Non-resected Patients Research Articles

Role of Primary Tumour Resection and Addition of Bevacizumab to Chemotherapy in the Management of Advanced Colorectal Cancer with Inoperable Metastasis: A Retrospective Analysis

Purpose:To analyze the impact of primary tumour resection on treatment outcomes in patients with advanced colorectal cancer (CRC) and inoperable metastases at diagnosis in combination with optimal systemic therapy. Methods:A retrospective study was carried out in four hospitals in Valencia (Spain) including all consecutive patients diagnosed between 1/2009 and 12/2010 of advanced CRC with inoperable metastasis and treated with a fluoropyrimidine and oxaliplatin combination chemotherapy regimens with or without bevacizumab (B). Treatment outcomes were compared between patients undergoing or not primary tumour resection. Results:A total of 112 patients met inclusion criteria: 62 patients underwent resection of the primary tumour (Group 1) and 50 were treated with exclusive chemotherapy (Group 2). Globally, patients in group 2 presented more disfavorable characteristics. Forty-five (72%) and 31 (62%) patients received chemotherapy with bevacizumab respectively. Overallresponse rate(ORR) were 67% in Group 1 and 56% in Group 2. There were no statistically significant differences between the two groups in progression free survival (PFS) (12 vs. 10 months; p =0.11) and overall survival (OS) (27 vs. 22 months; p 0.1). B regimens increased ORR (73% vs. 42%; p = 0.003) and PFS (12 vs. 11 months; p = 0.019) but not OS. Complications were higher in the group of patients without primary tumour resection, particularly when associated to B regimens. Conclusions:Primary tumour resection offers no survival gain for patients with advanced CRC and inoperable metastases. Benefits of adding Bevacizumab to standard chemotherapy were similar in both groups, but it increases the risk of complications in non-resected patients.

Transarterial chemoembolization combined with sorafenib in treatment of middle stage hepatocellular carcinoma: efficacy and safety

Objective To evaluate the efficacy and safety of transarterial chemoembolization (TACE)combined with sorafenib in treatment of patients with non-resected middle stage hepatocellular carcinoma(HCC).Methods From July 2009 to July 2011,38middle stage HCC patients treated with TACE plus sorafenib were included in the TACE+sorafenib group and the other 38patients with similar baseline characteristics receiving TACE alone were selected in the TACE group.All the patients belonged to the Barcelona Clinic Liver Cancer(BCLC)stage B.The adverse events of the TACE+sorafenib group and the overall survival of the two groups were analyzed.Results All the patients treated with sorafenib experienced at least one drug-related adverse event during the study,including 7(18.4%)experienced drug-related grade 3adverse events,with no grade 4or higher adverse events occurred.The median overall survival time was 11months(95% CI:7.4-14.6months)for the TACE group and 15months(95% CI:8.4-21.6months)for the TACE+sorafenib group,showing significant difference between the two groups(P=0.019).Conclusion The combination of sorafenib with TACE is well tolerated in non-resected middle stage HCC patients,with no severe adverse events and can effectively improve the overall survival time of patients.

Palliative surgery in patients with unresectable colorectal liver metastases: a propensity score matching analysis

The current study was primarily intended to determine the best surgical treatment for patients with unresectable liver metastatic colorectal cancer (CRC). In addition, we assessed whether the improvement in survival resulting from palliative resection (PR) of the primary tumor was a function of the extent of liver metastasis. The demographics, tumor characteristics, and survival outcomes of 261 patients who underwent palliative surgery for unresectable liver metastatic CRC were analyzed. A propensity-score model was used to compare the group of patients receiving PR and non-resection (NR). There were 195 PR patients and 66 NR. The median survival of PR and NR patients was 21 months and 10 months, respectively (P < 0.001). In a Cox multivariate analysis of 51 propensity-score matched pairs, PR resulted in longer survival than NR (Hazard Ratio for NR 1.481; 95% confidence interval: 1.003-2.185; P = 0.048). The extent of liver metastasis only led to better survival of PR than NR patients among patients with limited liver metastasis not among those with extensive liver metastasis (P = 0.001). PR appears to result in better survival than NR when the patient's overall condition permits an aggressive approach, especially in patients with limited liver metastases.

