM etiology was low-grade appendiceal mucinous neoplasm (71/116 [61.2%] patients); none of the patients exhibited mucinous cystadenocarcinoma. Among these 71 patients, there were 8 patients with microscopic appendiceal perforation or positive resection margins. No recurrence was detected. SILS for AM is feasible and safe perioperatively and in the short-term and yields favorable oncological outcomes. Despite the retrospective nature of the study, SILS may be suitable after careful selection of AM patients.

Clinical significance of revised microscopic positive resection margin status in ductal adenocarcinoma of pancreatic head.

PurposeRecent studies have suggested microscopic positive resection margin should be revised according to the presence of tumor cells within 1mm of the margin surface in resected specimens of pancreatic cancer. However, the clinical meaning of this revised margin status for R1 resection margin was not fully clarified.MethodsFrom July 2012 to December 2014, the medical records of 194 consecutive patients who underwent pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head were analyzed retrospectively. They were divided into 3 groups on margin status; revised microscopic negative margin (rR0) – tumor exists more than 1 mm from surgical margin, revised microscopic positive margin (rR1) – tumor present within less than 1 mm from surgical margin, classic microscopic positive margin (cR1) – tumor is exposed to surgical margin.ResultsThere were 76 rR0 (39.2%), 100 rR1 (51.5%), and 18 cR1 (9.3%). There was significant difference in disease-free survival rates between cR1 vs. rR1 (8.4 months vs. 24.0 months, P = 0.013). Margin status correlated with local recurrence rate (17.1% in rR0, 26.0% in rR1, and 44.4% in cR1, P = 0.048). There is significant difference in recurrence at tumor bed (11.8% in rR0 vs. 23.0 in rR1, P = 0.050). Of rR1, adjuvant treatment was found to be an independent risk factor for local recurrence (hazard ratio, 0.297; 95% confidence interval, 0.127–0.693, P = 0.005).ConclusionRevised R1 resection margin (rR1) affects recurrence at the tumor bed. Adjuvant treatment significantly reduced local recurrence of rR1. Accordingly, adjuvant chemoradiation for rR1 group should be taken into account.

Predictors of Early Recurrence Prior to Planned Postoperative Radiation Therapy for Oral Cavity Squamous Cell Carcinoma and Outcomes Following Salvage Intensified Radiation Therapy

To determine predictors and outcomes for oral squamous cell carcinoma (OSCC) patients who had early recurrence before commencement of postoperative radiation therapy (PORT). Retrospective review was performed for patients with OSCC treated with PORT between 2003 and 2015 after curative-intent surgery. Early recurrence was defined as tumor recurrence after surgical resection and before initiating planned PORT. Patients were classified into the following groups: (1) adjuvant PORT group (no early recurrence), (2) salvage PORT group (locoregional early recurrence), and (3) palliative PORT group (locoregional and distant early recurrence). For the whole cohort, multivariable analysis (MVA) was applied to identify predictors of early recurrence. In the salvage group, the post-PORT recurrence-free rate was estimated, and MVA was used to identify predictors of recurrence-free rate, disease-free survival, and overall survival (OS). Six hundred and one patients were identified, of whom 513 (85%) were treated with adjuvant PORT. Eighty-eight patients (15%) had early recurrence (28 of 88; 32% were biopsy proven) before PORT (70 in the salvage group and 18 in the palliative group). On MVA, oral tongue subsite, microscopic positive resection margin, pT3-4, and pN2-3 were associated with the development of early recurrence (P<.05 for all). The 3-year OS rates for patients with OSCC treated with adjuvant and salvage PORT were 71% (95% confidence interval [CI], 67%-75%) and 41% (95% CI, 30%-56%), respectively (P<.001; median follow-up was 3.4 and 2.9years, respectively). After salvage PORT, the 3-year recurrence-free rate was 36% (95% CI, 23%-47%). On MVA, extranodal extension and volume of early recurrent gross disease were associated with poor recurrence-free rate, disease-free survival, and OS (P<.05 for all). Early recurrences are not uncommon in patients with high-risk features, Further study is required to improve prediction and outcomes of this very high-risk group.

