non-CRT Group Research Articles

Head and neck small-cell carcinoma: A multicenter study of 39 cases from 10 institutions.

Basal information of head and neck small-cell carcinoma (HNSmCC) including epidemiology, primary site, treatment, and prognosis remains sparse due to its rarity. We report here a multicenter retrospective study on the diagnosis, treatment, and outcomes of patients with HNSmCC. This study involved 47 patients with HNSmCC from 10 participating institutions. Eight patients were excluded for whom no pathological specimens were available (n = 2) and for discrepant central pathological judgements (n = 6). The remaining 39 patients were processed for data analysis. As pretreatment examinations, computed tomography (CT) was performed for the brain (n = 8), neck (n = 39), and chest (n = 32), magnetic resonance imaging (MRI) for the brain (n = 4) and neck (n = 23), positron emission tomography-CT (PET-CT) in 23 patients, bone scintigraphy in 4, neck ultrasonography in 9, and tumor markers in 25. Primary sites were oral cavity (n = 1), nasal cavity/paranasal sinuses (n = 16), nasopharynx (n = 2), oropharynx (n = 4), hypopharynx (n = 2), larynx (n = 6), salivary gland (n = 3), thyroid (n = 2), and others (n = 3). Stages were II/III/IV-A/IV-B/IV-C/Not determined = 3/5/16/6/5/4; stage IV comprised 69%. No patient had brain metastases. First-line treatments were divided into 3 groups: the chemoradiotherapy (CRT) group (n = 27), non-CRT group (n = 8), and best supportive care group (n = 4). The CRT group included concurrent CRT (CCRT) (n = 17), chemotherapy (Chemo) followed by radiotherapy (RT) (n = 5), and surgery (Surg) followed by CCRT (n = 5). The non-CRT group included Surg followed by RT (n = 2), Surg followed by Chemo (n = 1), RT alone (n = 2), and Chemo alone (n = 3). The 1-year/2-year overall survival (OS) of all 39 patients was 65.3/53.3%. The 1-year OS of the CRT group (77.6%) was significantly better compared with the non-CRT group (31.3%). There were no significant differences in adverse events between the CCRT group (n = 22) and the Chemo without concurrent RT group (n = 9). Neck and chest CT, neck MRI, and PET-CT would be necessary and sufficient examinations in the diagnostic set up for HNSmCC. CCRT may be recommended as the first-line treatment. The 1-year/2-year OS was 65.3%/53.3%. This study would provide basal data for a proposing the diagnostic and treatment algorithms for HNSmCC.

PO-678-06 LEFT BUNDLE BRANCH AREA PACING INCREASES LEFT VENTRICULAR EJECTION FRACTION AND PREVENTS PACING-INDUCED CARDIOMYOPATHY IN THE LONG-TERM OBSERVATION

There is scarcity of data on long-term impact of left bundle branch area pacing (LBBAP) on left ventricular (LV) function. To evaluate LV function in patients with over 1 year of LBBAP and substantial pacing burden. Patients with LBBP for any indication were prospectively followed; ventricular pacing burden > 40% and R/r wave in lead V1 at the final follow-up were the only inclusion criteria. Following measures of LV function were assessed at baseline and at the last follow-up: LV ejection fraction (EF), global longitudinal strain (GLS), peak strain dispersion (PSD), LV end-diastolic diameter and volume (LVEDd, LVEDV), and LV end-systolic diameter and volume (LVESd, LVESV). A total of 100 consecutive patients were studied: age 76.7 ±10 y., female 41%, follow-up 21 ±7 months and ventricular pacing burden 87.6 ±20%. At baseline 31 patients had CRT indications (LV EF < 50%). In the whole group an increase in LV EF (53 ±12% vs 56 ±12%) and decrease in LVEDV, LVESV, LVEDd and absolute GLS (74 ± 37 mm vs 70 ±35 mm, 37 ±30 mm vs 34 ±28 mm, 48 ±9% vs 47 ±9%, 16.6 ±5% vs 17.5 ±5%, respectively) were observed, but there was no change in LVESd (37 ±11 mm vs 37 ±9.5 mm). In the CRT group the EF improved from 39 ±10% to 45 ±12.5%, while in the non-CRT group there was no change in EF (60.7 ±6% vs 60.9 ±7%). No patient had decrease in LV EF > 10%. The LV synchrony assessed by PSD improved in CRT group (74.4 ±35 ms vs 60.5 ±22 ms) and remained stable in non-CRT group (49.2 ±21 ms vs 49.3 ±19 ms). Left bundle branch pacing preserves or improves left ventricular function in the long-term observation and might prevent development of pacing-induced cardiomyopathy.