Primary cardiac sarcomas: A retrospective study of the French Sarcoma Group

IntroductionPrimary cardiac sarcomas (PCS) are rare tumours of dismal prognosis. MethodsData of 124 patients with PCS referred to institutions of the French Sarcoma Group (FSG) from 1977 and 2010 were reviewed. ResultsMedian age was 48.8years. PCS were poorly-differentiated sarcomas (N=45, 36.3%), angiosarcomas (N=40, 32.3%), leiomyosarcomas (N=16, 12.9%) and others (N=23, 18.6%). At diagnosis, 100 patients (80.6%) were localised and 24 (19.4%) metastatic. Tumours were located in the right (N=47, 38.8%), left atrial cavities (N=45, 37.2%) or encompassed several locations in nine cases (7.4%). Surgery was performed in 81 cases (65.3%). Heart transplant was performed in five patients. Radiotherapy adjuvant (N=18, 14.5%) or alone (N=6, 4.8%) was performed in non-metastatic patients only (N=24, 19.4%). With a median follow-up of 51.2months, median overall survival (OS) was 17.2months for the entire cohort, 38.8months after complete resection versus 18.2 after incomplete resection and 11.2months in non-resected patients. Radiotherapy was associated with improved progression-free survival (PFS) on multivariate analysis. Chemotherapy was significantly associated with better OS only in non-operated patients but not in operated patients. In non-metastatic patients, surgery (hazard ratio [HR]=0.42, p<0.001), male gender (HR=0.56, p=.032) was associated with better OS and surgery (HR=0.61; p=.076), radiotherapy (HR=0.43; p=.004) and chemotherapy (HR=0.30, p=.003) improved PFS. ConclusionOnly surgical resection is associated with a perspective of prolonged survival. Chemotherapy is associated with a better outcome in non-resected patients.

Conversion chemotherapy followed by hepatic resection in colorectal cancer with initially unresectable liver-limited metastases

The best management choice in colorectal cancer patients with unresectable liver-only metastases should be represented by conversion chemotherapy aiming to reduce liver cancer deposits, thereby permitting curative surgery. Forty-eight consecutive stage IV colorectal cancer patients were treated with different chemotherapeutic regimens including biological drugs. Objective responses to chemotherapy were seen in 27 patients (56.2%; 95% CI 42.1-70.2%). Four patients (8.3%) showed complete response, 23 patients (47.9%) partial and 13 patients (27.1%) stable response. Eight patients (16.7%) progressed. The conversion rate was 35.4% (95% CI 21.8-48.9%) with 17 patients suitable for liver resection. Four complete responder patients refused surgery. The remaining 13 patients underwent curative hepatic resection (resection rate 27.1%; 95% CI 14.5-39.6%). The likelihood of a successful conversion chemotherapy appeared significantly related to the best response and to the K-Ras status. Wild-type K-Ras patients undergoing cetuximab therapy showed the best conversion rate. The four-year survival rate was significantly enhanced in converted compared to non-converted patients (57.1 and 0%, respectively), and in resected compared to non-resected patients (53.3 and 10.1%, respectively). Synchronous metastases and no conversion were shown to be the only covariates independently associated with a poorer long-term outcome. The possibility of curative liver surgery significantly prolongs outcome for colorectal cancer patients with unresectable liver-limited metastases. Prospective randomized trials are required to define the conversion rates with biological drugs.