ACGH detects distinct genomic alterations of primary intrahepatic cholangiocarcinomas and matched lymph node metastases and identifies a poor prognosis subclass

Lymph node metastases (LNM) are an important prognostic factor for patients with intrahepatic cholangiocarcinoma, but underlying genetic alterations are poorly understood. Whole genome array comparative genomic hybridization (aCGH) was performed in 37 tumors and 14 matched LNM. Genomic analyses of tumors confirmed known and identified new (gains in 19q) copy number alterations (CNA). Tumors with LNM (N1) had more alterations and exclusive gains (3p, 4q, 5p, 13q) and losses (17p and 20p). LNM shared most alterations with their matched tumors (86%), but 79% acquired new isolated gains [12q14 (36%); 1p13, 2p23, 7p22, 7q11, 11q12, 13q13 and 14q12 (>20%)]. Unsupervised clustering revealed a poor prognosis subclass with increased alterations significantly associated to tumor differentiation and survival. TP53 and KRAS mutations occurred in 19% of tumors and 6% of metastases. Pathway analyses revealed association to cancer-associated pathways. Advanced tumor stage, microvascular/perineural invasion, and microscopic positive resection margin (R1) were significantly correlated to metastases, while N1-status, R1-resection, and poor tumor differentiation were significantly correlated to survival. ACGH identified clear differences between N0 (no LNM) and N1 tumors, while N1 tumors and matched LNM displayed high clonality with exclusive gains in the metastases. A novel subclass with increased CNAs and poor tumor differentiation was significantly correlated to survival.

Adjuvant concurrent chemoradiation therapy in patients with microscopic residual tumor after curative resection for extrahepatic cholangiocarcinoma.

We investigated the role of adjuvant concurrent chemoradiation therapy (CCRT) in patients with a microscopically positive resection margin (R1) after curative resection for extrahepatic cholangiocarcinoma (EHCC). A total of 84 patients treated with curative resection for EHCC were included. Fifty-two patients with negative resection margins did not receive any adjuvant treatments (R0+S group). The remaining 32 patients with microscopically positive resection margins received either adjuvant CCRT (R1+CCRT group, n=19) or adjuvant radiation therapy (RT) alone (R1+RT group, n=13). During the median follow-up period of 26months, the 2-year locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), and overall survival rates (OS) were: 81.8, 62.6, and 61.5% for R0+S group; 71.8, 57.8, and 57.9% for R1+CCRT group; and 16.8, 9.6, and 15.4% for R1+RT group, respectively. Multivariate analysis revealed that the R1+CCRT group did not show any significant difference in survival rates compared with the R0+S group. The R1+RT group had lower LRRFS [hazard ratio (HR) 3.008; p=0.044], DFS (HR 2.364; p=0.022), and OS (HR 2.417; p=0.011) when compared with the R0+S and R1+CCRT group. A lack of significant survival difference between R0+S group and R1+CCRT group suggests that adjuvant CCRT ameliorates the negative effect of microscopic positive resection margin. In contrast, adjuvant RT alone is appeared to be inadequate for controlling microscopically residual tumor.

Curiethérapie des sarcomes

The standard of care for local treatment for extremities soft tissue sarcomas relies on conservative surgery combined with external beam radiotherapy. Brachytherapy can be realized instead of external beam radiotherapy in selected cases, or more often used as a boost dose on a limited volume on the area at major risk of relapse, especially if a microscopic positive resection is expected. Close interaction and communication between radiation oncologists and surgeons are mandatory at the time of implantation to limit the risk of side effects. Long-term results are available for low-dose rate brachytherapy. Nowadays, pulsed dose rate or high-dose-rate brachytherapy are more often used. Brachytherapy for paediatric sarcomas is rare, and has to be managed in reference centres.

Impact of lymph node ratio on survival in patients with pancreatic and periampullary cancer.

According to some studies, the number of lymph nodes with metastases in relation to the total number of removed lymph nodes, the lymph node ratio (LNR), is one of the most powerful predictors of survival after resection in patients with pancreatic cancer. However, contradictory results have been reported, and small sample sizes of the cohorts and different definitions of a microscopic positive resection margin (R1) hamper the interpretation of data. The predictive value of LNR for 3-year survival was assessed using a Cox proportional hazards model. From 1992 to 2012, all patients with pancreatic and periampullary cancer operated on with pancreatoduodenectomy were selected from a database. Clinicopathological characteristics were analysed. Microscopic positive resection margin was defined as the microscopic presence of tumour cells within 1 mm of the margins. A nomogram was created. Some 760 patients were included. Predictive factors for death in 350 patients with pancreatic ductal adenocarcinoma included in the nomogram were: R1 resection (hazard ratio (HR) 1·55, 95percent c.i. 1·07 to 2·25), poor tumour differentiation (HR 2·78, 1·40 to 5·52), LNR above 0·18 (HR 1·75, 1·13 to 2·70) and no adjuvant therapy (HR 1·54, 1·01 to 2·34). The C statistic was 0·658 (0·632 to 0·698), and calibration was good (Hosmer-Lemeshow χ(2) = 5·67, P =0·773). LNR and poor tumour differentiation (HR 4·51 and 3·30 respectively) were also predictive in patients with distal common bile duct (CBD) cancer. LNR, R1 resection and jaundice were predictors of death in patients with ampullary cancer (HR 7·82, 2·68 and 1·93 respectively). LNR is a common predictor of poor survival in pancreatic, distal CBD and ampullary cancer.