Stage cT3 low rectal cancer: analysis of prognostic factors.

Whether all cT3 low rectal cancer patients should receive neoadjuvant chemoradiotherapy (nCRT) remains controversial. The depth of invasion beyond the muscularis propria of the cT3 rectal cancer is of great significance to the selection of a treatment plan and the evaluation of prognosis. A retrospective analysis was conducted of 187 patients with stage cT3 low rectal cancer, who had been treated at the Department of Colorectal Surgery, The First Affiliated Hospital of Xiamen University from June 2010 to December 2012. The patients were divided into the nCRT group (88 cases) and no-nCRT group (99 cases). Possible significant prognostic factors [i.e., primary tumor volume (PTV), cell differentiation, circumferential resection margin (CRM), nCRT, age, sex, carcinoembryonic antigen (CEA), lymph node status, surgical procedure, etc.] were collected for estimation of disease-free survival (DFS), distant metastases rate (DM), local recurrence rate (LR). Independent predictive factors or survival were determined using Cox proportional hazards model. The mean PTV was 16.2±11.1 (2.07-72.68) cm3. In the univariate and multivariate analyses: nCRT hazards ratio (HR) =4.258, 95% confidence interval (CI): 1.912-9.483 (P<0.001); PTV HR =0.381, 95% CI: 0.181-0.804 (P=0.011); CRM HR =0.227, 95% CI: 0.097-0.532 (P=0.001). For the PTV ≤15 cm3 group, there were no significant differences between the nCRT and no-nCRT group in 3-year follow-up (P>0.05). For the PTV >15 cm3 group, there were significant differences between the nCRT and no-nCRT group in 3-year DFS (84.2% vs. 51.1%; P=0.001), DM (13.1% vs. 31.2%; P=0.017) and LR (2.9% vs. 26.6%; P=0.009). For the CRM negative group, there were significant differences between the nCRT and no-nCRT group in 3-year DFS (94.0% vs. 79.0%; P=0.008), LR (1.5% vs. 10.7%; P=0.028) and DM (4.5% vs. 13.5%; P=0.039). For stage cT3 low rectal cancer patients, nCRT, PTV, and CRM were independent prognostic factors. NCRT may improve the survival of PTV >15 cm3 patients, but may not have a significant effect on patient with PTV ≤15 cm3 and CRM negative. Direct surgery is recommended for this group of patients.

Assessing survival and re-hospitalisation following transvenous lead extraction in cardiac resynchronisation therapy devices depending on reimplantation timing: a propensity score matched analysis

Abstract Funding Acknowledgements Type of funding sources: None. Background Among patients undergoing transvenous lead extraction (TLE), differences in complication rate and 1-year mortality has been explored in patients with cardiac resynchronisation therapy (CRT) devices. Longer term outcomes and the influence of timing of reimplantation of device, with respect to rehospitalisation and longer-term mortality is poorly understood. Purpose The purpose of this study was to evaluate whether early reimplantation following TLE in patients with CRT devices influenced survival and rehospitalisation. Methods Clinical data from consecutive patients undergoing TLE in the reference centre between the years 2000 to 2019 were prospectively collected. Patients surviving to discharge who were re-implanted with the same device were included. The cohort was split depending on whether or not they had a CRT device at time of explant. The association between TLE in CRT patients and all-cause mortality and re-hospitalisation was assessed by Kaplan Meier estimates in a 1:1 propensity-score matched cohort, with a calliper of 0.10. Early reimplantation was defined as reimplantation within 7 days of TLE, and late reimplantation as reimplantation after greater than 7 days of TLE. Results Of 1005 patients included in the analysis, 285 (25%) had a CRT device. After matching, 192 CRT patients were compared with 192 non-CRT patients. Propensity scores were calculated using 39 baseline characteristics, including age, gender, co-morbidities, TLE indication, left ventricular ejection fraction, baseline creatinine and technical extraction data. Mean follow up was 53.5 ± 38.3 months, mean age at explant was 67.7 ± 12.1 years, 83.3% were male and 54.4% had an infective indication for TLE. In the matched cohort, there was no significant difference between the CRT and non-CRT group with respect to long-term mortality (hazard ratio [HR] = 1.01, 95% confidence interval [CI] [0.74-1.39], p = 0.093) or rehospitalisation (HR = 1.2 [0.87-1.66], p = 0.265). A similar proportion of patients were reimplanted within 7 days in the CRT and non-CRT groups (59.4% vs 61.5%, p = 0.754). In the matched non-CRT group, late reimplantation was associated with similar mortality to early reimplantation (HR = 1.33 [0.86-2.05], p = 0.208) and rehospitalisation (HR = 0.88 [0.53-1.45], p = 0.603). In the matched CRT group, late reimplantation was associated with higher mortality (HR = 1.64 [1.04-2.57], p = 0.032) and rehospitalisation (HR = 1.57 [1.00-2.46], p = 0.049] (see figure). Conclusion In this closely matched population, TLE in CRT patients resulted in similar long-term outcomes compared with non-CRT patients. Early reimplantation post CRT explant was associated with reduced long-term mortality and rehospitalisation. This suggests a longer duration without biventricular pacing post TLE may induce negative reverse-remodelling and should be avoided in a CRT population. Abstract Figure. Kaplan-Meier survival curves