Contemporary management of perihilar cholangiocarcinoma in a nontransplant hepatopancreatobiliary center

Perihilar cholangiocarcinoma (PHCC) is a rare tumor with a poor prognosis. Outcomes may be optimized by centralization. Recent trends suggest further improvement by localization to transplant centers. This study examines outcomes from the management of PHCC in a nontransplant hepatopancreatobiliary center. Data were collected prospectively from patients undergoing treatment for PHCC from October 1999 to May 2011. Twenty-four patients underwent surgery. A further 54 patients had inoperable PHCC. Outcome data are reported. Twenty-two of 24 patients required liver resection with histological R0 status in 12 (50%). In-hospital mortality occurred in two (8%). The mean survival of patients undergoing resection was 39 (95% CI: 16-61) months. The mean survival of nonresected patients was 5 (95% CI: 3-7) months (P<0.0001; log-rank; Mantel-Cox test). Currently acceptable standards of holistic care for patients with PHCC can be provided in a nontransplant regional hepatopancreatobiliary center. Further centralization may improve resection volumes and allow more patients to benefit from extended liver resection techniques.

Evaluation of prognostic factors in liver-limited metastatic colorectal cancer: a preplanned analysis of the FIRE-1 trial

Background:Liver-limited disease (LLD) denotes a specific subgroup of metastatic colorectal cancer (mCRC) patients.Patients and Methods:A total of 479 patients with unresectable mCRC from an irinotecan-based randomised phase III trial were evaluated. Patients with LLD and non-LLD and hepatic resection were differentiated. Based on baseline patient characteristic, prognostic factors for hepatic resection were evaluated. Furthermore, prognostic factors for median overall survival (OS) were estimated via Cox regression in LLD patients.Results:Secondary liver resection was performed in 38 out of 479 patients (resection rate: 7.9%). Prognostic factors for hepatic resection were LLD, lactate dehydrogenase (LDH), node-negative primary, alkaline phosphatase (AP) and Karnofsky performance status (PS). Median OS was significantly increased after hepatic resection (48 months), whereas OS in LLD (17 months) and non-LLD (19 months) was comparable in non-resected patients. With the inapplicability of Koehne's risk classification in LLD patients, a new score based on only the independent prognostic factors LDH and white blood cell (WBC) provided markedly improved information on the outcome.Conclusion:Patients undergoing hepatic resection showed favourable long-term survival, whereas non-resected LLD patients and non-LLD patients did not differ with regard to progression-free survival and OS. The LDH levels and WBC count were confirmed as prognostic factors and provide a useful and simple score for OS-related risk stratification also in LLD.

Palliative Resection for Advanced Gastric and Junctional Adenocarcinoma: Which Patients will Benefit from Surgery?

Whereas palliative chemotherapy offers a median survival of approximately 10months in advanced gastric and junctional adenocarcinoma (AGJA), the survival impact of primary tumor resection is controversial. Our purpose was to identify which AGJA patients benefit from palliative resection. In 3,202 AGJA patients scheduled for surgery in 21 French centers between 1997 and 2010, prognostic factors were identified in palliative group and the impact of each combination of these factors on survival was studied. Surgery was defined as palliative due to solid organ metastasis (5.6%), localized (4.6%) or diffuse (2.3%) peritoneal carcinomatosis (PC), or incomplete tumoral resection (12.8%). Median survival of AGJA patients resected with a palliative intent (n=677) was longer than in nonresected patients (n=532; 11.9 vs. 8.5months, P<0.001). Multivariable analyses identified ASA score III-IV (P<0.001) as a predictor of postoperative mortality and solid organ metastasis (P=0.009), localized PC (P=0.004), diffuse PC (P=0.046), and signet ring cell histology (SRC; P=0.02) as predictors of survival. Only ASA I-II patients with incomplete resection without metastasis or PC, one site solid organ metastasis without PC, or localized PC without SRC had a survival benefit after palliative surgery with median survivals from 12.0 to 18.3months. Nonresected ASA I-II patients with same risk factors had median survivals from 3.5 to 8.8months (P<0.05 for each). In AGJA, patient and tumor-related factors should be used to select candidates for palliative surgery in association with chemotherapy.