The clinical features and prognosis of radiotherapy associated sarcoma (RAS) following radiotherapy for nasopharyngeal carcinoma

To analyze the clinical features and prognosis of radiotherapy associated sarcoma (RAS) in the head and neck following radiotherapy for nasopharyngeal carcinoma (NPC). The clinicopathologic data, diagnosis, treatment and follow-up results of 11 patients with RAS diagnosed between January 1995 and December 2011 at Zhejiang Cancer Hospital were analyzed retrospectively. Among these patients, 6 were males and 5 were females. Patients' ages ranged from 33 to 66 years (median 50 years). The latency period for development of the RAS was between 3 years and 23 years (median 7 years) after irradiation. Overall survival rate was calculated using the Kaplan-Meier method and Log rank test. All cases underwent surgery, of them 6 casesachieved radical resection3 cases left with microscopic positive resection margins and 2 caseshad palliative surgery. Among 11 patients, 4 had re-surgery after recurrence, including 1 case had repeated surgeries followed by chemotherapy and radioactive seed implantation. Follow-up time ranged from 2 to 102 months, andeight patients died The 2-year, 3-year and 5-year cumulative survival rateswere 45.5%, 30.3% and 15.2%, respectively. The median survival time was 15 months. Surgical resection with clear margins achieved significantly better prognosis (P = 0.04). The incidence of RAS after radiation of NPC is generally low, but the treatment of RAS is very difficult, with poor prognosis.

Prognostic value of surgical margin status in gastric cancer patients

It has been reported that positive surgical margin is one of the most significant risk factors for local recurrence and poor survival. However, the survival of gastric cancer (GC) patients with positive margin is still controversial. A total of 1025 stage I-III GC patients who underwent gastrectomy with curative intent between January 2003 and April 2008 in our centre were enrolled in this study, of whom, 75 patients got a microscopic positive resection margin. Other 950 patients with negative resection margin were used for comparison. Borrmann type and extranodal metastasis were independent risk factors for positive margin. The 5-year overall survival for the patients with positive margin is merely 13.3%. Survival in such patients was similar to that of the patients staged IIIc with R0 resection. In multivariate analysis, surgical margin status was found to be an independent prognostic factor for GC patients, while histology, tumour location, TNM stage and chemotherapy were independently associated with overall survival for patients with positive margin. Surgical margin status is an independent prognostic factor for GC. Patients with positive margin have a poor prognosis, similar to that of IIIc stage disease. When the tumour demonstrates infiltrative growth pattern (Borrmann type III and IV) and the surgical margin status is difficult to determine, extended gastrectomy should be implemented to ensure an R0 resection. Those high-risk patients should be considered for postoperative chemotherapy.

Pre-operative hypoalbuminaemia predicts poor overall survival in rectal cancer: a retrospective cohort analysis

BackgroundSerum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer.Method226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05.ResultsOf 226 patients (median age- 59 years; range 19 – 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE – 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant.ConclusionPreoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

Should we remove splenic hilus lymph nodes for esophagogastric junction adenocarcinoma?

For the surgical treatment of gastric cancer with curative intent, two issues are of main importance: the radical removal of the tumor and the radical removal of affected lymph nodes. For radical removal of the tumor, margins up to 8 cm for diffuse-type carcinoma (German guidelines) are advised because microscopic positive resection margins lead to poor prognosis [1]. In a comparative study of 619 patients, it was shown that intraoperative re-excision of microscopically involved resection margins may be beneficial for patients with less than five affected lymph nodes [2]. When Billroth performed his first gastric resection in 1881, he actually also removed some enlarged nodes. His patient died 14 months after the operation of recurrent disease. Since then, the extent of lymph node dissection has been an issue in the treatment of gastric cancer. Theoretically, removal of a wide range of lymph nodes improves the chances for cure. Such resection, however, could be irrelevant when no lymph nodes are affected, or when the cancer has developed into systemic disease, or the dissection increases morbidity and mortality substantially. From randomized studies, nowadays a D2 lymph node dissection is advised [3]. More extended lymph node dissections did not lead to improved survival, as shown by Sasako et al. [4], in a randomized D2 versus D4 trial in Japan. One of the main problems in the Western D1-D2 trials was the occurrence of major complications in the D2 dissection group, mostly caused by pancreatico-splenectomy. The increased morbidity and mortality in the D2 group probably offset the survival gain at that time. Subgroup analysis from the Dutch gastric cancer trial of patients who did not undergo a pancreatico-splenectomy showed a significant survival advantage for those who had a D2 lymph node dissection (11-year survival, 33 % for D1 and 47 % for D2; p = 0.018) [3]. In a late follow-up study it was shown that local recurrence rate and cancer-related death were significantly higher in the D1 dissection group as compared to the D2 dissection group [5]. To make lymph node dissections more ‘tailor made,’ Prof. Maruyama introduced the Maruyama index of unresected disease [6]. Based on seven input variables (age, sex, Borrman type, tumor size, tumor position, and histology), the likelihood for nodal involvement can be calculated. The chance of affected lymph nodes along the splenic artery (station no. 11) and the splenic hilum (no. 10) is highest is patients with large, proximal, poorly differentiated tumors. For adequate removal of these lymph node stations, a splenectomy is often performed. Another way to individualize gastric cancer treatment is the use of the index of estimated benefit from lymph node dissection (IEBLD) [7]. This index is calculated by multiplying the frequency of lymph node metastasis to each station by the 5-year survival rate of patients with positive lymph nodes at each station. To evaluate the effect of splenectomy for gastric cancer, three randomized trials have been performed in the past. In these randomized trials from Chile [8], Korea [9], and Japan [10], researchers reported no survival benefit from splenectomy in patients with a total gastrectomy, whereas morbidity was increased. A meta-analysis of operative survival with the data from these randomized trials showed no statistically significant difference (OR, 1.59; 95 % CI, This editorial refers to the article at doi:10.1007/s10120-013-0214-y.