Association of Chemoradiotherapy With Thoracic Vertebral Fractures in Patients With Esophageal Cancer

The association of chemoradiotherapy (CRT) with a thoracic vertebral fracture in patients with esophageal cancer is unknown. To determine whether CRT is associated with thoracic vertebral fractures in patients with esophageal cancer. This retrospective cohort study included patients with clinical stages I to III thoracic esophageal cancer who visited the Kyoto University Hospital, Kyoto, Japan, from January 1, 2007, to December 31, 2013. Data were analyzed from April 6, 2018, to June 4, 2020. Chemoradiotherapy (CRT group) or surgery or endoscopic treatment (non-CRT group). The main outcome of this study was the cumulative incidence rate of thoracic vertebral fractures in 36 months. The incidence rate was calculated taking censoring into account. Possible risk factors, including CRT, were explored in the multivariable analysis. The association of irradiated doses with fractured vertebrae was also evaluated. A total of 315 patients (119 for the CRT group and 196 for the non-CRT group) were included. The median age of patients was 65 (range, 32-85) years. Fifty-six patients (17.8%) were female and 259 (82.2%) were male. The median observation time was 40.4 (range, 0.7-124.1) months. Thoracic vertebral fractures were observed in 20 patients (16.8%) in the CRT group and 8 patients (4.1%) in the non-CRT group. The 36-month incidence rate of thoracic vertebral fractures was 12.3% (95% CI, 7.0%-19.1%) in the CRT group and 3.5% (95% CI, 1.3%-7.5%) in the non-CRT group (hazard ratio [HR], 3.41 [95% CI, 1.50-7.73]; P = .003). The multivariable analysis showed that the HR of the thoracic vertebral fracture in the CRT group to non-CRT group was 3.91 (95% CI, 1.66-9.23; P = .002) with adjusting for sex, 3.14 (95% CI, 1.37-7.19; P = .007) with adjusting for age, and 3.10 (95% CI, 1.33-7.24; P = .009) with adjusting for the history of vertebral or hip fractures. The HR of the thoracic vertebral fracture for a 5-Gy increase in the mean radiation dose to the single vertebra was 1.19 (95% CI, 1.04-1.36; P = .009). This study found that chemoradiotherapy was associated with thoracic vertebral fractures in patients with esophageal cancers. A reduced radiation dose to thoracic vertebrae may decrease the incidence of fractures.

The impact of previous therapy strategy on the efficiency of anlotinib hydrochloride as a third-line treatment on patients with advanced non-small cell lung cancer (NSCLC): a subgroup analysis of ALTER0303 trial

Lung cancer remains one of the deadliest cancers worldwide. The ALTER0303 trial revealed that anlotinib might be used as a third-line or further treatment in non-small cell lung cancer (NSCLC) patients. Meanwhile, the impact of previous therapy strategies on the efficiency of anlotinib still remains unknown. The subgroup of patients in ALTER0303 were analyzed by using Kaplan-Meier estimates, Pearson χ2, or Fisher's exact test. There was no statistical significance on progression-free survival (PFS) and overall survival (OS) among patients in different previous antiangiogenic treatments groups. Patients in the chest radiotherapy (CRT) group had longer median PFS than the non-CRT group (5.93 vs. 4.63 m, P=0.027). Regardless of what kind of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) and chemotherapy regimens were used previously, all patients gained longer PFS in the anlotinib group, while only patients treated with vinorelbine/platinum in the EGFR wild type group, pemetrexed/platinum, vinorelbine/platinum, and gefitinib in the EGFR mutation group, and EGFR TKI used as the first line group could benefit from anlotinib on OS. When the OS was calculated from the time of diagnosis to the death, anlotinib could have increased median OS about 6 months (33.8 vs. 27.8 m, P<0.001) compared to the placebo with a hazard ratio (HR) (95% CI): 0.77 (0.60, 1.00). This study indicated that previous bevacizumab or endostatin treatments had no impact on the efficiency of anlotinib. Patients with CRT history benefited more from anlotinib on PFS. EGFR TKI and chemotherapy treatment history had more impact on OS than PFS in patients treated with anlotinib compared to placebo.