Induction gemcitabine and oxaliplatin therapy followed by a twice‐weekly infusion of gemcitabine and concurrent external‐beam radiation for neoadjuvant treatment of locally advanced pancreatic cancer

Chemoradiotherapy (CRT) may render curative resection feasible in patients with locally advanced pancreatic carcinoma (LAPC). The authors previously demonstrated the achievement of significant disease control and a median survival of 14 months by CRT in patients with LAPC. In this study, they evaluated the use of induction chemotherapy followed by a CRT neoadjuvant protocol. Patients first received induction gemcitabine and oxaliplatin (GEMOX) (gemcitabine 1000 mg/m(2), oxaliplatin 100 mg/m(2)). Patients without disease progression then received gemcitabine twice weekly (50 mg/m(2) daily) concurrent with radiotherapy (50.4 grays) and were re-evaluated for resectability. Thirty-nine patients (15 with borderline resectable disease and 24 with unresectable disease) entered the study. The treatment was well tolerated. Disease control was obtained in 29 of 39 patients. Two patients progressed after GEMOX, and 7 progressed after CRT. After a median follow-up of 13 months, the median progression-free survival (PFS) was 10.2 months. The median PFS of patients with borderline resectable and unresectable disease was 16.6 and 9.1 months, respectively (P = .056). For the whole group, the median overall survival (OS) was 16.7 months (27.8 months for patients with borderline resectable disease, 13.3 for patients with unresectable disease; P = .045). Eleven patients (9 with borderline resectable disease and 2 with unresectable disease at diagnosis) underwent successful resection. Patients who underwent resection had a significantly longer median PFS compared with nonresected patients (19.7 months vs 7.6 months, respectively). The median OS among resected and nonresected patients was 31.5 months and 12.3 months, respectively (P < .001). The current results indicated that induction GEMOX followed by CRT is feasible in patients with LAPC. Both those with borderline resectable disease and those with unresectable disease received clinical benefit, a chance to obtain resectability, and improved survival. The authors concluded that this protocol warrants further evaluation.

PWE-168 Palliative resection for advanced gastric and junctional adenocarcinoma (AGJA): which patients will benefit from surgery?

IntroductionWhereas palliative chemotherapy offers median survival of 10 months in AGJA, the survival impact of associated primary tumour resection is controversial. The objective of this study was to identify which...

Neoadjuvant chemoradiation with Gemcitabine for locally advanced pancreatic cancer

IntroductionTo evaluate efficacy and secondary resectability in patients with locally advanced pancreatic cancer (LAPC) treated with neoadjuvant chemoradiotherapy (CRT).Patients and methodsA total of 215 patients with locally advanced pancreatic cancer were treated with chemoradiation at a single institution. Radiotherapy was delivered with a median dose of 52.2 Gy in single fractions of 1.8 Gy. Chemotherapy was applied concomitantly as gemcitabine (GEM) at a dose of 300 mg/m2 weekly, followed by adjuvant cycles of full-dose GEM (1000 mg/m2). After neoadjuvant CRT restaging was done to evaluate secondary resectability. Overall and disease-free survival were calculated and prognostic factors were estimated.ResultsAfter CRT a total of 26% of all patients with primary unresectable LAPC were chosen to undergo secondary resection. Tumour free resection margins could be achieved in 39.2% (R0-resection), R1-resections were seen in 41.2%, residual macroscopic tumour in 11.8% (R2) and in 7.8% resection were classified as Rx. Patients with complete resection after CRT showed a significantly increased median overall survival (OS) with 22.1 compared to 11.9 months in non-resected patients. Median OS and disease-free survival (DFS) of all patients were 12.3 and 8.1 months respectively. In most cases the first site of disease progression was systemic with hepatic (52%) and peritoneal (36%) metastases.DiscussionA high percentage of patients with locally advanced pancreatic cancer can undergo secondary resection after gemcitabine-based chemoradiation and has a relative long-term prognosis after complete resection.

