Palliative Surgical Resection Research Articles

Abstract 17445: Near Occlusion of the Tricuspid Valve By Metastatic Melanoma

Introduction: Metastatic tumors to the heart can have varied clinical presentations depending on location. We present a case of right atrial (RA) metastatic melanoma with near obstruction of the tricuspid valve resulting in significant hypoxia. Case Presentation: A 34-year-old man with a history of retinoblastoma and astrocytoma presented to the emergency department with 2 weeks of progressively worsening shortness of breath. On examination he was hypoxic and in respiratory distress. Computed tomography of the chest with contrast showed a large hypoattenuating homogeneous mass in the RA that protruded into the right ventricle and extended to the superior and inferior vena cavae. Transthoracic echocardiography (TTE) showed a large (9.1 x 4.6 cm) echodensity filling the RA and almost completely obstructing the tricuspid valve. Due to worsening hypoxia, the patient underwent palliative surgical resection of the mass. Intraoperatively, the mass was densely adherent to all walls of the RA. Surgical pathology identified the mass as metastatic malignant melanoma. The patient was started on pembrolizumab and discharged home in stable condition. At his 1-month follow-up, his symptoms had improved and he had returned to work. Discussion: Metastases to the heart are more common than primary cardiac tumors. Left-sided cardiac masses are commonly benign, whereas right-sided masses raise suspicion for metastatic disease. Melanoma, lymphoma, leukemia, and breast and lung cancers commonly metastasize to the heart. The size of the RA mass in this patient was significant enough to cause hypoxia and near occlusion of the tricuspid valve. Successful palliative resection of the mass resulted in a large improvement in symptoms. Conclusion: As the incidence of malignant melanoma increases, clinicians need to have a high index of suspicion for cardiac metastasis. Early identification of cardiac metastasis is critical as these cases can often be associated with poor prognosis.

A rare metastatic mesenteric malignant PEComa with TSC2 mutation treated with palliative surgical resection and nab-sirolimus: a case report

BackgroundMalignant perivascular epithelioid cell tumors (PEComas) are exceedingly rare malignant mesenchymal neoplasms with characteristic morphological and immunohistochemical (IHC) patterns. However, some malignant PEComas are poorly differentiated with atypical histopathological features, making a definitive diagnosis difficult. PEComas are most commonly found in females and often show either TSC1 or TSC2 alterations, which result in the activation of the mTOR pathway, or TFE3 fusions. Given these molecular characteristics, mTOR inhibitors have recently been approved by the FDA in the treatment of malignant PEComas, particularly in those with TSC1/2 alterations. Therefore, molecular analyses may be helpful for both the diagnostic workup of and predicting response to mTOR inhibitors in cases of malignant PEComas.Case presentationHere, we report a case of an aggressive, 23 cm mesenteric malignant PEComa with multiple peritoneal metastases in a young male patient. Pathological examination of the initial biopsy showed a malignant epithelioid neoplasm with high-grade morphology and atypical immunoprofile, which precluded a definitive diagnosis. Because of the patient’s excessive transfusion requirements due to intra-tumoral hemorrhage, a palliative R2 resection was performed. Histopathological examination of the tumor revealed focal immunoreactivity for Melan-A, HMB-45, desmin, and CD117. Although a diagnosis of malignant PEComa was favored, other entities such as epithelioid gastrointestinal stromal tumor (GIST) or melanoma could not be definitively ruled out. Given the favored diagnosis, the patient was started on sirolimus, an mTOR inhibitor, rather than chemotherapy. Molecular analyses were performed and the tumor was found to harbor mutations in TP53 and TSC2, supporting a definitive diagnosis of malignant PEComa. The patient was then switched to nab-sirolimus, with initial stabilization of the disease.ConclusionsThis report details a multidisciplinary approach for the diagnosis and management of a highly aggressive, metastatic malignant PEComa in a young male patient. The basis for the treatment of malignant PEComas with the recently FDA-approved mTOR inhibitor, nab-sirolimus, is also reviewed. In summary, this case highlights the importance of molecular analysis, particularly TSC1/2 alterations, for both the definitive diagnosis of malignant PEComas and predicting their response to nab-sirolimus.