Neoadjuvant conformal radiotherapy before liver transplantation for hepatocellular carcinoma: a propensity score matched analysis of postoperative morbidity and oncological results.

Aim: To assess neoadjuvant conformal radiotherapy (CRT) before orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) not suitable for standard locoregional treatments. Methods: Patients undergoing OLT for HCC with or without prior CRT were compared using 1:3 propensity score matching. Results: After propensity score matching, 23 patients with CRT were compared with 66 control subjects. Severe morbidity rate was 34.8 versus 24.2% in the CRT and non-CRT groups (p=0.289). Complete pathological response was observed in 47.8% of CRT-targeted nodules. The 1-/3-/5-year disease-free survivals were 77.3, 77.3 and 68.7% in the CRT group versus 85.4, 68.0 and 61.7% in the non-CRT group (p=0.829). Conclusion: Conformal radiotherapy represents a satisfactory neoadjuvant therapy for OLT candidates not suitable for standard HCC locoregional therapies.

Clinical Evaluation of Preoperative Radiotherapy Combined with FOLFOX Chemotherapy on Patients with Locally Advanced Colon Cancer

This study explores the effect of preoperative radiotherapy combined with FOLFOX chemotherapy on patients with locally advanced colon cancer (LACC). Data of 102 patients with LACC were retrospectively analyzed. All received surgical resection plus postoperative FOLFOX chemotherapy; whereas 58 patients underwent preoperative radiotherapy combined with FOLFOX chemotherapy (CRT group, combined with radiotherapy treatment group), 44 patients did not undergo radiotherapy (non-CRT group). Short- and long-term effects as well as operative complications were compared. The optical density values of the caudal-related homeobox transcription factor 2 and inhibitor of growth 4 in lesions, and malignant molecules including vascular endothelial growth factor and cathepsin-D in serum were compared. The CRT group showed higher total pathological complete tumor response rate and resection rate, and lower incidence of incisional infection than the non-CRT group (all P < 0.05). The CRT group was significantly better in the three-year disease-free survival than the non-CRT group (P < 0.05), but slightly better in the three-year overall survival and disease-free survival in the first, second, and third years (P > 0.05). The optical density values of the caudal-related homeobox transcription factor 2 and inhibitor of growth 4 were higher than those in the non-CRT group (both P < 0.05). The levels of serum vascular endothelial growth factor and cathepsin-D in the CRT group were lower than those in the non-CRT group (both P < 0.05). Preoperative radiotherapy combined with FOLFOX chemotherapy can improve the resection rate and the pathological complete response rate in LACC surgery, and improve the survival time and the disease-free survival condition.

Efficacy analysis of neoadjuvant chemoradiotherapy combined with total pelvic exenteration in the treatment of primary T4b rectal cancer