Non-curative gastric resection for patients with stage 4 gastric cancer—a single center experience and current review of literature

The majority of patients with gastric cancer present with an advanced stage and, therefore, may not be eligible for curative treatment. The role of non-curative gastric resection in situations other than emergency treatment for life threatening tumor-related complications is still under discussion. Data from 290 consecutive patients with advanced gastric cancer who were treated in our hospital were analyzed. A total of 48 patients underwent primary non-curative gastric resection. The overall survival in the non-curatively resected group was 15 months and 6 months for non-resected patients, respectively (p < 0.001). The incidence of tumor-related complications which required intervention was 63% in non-resected patients as compared to 12% in patients who underwent primary non-curative resection. Younger age, less than three tumor locations, and chemotherapy have been identified as prognostic factors for improved survival by univariate analysis. D3 lymph node involvement and chemotherapy were independent prognostic factors in the multivariate analysis. Peritoneal carcinosis did not significantly influence survival in resected patients. Non-curative resection in combination with chemotherapy resulted in longer overall survival than resection alone. Primary non-curative gastric resection can reduce the incidence of severe tumor-related complications and can prolong overall survival in selected subgroups. In particular, younger patients with no more than two tumor locations should be considered for this procedure.

Evaluation of the necessity of primary tumor resection for synchronous metastatic colorectal cancer.

592 Background: Recent advances in chemotherapy have improved survival in patients with metastatic colorectal cancer. Resection of primary tumor for patients with metastatic colorectal cancer remains controversial. Primary tumor with obstruction or bleeding may be recommended to resection pior to chemotherapy. In contrast, it should be considered potential complications associated with resection of primary tumor and disadvantage of the delay in chemotherapy. Here, we evaluate the needs of primary tumor resection for colorectal cancer patients with synchronous metastases. Methods: A retrospective analysis of patients with synchronous metastatic colorectal cancer treated at Kumamoto University Hospital between April, 2005 and December, 2009 was performed. We compared the survival of resected patients and non-resected patients. Results: 104 patients were identified. Sixty-four and 40 patients were included in the resected group and the non-resected group respectively. The mean follow-up time was 16.1 months. Median age was 61.9 and 64.3 years respectively. The non-resected group was more likely to have right-sided tumors (resected: 28%, non-resected: 43%). The number of patient with metastatic disease limited to the liver was similar in both group(resected: 48%, non-resected: 50%). In the resected group, 12 patients (18%) developed postoperative complications. In the nonresected group, 5 patients (12.5%) required creation of a diverting colostomy during the course of their treatment due to obstruction, and 2 patients (5%) required emergency surgical treatment for intestinal perforation due to the primary tumor. No significant difference in survival was observed between the groups, (logrank P=0.33). Median survival period was not significantly different (resected: 27.3 months, non-resected: 21.5 months, P=0.43). Conclusions: We concluded that it was not necessary to resect the primary lesion in patients with synchronous metastatic colorectal cancer when obstruction or bleeding was not found in primary lesions.

Clinical benefit of radiation therapy and metallic stenting for unresectable hilar cholangiocarcinoma