Current status of diagnosis and treatment of gastric cancer peritoneal metastasis

Peritoneal metastasis is the most common distant metastasis of gastric cancer. As an end-stage event of gastric cancer, patients with peritoneal metastasis often have lost the chance of radical resection, and even after palliative surgical resection, the long-term outcomes are still not satisfactory. In recent years, with the application and promotion of laparoscopic technology, neoadjuvant intraperitoneal and systemic chemotherapy, hyperthermic intraperitoneal chemotherapy and cytoreductive surgery, through perioperative comprehensive treatment strategies by multidisciplinary team, the quality of life and survival of patients with peritoneal metastasis have been significantly improved. Some patients with gastric cancer peritoneal metastasis diagnosed by laparoscopy even get the opportunity to have radical cytoreductive surgery and hyperthermic intraperitoneal chemotherapy after neoadjuvant intraperitoneal and systemic chemotherapy. Taking into account the progress in the treatment of gastric cancer peritoneal metastasis in recent years, this article intends to combine current clinical evidence and to discuss the key issues in the course of clinical diagnosis and treatment of gastric cancer peritoneal implantation and metastasis, including the imaging diagnosis of peritoneal metastasis, laparoscopic examination, evaluation of peritoneal metastasis and comprehensive treatment plan.

Multidisciplinary Management of Orbital Metastasis and Survival Outcomes.

To study the multidisciplinary management and survival outcomes of orbital metastasis (OM). All patients with a diagnosis of OM treated during 1999-2019 were included. Clinical data were retrospectively collected and analyzed. The study included 118 patients, 71 females and 47 males, with a median age of 61 years. The most common primary tumor types were breast carcinoma (43 patients), melanoma (17), and lung (13), thyroid (7), renal cell (6), and neuroendocrine carcinoma (6). Ninety-six patients had a known history of cancer at OM diagnosis. The median time from diagnosis of primary cancer to OM was 31 months (range, 0-304). In 22 patients, OM was the first sign of cancer. In 47 patients, the orbit was the only site of metastasis. The most common presenting features were restricted by extraocular motility (77 patients) and proptosis (61). Eight patients had enophthalmos. OM was diagnosed based on clinical history and imaging studies in 81 patients and orbital biopsy in 37. One hundred nine patients were treated with chemotherapy and immunotherapy, 75 with radiation, and 21 with palliative surgical resection. Eighty-two patients died during follow up. The median overall survival (OS) time after diagnosis of OM was 17 months (95% CI: 12-28). OM from renal cell carcinoma was associated with the best and OM from thyroid cancer with the worst OS. Patients with breast cancer had longer median survival (28 months; 95% CI: 15-60) than patients with lung, melanoma, neuroendocrine, or thyroid cancer. In this large series, breast cancer and melanoma were the most common causes of OM. Most patients had a known history of cancer at OM diagnosis and did not require orbital biopsy to confirm the diagnosis. Patients with renal cell carcinoma and breast carcinoma had the best prognosis after diagnosis of OM.

Combination versus single-agent as palliative chemotherapy for gastric cancer

BackgroundAlthough combination chemotherapy (CC) is generally recommended in recurrent or primary metastatic gastric cancer (RPMGC), the results of randomized trials are conflicting.MethodsA retrospective review was conducted on 687 RPMGC patients who received palliative chemotherapy. We compared the overall survival (OS) between CC and single-agent chemotherapy (SC) among these patients, and we analyzed the clinicopathological characteristics affecting outcome including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR).ResultsAlthough 521 patients (75.8%) underwent CC, SC was more frequently performed in elderly patients (57.6%) and ECOG performance status (PS) 2 or 3 (65.8%) patients (p < 0.0001, in each case). The median OS of patients who received CC was significantly longer than that of patients who received SC (11 vs. 8 months, p < 0.0001). No difference in OS between CC and SC was observed in elderly patients (p = 0.583), poor PS (p = 0.810), signet ring cell (p = 0.347), palliative surgical resection (p = 0.307), and high PLR (p = 0.120), with a significant interaction between age and type of regimen (p = 0.012). Moreover, there was no difference in OS between CC and SC after propensity score matching (p = 0.322). Multivariate analysis revealed that palliative resection and ≥ second-line chemotherapy were independently associated with favorable OS (p < 0.0001, in each case), whereas poor PS (p = 0.004), signet ring cell (p < 0.0001), peritoneal metastasis (p = 0.04), high NLR (p = 0.001), and high PLR (p = 0.033) were independent prognostic factors of poor OS.ConclusionsAlthough CC is the standard of care in RPMGC, SC can be considered a reasonable option in certain subgroups, such as elderly patients.