To investigate the value of neoadjuvant chemoradiotherapy (nCRT) combined with total pelvic exenteration (TPE) in the treatment of primary T4b rectal cancer. A retrospective cohort study was conducted to analyze the clinicopathological data of 31 patients with primary T4b rectal cancer who underwent TPE from January 2008 to December 2015 at Peking University First Hospital. preoperative clinical stage (cTNM) was defined as cT4b primary rectal cancer with only front wall Invasion; the lower edge of tumor was within 10 cm from the anal margin; TPE was performed; R0 resection was confirmed by pathology. Patients with recurrent rectal cancer, distant metastasis, and undergoing TPE for non-rectal tumors were excluded. Patients were divided into nCRT group and non-nCRT group according to whether receiving nCRT before surgery. The nCRT group received long course radiotherapy (total dose 50 Gy in 25 daily fractions) with concomitant chemotherapy (Capecitabine), and the surgery was performed 6-8 weeks after the neoadjuvant chemoradiation, while the non-nCRT group received surgery directly. The intraoperative, postoperative and pathological conditions and local recurrence were compared between the two groups. The survival curves were drawn by Kaplan-Meier method and the survival of two groups were compared. A total of 31 patients were enrolled, including 13 patients in the nCRT group and 18 patients in the non-nCRT group. The baseline data, such as age, duration of disease, preoperative basic disease, body mass index, smoking rate, and tumor distance from the anal margin, were not significantly different between the two groups (all P>0.05). In the nCRT group and non-nCRT group respectively, the ratio of anal preservation was 30.8%(4/13) and 38.9%(7/18) (P=0.468), the median intraoperative blood loss was 1 000 ml and 800 ml (P=0.644), the operation time was (531.7±137.2) minutes and (498.0±90.1) minutes (P=0.703), the median hospital stay was 18 days and 14 days (P=0.400), the morbidity of complications within 30 days after surgery was 23.1%(3/13) and 38.9%(7/18)(P=0.452), the incidence of postoperative abdominal abscess was 15.4%(2/13) and 0 (P=0.168), the proportion of secondary surgery was 7.7%(1/13) and 11.1%(2/18)(P=1.000), whose differences were not significantly different. The proportion of postoperative pathological pT4b in whole group was 58.1%(18/31), including 53.8%(7/13) in nCRT group and 61.1%(11/18) in non-nCRT group, which was not significantly different between the two groups (P=0.691). The number of harvested lymph node in nCRT group was 13.5±5.9, which was significantly less than 23.0±11.8 in non-nCRT group (P=0.013). There was no pathological complete remission (ypCR) case in nCRT group, and among 13 patients, tumor regression grade (TRG) of 2, 3, 4, and 5 was in 1 case (7.7%), 6 cases (46.2%), 5 cases(38.5%), and 1 case (7.7%), respectively. The median follow-up time was 33 (2 to 115) months, and the follow-up rate was 93.5%(29/31). One case was lost in both the nCRT group and non-nCRT group. The 3-year disease-free survival rate was 43.5% in pooled data, and was 43.6% and 43.3% in nCRT group and non-CRT group respectively without significant difference (P=0.833). The 3-year overall survival rate was 51.1% in pooled data, and was 45.7% and 54.7% in nCRT group and non-nCRT group respectively without significant difference (P=0.653).The local recurrence rate of nCRT and non-nCRT groups was 8.3%(1/12) and 5.9%(1/17) respectively, and the distant metastasis rate was 50.0%(6/12) and 41.2%(7/17) respectively, whose differences were not statistically significant as well (P=1.000 and P=0.865, respectively). For primary T4b rectal cancer which can achieve R0 resection through total pelvic exenteration, neoadjuvant chemoradiotherapy has not been demonstrated any advantage in tumor regression, reducing local recurrence, or improving survival, and may increase postoperative complications.

Transvenous lead extraction in patients with cardiac resynchronization therapy devices is not associated with increased 30-day mortality.

Transvenous lead extraction (TLE) may be necessary due to system infection/erosion or lead malfunction. Cardiac resynchronization therapy (CRT) patients undergoing TLE may be at greater risk due to increased comorbidities. We examined whether patients with CRT systems undergoing TLE had more comorbidities and higher 30-day mortality than those with non-CRT devices. All TLEs between October 2000 and December 2016 were prospectively collected. During this period 925 TLEs occurred (CRT group 231, non-CRT group 694). Cardiac resynchronization therapy patients were older (68.1 ± 10.8 years vs. 64.3 ± 16.1 years, P = 0.024); more likely male (85.7% vs. 69%, P < 0.001); had lower mean left ventricular ejection fraction (34.1 ± 12.7% vs. 48.3 ± 12.9%, P < 0.001); had higher prevalence of renal impairment (33.8% vs. 13.7%, P < 0.001) and were more likely to have ≥2 comorbidities (84% vs. 40.1%, P < 0.001). Mean lead dwell time was lower in the CRT group (5.6 ± 5.5 years vs. 7.6 ± 7.1 years, P = 0.002). There was no significant difference in all-cause 30-day mortality rates between CRT (3.0%, n = 7) and non-CRT patients (2.0%, n = 14) (P = 0.443). The majority of deaths in both groups were due to sepsis. Univariate and multivariate analysis showed age, renal impairment and sepsis were associated with increased risk of 30-day mortality. Transvenous lead extraction of a CRT system did not predict 30-day mortality. Transvenous lead extraction in CRT patients was not associated with increased 30-day mortality when compared with non-CRT patients. Age, renal impairment and sepsis were independent predictors of 30-day mortality. Sepsis was the main cause of 30-day mortality.