To determine the efficacy of external beam radiotherapy (EBRT), with or without intraluminal brachytherapy (ILBT), in patients with non-resected locally advanced hilar cholangiocarcinoma. We analyzed 64 patients with locally advanced hilar cholangiocarcinoma, including 25 who underwent resection (17 curative and 8 non-curative), 28 treated with radiotherapy, and 11 who received best supportive care (BSC). The radiotherapy group received EBRT (50 Gy, 30 fractions), with 11 receiving an additional 24 Gy (4 fractions) ILBT by iridium-192 with remote after loading. ILBT was performed using percutaneous transhepatic biliary drainage (PTBD) route. Uncovered metallic stents (UMS) were inserted into non-resected patients with obstructive jaundice, with the exception of four patients who received percutaneous transhepatic biliary drainage only. UMS were placed endoscopically or percutaneously, depending on the initial drainage procedure. The primary endpoints were patient death or stent occlusion. Survival time of patients in the radiotherapy group was compared with that of patients in the resection and BSC groups. Stent patency was compared in the radiotherapy and BSC groups. No statistically significant differences in patient characteristics were found among the resection, radiotherapy, and BSC groups. Three patients in the radiotherapy group and one in the BSC group did not receive UMS insertion but received PTBD alone; cholangitis occurred after endoscopic stenting, and patients were treated with PTBD. A total of 16 patients were administered additional systemic chemotherapy (5-fluorouracil-based regimen in 9, S-1 in 6, and gemcitabine in 1). Overall survival varied significantly among groups, with median survival times of 48.7 mo in the surgery group, 22.1 mo in the radiotherapy group, and 5.7 mo in the BSC group. Patients who underwent curative resection survived significantly longer than those who were not candidates for surgery (P = 0.0076). Cumulative survival in the radiotherapy group was significantly longer than in the BSC group (P = 0.0031), but did not differ significantly from those in the non-resection group. Furthermore, the median survival time of patients in the radiotherapy group who were considered for possible resection (excluding the seven patients who were not candidates for surgery due to comorbid disease or age) was 25.9 mo. Stent patency was evaluated only in the 24 patients who received a metallic stent. Stent patency was significantly longer in the radiotherapy than in the BSC group (P = 0.0165). Biliary drainage was not eliminated in any patient. To determine the efficacy of ILBT, we compared survival time and stent patency in the EBRT alone and EBRT plus ILBT groups. However, we found no significant difference in survival time between groups or for stent patencies. Hemorrhagic gastroduodenal ulcers were observed in 5 patients (17.9%), three in the EBRT plus ILBT group and two in the EBRT alone group. Ulcers occurred 5 mo, 7 mo, 8 mo, 16 mo, and 29 mo following radiotherapy. All patients required hospitalization, but blood transfusions were unnecessary. All 5 patients recovered following the administration of anti-ulcer medication. Radiotherapy improved patient prognosis and the patency of uncovered metallic stents in patients with locally advanced hilar cholangiocarcinoma, but ILBT provided no additional benefits.

Thyroid cancers with laryngotracheal invasion

Management of thyroid cancers with laryngotracheal invasion is controversial. A retrospective analysis of our database found 69 patients (38 females, mean age 59.6 ± 11.6) between March 1995 and July 2010; of them 42 (61%) were managed by non-resectional methods due to the extensive airway or regional involvement, severe co-morbidities, diffuse metastases or patient's preference. Segmental airway resection was performed in 27 (39%) patients; concurrent with thyroidectomy in 17 (Immediate group (IG)), and as a delayed procedure in 10 referred patients (Delayed group (DG)), who had previously undergone thyroidectomy with conservative airway management, like shaving procedures. Follow-up was completed in 81% of patients with a mean duration of 30 months. Tracheal or laryngotracheal resection and reconstruction was performed in 18, laryngectomy in eight and pharyngolaryngectomy in one patient. There were two anastomotic dehiscence (11.1%), one resulted in mortality (3.7%). One or a combination of bronchoscopic core-out, laser, tracheostomy and stent placement was performed in 42 non-resected patients with two mortalities (4.7%). Overall 1-, 2-, 3- and 5-year survival was 85, 85, 68 and 49% in resected group, as well as 56, 46, 40 and 31% in non-resected group (P = 0.049), respectively. Among resected group, the overall 1-, 2-, 3- and 5-year survival was 92, 92, 76 and 61% in the IG as well as 75, 75, 56 and 28% in the DG (P = 0.43). Complete segmental airway resection during or even after thyroidectomy could be safely performed, might be curative and may be associated with improved survival.