Curiethérapie des sarcomes des tissus mous des membres

The standard of care of local treatment for extremities soft tissue sarcomas relies on conservative surgery combined with external beam radiotherapy. Brachytherapy can be realized instead of external beam radiotherapy in selected cases, or more often used as a boost dose on a limited volume on the area at major risk of relapse, especially if a microscopic positive resection is expected. In these cases, this combination allows to obtain the best local control rates published. Close interaction and communication between radiation oncologist and surgeon are mandatory at the time of implantation to limit the risk of side effects. Long-term results are available for low-dose rate brachytherapy. Nowadays, pulsed dose rate is more often used. More limited experience has been reported for high dose rate.

Postradiation sarcoma after radiotherapy for nasopharyngeal carcinoma

Postradiation sarcoma (PRS) is a notorious complication after radiotherapy (RT). The prognosis is poor, and the role of surgery is not well defined. The aim of our study was to review our experience in the management of PRS after RT for nasopharyngeal carcinoma (NPC). Case series. Between 1998 and 2011, all patients treated for PRS after radiation for NPC were reviewed retrospectively. Twenty-five patients were included. The mean latency period for the development of PRS after previous RT was 12.4 years. The histologic subtypes included osteosarcoma (n = 8), rhabdomyosarcoma (n = 6), undifferentiated sarcoma (n = 6), malignant fibrous histiocytoma (n = 4), and leiomyosarcoma (n = 1). Twenty patients underwent surgery with curative intent, but 14 of them eventually had microscopic positive resection margins. Among them, all received postoperative adjuvant chemoradiation, and six of them had brachytherapy as well. However, 71.4% of them eventually developed local recurrence. The median survival was significantly better for those with clear margin resection than for those with positive margins (5.12 years vs. 1.44 years, P = .04). Surgery was effective in symptom palliation, including tumor pain, bleeding, and trismus. PRS remains a disease with poor prognosis. Surgical resection with clear margins achieves significantly better survival. Surgery is also effective in the palliation of pain, bleeding, and trismus in patients with advanced staged disease.

Predictors of Recurrence After Resection of Small Gastric Gastrointestinal Stromal Tumors of 5 cm or Less

To evaluate the recurrence predicting factors of small gastric gastrointestinal stromal tumors (GISTs) through the long-term follow-up after surgical/endoscopic resection. Although small gastric GISTs are known to have a low risk of recurrence after complete resection, the prognostic factors are not well known. The study retrospectively analyzed the records of 136 patients with primary gastric GISTs of 5 cm or less without metastasis who underwent surgical/endoscopic resection between March 1997 and December 2008 at the Asan Medical Center, and who were followed-up for at least 3 months after resection. Specimens were assessed for tumor size, mitotic index, and microscopic resection margin. Specimen sections were immunohistochemically stained to determine the levels of expression of the cell cycle proteins p53, p16(INK4), pRb, cyclin D1, and Ki-67. DNA was extracted from high-risk tumors to analyze for KIT mutations. Among 136 patients, 5 (3.7%) patients with tumors with a high mitotic index showed recurrence at a median 23 months post resection. None of 14 patients with microscopic positive resection margins showed recurrence during a median follow-up time of 32 months. A high mitotic index was a predictor of recurrence (P<0.001), but that tumor size, method of resection, or margin status were not. In addition, abnormal p53 expression was found to be associated with recurrence (P=0.004). All assessable high-risk tumors had a KIT exon 11 mutation. Predictors of recurrence of gastric GISTs of 5 cm or less were a high mitotic index and abnormal p53 expression. A positive microscopic resection margin was not associated with recurrence.