Effect of cardiac resynchronization therapy on quality of life: Role of hypertension

Aims: To evaluate cardiac function, quality of life and role of hypertension in symptomatic heart failure in patients with Cardiac Resynchronization Therapy (CRT). Methods: 80 patients with heart failure were enrolled in our study. Among them 30 patients underwent CRT implantation (CRT group) and 50 patients received optimal medical therapy only (non-CRT group). Follow-up was carried out for 20 ± 2.828 months. Assessment of New York Hear Association (NYHA) class, QRS width, Ejection Fraction (EF), left ventricular end diastolic diameter, left ventricular end systolic diameter, interventricular septum, posterior wall thickness, degree of Mitral Regurgitation (MR) and Basic Natriuretic Peptide (BNP) level was performed at baseline and follow-up along with number of admissions and Quality of Life (QOL) assessment. Results: The baseline indices of patients in the CRT and non-CRT groups were statistically same (P&gt;0.05). At the end of follow-up most indices showed significant improvement in the CRT group (P&lt;0.05) except thickness of IVS and the PWT (P&gt;0.05). The indices in the non-CRT group only showed significant improvement in EF and BNP level (P&lt;0.05). Hypertensive patients did not show significant impact on number of admissions and QOL (P&lt;0.05). Conclusions: Patients receiving CRT had an overall improved outcome with beneficial effects in cardiac remodeling, enhancing the left ventricular function and improving the quality of life. Hypertension was associated with poorer outcome

Neoadjuvant conformal radiotherapy as a bridge to liver transplantation for hepatocellular carcinoma

Background: Patients with hepatocellular carcinoma (HCC) not suitable for standard loco-regional treatments who are on the waiting for liver transplantation (LT) are at high risk of drop-out. Conformal radiotherapy (CRT) may represent a potential alternative for such patients but its oncological outcome in that setting was never assessed. We aimed to assess the oncological results of this strategy. Methods: Patients undergoing LT for HCC with or without prior CRT between 2005 and 2017 were compared using 1:3 propensity score matching (PSM) for postoperative and oncological outcomes. Results: During the study period, LT for HCC with or without CRT was performed in 24 and 259 patients, respectively. After PSM, 23 patients with CRT were compared to 66 control subjects. There was no difference between the CRT and non-CRT groups in terms of severe morbidity (34.8% vs. 24.2%, p = 0.327), arterial complications (34.8% vs. 19.7%, p = 0.142) and biliary complications (26.1% vs. 18.2%, p = 0.547). Complete pathological response was observed in 17.4% and 25.8% of patients in the CRT and non-CRT groups, respectively. The 1-, 3-, and 5-year overall survivals were 81.8%, 81.8% and 72.7% in the CRT group and 89.0%, 76.2% and 66.2% in the non-CRT group (p = 0.860). The corresponding 1-, 3- and 5-year disease-free survivals were 77.3%, 77.3% and 68.7% vs. 85.4%, 68.0% and 61.7% (p = 0.829). Conclusion: Patients with HCC treated with CRT prior to LT achieved equivalent oncological results compared to those having no CRT. CRT represents a satisfactory alternative neoadjuvant therapy for patients with HCC not suitable for standard loco-regional therapies.

Clinicopathological examination of ESD as salvage therapy for esophageal cancer after definitive chemo-radiation therapy.

Background and study aims Salvage therapy for esophageal cancer following chemo-radiation therapy (CRT) has not been established. We aimed to evaluate endoscopic submucosal dissection (ESD) as a salvage therapy based on histopathological features of lesions. Patients and methods We compared 10 lesions in eight patients with local residual, recurrent, or metachronous esophageal squamous cell carcinoma treated by ESD after CRT (CRT group) and 59 lesions treated by ESD without CRT (non-CRT group) during the same period. Results The en bloc resection rate was 100 % while the complete resection rate was 80.0 % in the lesions after CRT, indicating no difference between the CRT and non-CRT groups. Pathological examination showed that fibrosis was more intense in the lamina propria mucosa, muscularis mucosa, and submucosa. The muscularis mucosa was thicker in both non-tumor and tumor sites in the CRT group compared to the non-CRT group. However, severe submucosal fibrosis was observed only in one lesion in the CRT group. The maximum diameter of the submucosal artery was significantly larger in the CRT group ( P < 0.001). Conclusions Compared to the non-CRT group, the lesions in the CRT group were accompanied by fibrosis while the muscularis mucosa were thicker; however, severe fibrosis of the submucosa was rare. It is important to dissect the muscularis mucosa appropriately during ESD, which makes successful dissection of the submucosa possible. Attention should be paid to bleeding from large arteries.

Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer.

The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not. This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups. In the non-CRT group (n=131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n=19), the optimal cutoff value was 5.0mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836. The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.