Elevated urinary levels of urokinase-type plasminogen activator receptor (uPAR) in pancreatic ductal adenocarcinoma identify a clinically high-risk group

BackgroundThe urokinase plasminogen activator receptor is highly expressed and its gene is amplified in about 50% of pancreatic ductal adenocarcinomas; this last feature is associated with worse prognosis. It is unknown whether the level of its soluble form (suPAR) in urine may be a diagnostic-prognostic marker in these patients.MethodsThe urinary level of suPAR was measured in 146 patients, 94 pancreatic ductal adenocarcinoma and 52 chronic pancreatitis. Urine from 104 healthy subjects with similar age and gender distribution served as controls. suPAR levels were normalized with creatinine levels (suPAR/creatinine, ng/mg) to remove urine dilution effect.ResultsUrinary suPAR/creatinine values of pancreatic ductal adenocarcinoma patients were significantly higher (median 9.8; 25th-75th percentiles 5.3-20.7) than those of either healthy donors (median 0; 0-0.5) or chronic pancreatitis patients (median 2.7; 0.9-4.7). The distribution of values among cancer patients was widespread and asymmetric, 53% subjects having values beyond the 95th percentile of healthy donors. The values of suPAR/creatinine did not correlate with tumour stage, Ca19-9 or CEA levels. Higher values correlated with poor prognosis among non-resected patients at univariate analysis; multivariate Cox regression identified high urinary suPAR/creatinine as an independent predictor of poor survival among all cancer patients (odds ratio 2.10, p = 0.0023), together with tumour stage (stage III odds ratio 2.65, p = 0.0017; stage IV odds ratio 4.61, p < 0.0001) and female gender (odds ratio 1.85, p = 0.01).ConclusionsA high urinary suPAR/creatinine ratio represents a useful marker for the identification of a subset of patients with poorer outcome.

Overall survival peri‐hilar cholangiocarcinoma: R1 resection with curative intent compared to primary endoscopic therapy

Patients with peri-hilar cholangiocarcinoma who undergo R1 resection with curative intent will have an improved survival compared to patients who were not resected. Review of a prospective hepatobiliary database identified 130 patients. Survival was compared using the log-rank test. Seventy-nine patients (61%) were resected while 51 (49%) patients were not. Forty-two patients (54%) had an R0 resection. There was no difference in mean age (69 vs. 67; P = 0.8), BMI (27.8 vs. 27.9; P = 1.0), gender (73% vs. 43% male; P = 0.1), presence of jaundice (77% vs. 64%; P = 0.5), vascular involvement on pre operative imaging (77% vs. 64%; P = 0.5), stent (73.1% vs. 64.3%; P = 0.72), and lobar atrophy (27% vs. 7%, P = 0.2) in the resected versus non-resected patients. All patients underwent chemotherapy and/or radiation therapy. After a median follow up of 35.6 months the median OSl for all peri-hilar patients was 16.2 months (95% CI = 11.2-23.4). The median OS for resected patients was 18.9 months (95% CI = 12.5-24.7) versus 5.0 months (95% CI = 0-6.9) for patients not resected (P < 0.001). The only pre-operative predictor of OS was resection (P = 0.041). Vascular invasion, lobar atrophy, and stent placement were not statistically significant predictors. Overall survival is improved in patients undergoing R1 resection and multi-modality therapy compared to patients not resected.

A population-based analysis on the rate and surgical management of colorectal liver metastases in Southern Germany

Early detection and multidisciplinary treatment of colorectal liver metastases (CLM), preferably resection, can significantly prolong the survival of colorectal cancer patients. The purpose of this study was to analyze the incidence, management and long-term clinical outcome of CLM patients using data from a regional German tumour registry. We conducted a retrospective analysis of 884 patients diagnosed with colorectal adenocarcinoma in the year 2002 and documented in a regional tumor registry in Southern Germany. Two hundred thirty-six patients (26.7%) had or developed CLM, 132 patients (14.9%) had synchronous CLM and 104 patients (11.8%) developed metachronous CLM. At diagnosis of CLM, 86 patients (36.4%) had 3 or less documented lesions, 6 patients (2.5%) had 4 to 6 lesions and 89 patients (37.7%) showed multiple, diffuse metastases; for 55 patients (23.3%), the number of lesions was not specified. CLM patients (19.1%) (5.1% of all patients) underwent liver resection; a higher resection rate (28.3%) was observed in a subgroup of patients treated in two academic centres. Patients without CLM had a significantly better 5-year survival rate than patients with liver metastases (65.5% versus 16.3%). CLM patients with up to 3 liver metastases (i.e., potentially resectable) who underwent liver resection (n=34) showed a significantly higher 5-year survival than non-resected (n=52) patients (40% versus 5%). The present study is the first population-based analysis of the surgical management and outcome of CLM in Southern Germany. The percentage of liver resections was lower than expected, particularly for patients with three or less metastases. The present data suggest that relevant undertreatment of CLM patients may occur which may have a negative impact on survival.

Prognostic value of jaundice in patients with gallbladder cancer by the AFC-GBC-2009 study group

Introduction Jaundice is frequent in patients with gallbladder cancer (GBC) and indicates advanced disease and, according to some teams, precludes routine operative exploration. The present study was designed to re-assess the prognostic value of jaundice in patients with GBC. Methods Patients with GBC operated from 1998 to 2008 were included in a retrospective multicenter study (AFC). The main outcome measured was the prognostic value of jaundice in patients with GBC focusing on morbidity, mortality and survival. Results A total of 110 of 429 patients with GBC presented with jaundice, with a median age of 66 years (range: 31–88). The resectability rate was 45% ( n = 50) and the postoperative mortality and morbidity rates were 16% and 62%, respectively; 71% had R0 resection and 46% had lymph node involvement. Overall 1- and 3-year survivals of the 110 jaundiced patients were 41% and 15%, respectively. For the 50 resected patients, 1- and 3-year survivals were 48% and 19%, respectively (real 5-year survivors n = 4) which were significantly higher than that of the 60 non-resected patients (31%, 0%, p = 0.001). Among the resected jaundiced patients, T-stage, N and M status were found to have a significant impact on survival. R0 resection did not increase the overall survival in all resected patients, but R0 increased median survival in the subgroup of N0 patients (20 months versus 6 months, p = 0.01). Conclusion This series confirms that jaundice is a poor prognostic factor. However, the presence of jaundice does not preclude resection, especially in highly selected patients (N0).

Carcinoid lung tumors – incidence, treatment and outcomes: a population-based study

Few published reports have examined the incidence and outcomes for patients with carcinoid lung tumors. The aim of the current study was to explore incidence, type of surgical treatment given, and outcome for patients with typical (TC) and atypical (AC) lung carcinoids in a national cohort (Norway). All lung-cancer patients diagnosed in the period 1993-2005 and who were reported to the Cancer Registry of Norway were identified. Biopsies or resection specimens were reviewed and reclassified according to the World Health Organization (WHO) 2004 classification. Surgically treated patients were staged according to the seventh edition of the pathological tumor-node-metastasis (pTNM) staging system. Of 26665 lung cancers registered during the period, 265 (1%) had carcinoid tumors, of which 11 were diagnosed coincidentally at autopsy. In the remaining 254 patients, TCs were found in 188 cases, and ACs were found in 59 cases; seven cases had unclassifiable carcinoids. Of the 217 resected tumors, 173 (80%) were TCs. General surgeons performed 94 resections, including 11 of 17 pneumonectomies. All six bronchial resections were performed by thoracic surgeons. Of the 33 operated patients who died during follow-up, 18 had metastatic carcinoid tumors, of which 10 (56%) were ACs. In 37 non-resected patients (15 with AC and seven with unclassifiable histology), metastatic or locally advanced disease (N=21, 12 of which were ACs) was the main cause of inoperability and death. Five-year survival for all patients was 92% for TC and 66% for AC; for resected patients, the survival rates were 96% and 79%, respectively. Carcinoids are rare malignant tumors and are, in most cases, resectable; the TC subgroup had better prognosis than the AC in univariate analyses. The main cause of death was metastasis/locally advanced tumor at presentation or recurrent disease following resection; both situations were three times more common in patients with AC.