Efficacy and short-term outcomes of preoperative chemoradiotherapy with intermittent oral tegafur-uracil plus leucovorin in Japanese rectal cancer patients: a single center experience retrospective analysis

BackgroundVarious types of preoperative chemoradiotherapy (CRT) have been established for rectal cancer; thus,Physicians will need to refine the selection of appropriate preoperative CRT for different patients since there are various treatment regimens. Oral tegafur-uracil (UFT) plus leucovorin (LV) is commonly used to treat rectal cancer in Japan. Oral chemotherapy offers patients many potential advantages. Since 2008, we have been performing preoperative CRT with intermittent oral UFT plus LV in locally advanced rectal cancer patients to prevent postoperative local recurrence. Here, in a retrospective analysis, we evaluated the efficacy and short-term outcomes of preoperative CRT with intermittent oral UFT plus LV.MethodsWe analyzed data from 62 patients with locally advanced rectal cancer, including 31 patients who underwent preoperative CRT between 2009 and 2013 (the CRT group) and 31 patients who were treated with surgery alone between 2001 and 2008 (the non-CRT group). Clinicopathologically, both groups included patients with rectal cancer at clinical tumor stages 3-4 or clinical node stages 0-3. In the CRT group, curative operations were performed ≥8 weeks after CRT. Patients were concomitantly treated with 2 cycles of oral UFT (300 mg/m2/day, days 1–14 and 29–42) plus LV (75 mg/day, days 1–14 and 29–42) and 45 Gy of radiotherapy. Chemotherapy was repeated every 28 days, followed by a 2-week break.ResultsThe completion rate of CRT was high at 94% (n = 29/31). The downstaging rate of CRT was 61% (n = 19/31). The pathological complete response rate was 6.5% (n = 2/31). Significant differences were observed in the 3-year local recurrence rate between the two groups (P < 0.05).ConclusionsPreoperative CRT with intermittent oral UFT plus LV appears to be a tolerable and effective treatment for Japanese patients with rectal cancer. A further investigation of a diversification of preoperative CRT for Japanese rectal cancer patients is required.

Effects of neoadjuvant chemoradiotherapy on the rates of sphincter preserving surgery in lower rectal cancer and analysis of their prognostic factors

Objectives: To identify independent factors of sphincter preserving surgery, and to evaluated whether preoperative chemoradiotherapy (CRT) improves the sphincter preservation rate for lower rectal cancers. Methods: A total of 541 consecutive patients who underwent curative surgery for locally advanced rectal cancer (cT3-4Nx or cTxN+ ) within 6 cm of the anal verge with or without neoadjuvant CRT in Department of Colorectal Surgery, Union Hospital, Fujian Medical University between September 2000 and September 2013 were reviewed. Of these, 333 patients underwent surgery alone (Non-CRT group) and 208 patients also received preoperative chemoradiotherapy (CRT group). Clinical data were retrospectively reviewed to determine the factors influencing sphincter preservation, and to evaluate sphincter preservation rate according to tumor height over 1-cm intervals. The categorical variables were compared using χ2 test and Fisher exact test. Continuous variables were compared using t test. Logistic regression was used to identify factors influencing sphincter preservation. A receiver operating characteristic (ROC) curve was constructed, and Youden's index was calculated to evaluate the predictive abilities of factors. Results: Multivariate analysis indicated that the independent factors influencing sphincter preservation were tumor height (OR=5.867, 95% CI: 4.155 to 8.285, P=0.000), pathological T stage (OR=0.688, 95% CI: 0.462 to 1.025, P=0.066), CRT (OR=2.088, 95% CI: 0.971 to 4.492, P=0.060) and histopathological type (OR=0.288, 95% CI: 0.136 to 0.611, P=0.001). The results of ROC analysis showed that the cut-off points for factors affecting sphincter preservation were as follows: (1) tumor height prior to CRT higher than 4.5 cm, (2) not mucinous or signet ring adenocarcinoma, (3) pathological T stage higher than T3, (4) had received preoperative CRT. In an analysis according to tumor height, the sphincter preservation rate was higher in CRT group only when tumor was located in 3.0 to 3.9 cm and 4.0 to 4.9 cm from the annal verge (3.0 to 3.9 cm, 59.4% vs. 2.8%, χ2=26.138, P=0.000; 4.0 to 4.9 cm, 76.9% vs. 37.9%, χ2=10.563, P=0.001). Conclusions: There is a large increased rate of sphincter preservation when patients meet the following conditions: (1) tumor height prior to CRT higher than 4.5 cm, (2) not mucinous or signet ring adenocarcinoma, (3)pathological T stage higher than T3, (4) had received preoperative CRT. Only when tumors are between 3 and 5 cm from the anal verge, CRT could increase the rate of anal sphincter preservation.

Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer.

Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT. This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared. Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group. With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.

Significance of postoperative radiotherapy for stage II/III upper rectal cancer

Objective To investigate the value of postoperative adjuvant chemoradiotherapy (CRT) in the treatment of stage Ⅱ/Ⅲ upper rectal cancer. Methods A total of 3995 patients with rectal cancer were admitted to our hospital from 2000 to 2010. Among them, patients who were pathologically diagnosed with adenocarcinoma and underwent radical surgery were enrolled as subjects for retrospective analyses. Moreover, all selected patients had the lower margin of the tumor located within 10-16 cm from the anal verge, as determined by a colonofiberscope before surgery, and were pathologically staged as T3-4 or N0-2 M0 after surgery, according to the 7 th edition of American Joint Committee on Cancer tumor-node-metastasis staging system. Results A total of 547 patients were enrolled as subjects. The 5-year sample size was 249. In all patients, the 5-year overall survival (OS), disease-free survival, local recurrence-free survival (LRFS) , and distant metastasis-free survival rates were 79.0%, 76.8%, 94.0%, and 80.1%, respectively. One hundred and fifty-five patients were enrolled into either postoperative concurrent CRT group or postoperative non-CRT group, with the baseline characteristics balanced between the two groups by the propensity-score matching method (1:1). Patients who were staged as pT4b and had paracancerous nodules and lymph node metastases (stage N2) were enrolled into high-risk group. In the high-risk group, patients treated with postoperative CRT had significantly higher LRFS and OS rates than those treated with only surgery (96.3% vs. 82.0%, P = 0. 044; 81.6% vs. 59.1%, P=0.019). Conclusions Radical surgery achieves a good prognosis in patients with stage Ⅱ/Ⅲ upper rectal cancer, and postoperative CRT can further reduce the locoregional recurrence rate. Particularly, postoperative CRT/RT can substantially improve local and long-term outcomes in patients with high-risk factors. Key words: Upper rectal neoplasms/surgery; Upper rectal neoplasms/postoperative radiotherapy; Prognosis analysis

The impact of lymph node size to predict nodal metastasis in patients with rectal cancer after preoperative chemoradiotherapy.

During restaging after preoperative chemoradiotherapy (CRT), the assessment of lymph node (LN) metastasis is vital for selecting further treatment strategies. This study aimed to evaluate the impact of LN size to predict LN metastasis in rectal cancer patients after preoperative CRT. A total of 30 consecutive patients who underwent preoperative CRT followed by curative resection of primary rectal cancer were selected as a study group (CRT group). As a control group (non-CRT group), 30 patients who underwent primary tumor resection were selected using a 1:1 case-match design. Matching criteria were gender, age, and clinical T stage. The size of each LN was measured from the surgical specimen. To clarify optimal cutoff values for node size according to the risk of detecting metastasis, receiving-operator characteristic (ROC) curves were generated. In the non-CRT group, 39/474 LNs were confirmed to have metastasis. In the CRT group, 29/422 LNs showed metastasis. The median size of metastatic LNs was 6.0 mm in CRT group, which was significantly larger than 4.0 mm in the non-CRT group (p = 0.006). The optimal cutoff value for determining metastasis in the CRT group was 4.5 mm, compared to 3.5 mm in the non-CRT group. The accuracy of the cutoff value was much higher in the CRT group (CRT vs. non-CRT, 77.9 vs. 59.9%). LN size is a strong indicator for prediction of regional LN metastasis in rectal cancer patients after preoperative CRT, compared to those without CRT.

The Effect of Concomitant Cardiac Resynchronization Therapy on Quality of Life in Patients with Heart Failure Undergoing Cardiac Surgery

Objectives:To evaluate the effect of concomitant cardiac resynchronization therapy (CRT) on health related quality of life (QoL) in patients with heart failure (HF) and ventricular dyssynchrony undergoing cardiac surgery.Methods:Twenty-eight patients received permanent epicardial CRT in connection to coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) (CRT group). Thirty-seven HF patients without concomitant CRT served as a comparison group (non-CRT group). SF-36 was used to assess QoL in the two groups and was also compared with the general Swedish population.Results:The median follow-up time was 28 months after surgery (range 8 to 44 months). No difference in QoL could be shown between the CRT group and the comparison group. Several subscales of QoL in the CRT group were in range with the general Swedish population.Conclusion:Concomitant CRT for patients with HF and ventricular dyssynchrony undergoing CABG and/or AVR did not result in a higher estimated QoL compared to HF patients without CRT.