Retrospective analysis on resectability, survival and disease free survival prognostic factors in patients with pancreatic adenocarcinoma

Background: Pancreatic cancer is the fourth leading cause of cancer death, and its prognosis remains poor despite recent advances in treatment. Our goal was to determine prognostic factors associated with pancreatic cancer outcome by retrospective analysis of the clinical characteristics and follow-up data of patients who received palliative or curative surgical treatment. Methods: In this retrospective study, we analyzed the medical records and follow-up information of 344 pancreatic cancer patients who received curative or palliative surgical treatment at a tertiary care referral center in Greece from January 2004 to December 2015. The overall survival (OS) and disease free survival (DFS) rates were determined by the Kaplan- Meier method and univariate analysis was conducted to identify potential prognostic factors. Multivariate analysis, using the Cox proportional hazards model, was conducted to define independent prognostic factors. Results: Among the 344 patients with resectable tumors in the study cohort, 226 and 118 patients, respectively, underwent curative and palliative surgical resection. The median survival after curative resection was statistically higher compared to palliative resection (23.129 vs. 5.025months, p<0.05). The estimated 1-, 3-, and 5-year OS rates after curative resection were 35.84%, 15.48%, and 6.19% respectively. Univariate and multivariate analyses identified the following independent prognostic factors for OS: microvacular invasion, neutrophil to lymphocyte ratio (NLR), modified Glasgow prognostic score (mGPS) and lymph node ratio (LNR). Additionally, microvascular invasion, NLR >5 and PLR >160 were independent prognostic factors for DFS. Conclusion: Surgery remains the only curative therapy in pancreatic cancer treatment. Inflammation markers and LNR should be thoroughly assessed as independent prognostic factors in pancreatic cancer patients

The role of surgical resection before palliative chemotherapy in advanced gastric cancer

The role of palliative surgical resection in recurrent or metastatic gastric cancer is still controversial. A retrospective review was conducted on 689 patients who received palliative chemotherapy for recurrent (n = 307) or primary metastatic (n = 382) gastric cancer. Among 131 patients (89 primary metastatic and 42 recurrent) with surgical resection before chemotherpay, 75 underwent gastrectomy, 42 metastasectomy, and 14 gastrectomy with metastasectomy. The median overall survival (OS) of patients who underwent surgical resection was significantly longer than that of patients who received chemotherapy alone (18 vs. 9 months, p < 0.0001). The OS benefit of surgical resection was consistent across subgroups. In multivariate analysis, surgical resection was independently associated with favorable OS (hazard ratio = 0.42, p < 0.0001). Moreover, patients with surgical resection showed favorable OS both in univariate (p < 0.0001) and multivariate (p < 0.0001) analysis even after propensity score matching. In addition, the median OS of patients who underwent gross complete resection (n = 54) was significantly longer than that of patients who underwent incomplete resection (n = 77) (30 vs. 15 months, p = 0.002). The present study suggests that judicious use of surgical resection before chemotherapy in recurrent or metastatic gastric cancer patients may result in a favorable outcome, especially when complete resection is achievable.

Pancoast tumour: current therapeutic options.

Pancoast's syndrome is caused by malignant neoplasm of superior sulcus of the lung which produces destructive lesions of thoracic inlet and comes along with the involvement of brachial plexus and stellate ganglion. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can detect early lesions otherwise missed by routine radiographs and can also define the local extent or metastatic progression of the disease. Protocols involving combinations of irradiation, chemotherapy, and surgery are currently being under investigation to determine the best management. This work reviewed the current diagnostic and therapeutic approaches to Pancoast's tumors. Patients with lung superior sulcus carcinoma should be considered for surgery only after an appropriate diagnostic assessment. The perfect candidate for surgery should have a confined to the chest disease with T3N0M0 staging. Inoperable patient with severe pain after irradiation therapy may benefit from palliative surgical resection. Medical therapy plays only a secondary role in lung cancers, patients with disseminated lung cancer might require palliative treatment and medical management of paraneoplastic syndrome symptoms. Following surgery, radiation and chemotherapy may improve local and systemic control by addressing individual adverse findings. The cooperation of surgeons, clinicians and radiologists represents the gold standard today and a multidisciplinary approach is essential to achieve the best outcome possible. Further studies are advisable in order to define the best surgical approach and the real advantage of mini-invasive surgery by comparison with open surgery.

Radiofrequency assisted pancreaticoduodenectomy for palliative surgical resection of locally advanced pancreatic adenocarcinoma.

BackgroundDespite careful patient selection and preoperative investigations curative resection rate (R0) in pancreaticoduodenectomy ranges from 15% to 87%. Here we describe a new palliative approach for pancreaticoduodenectomy using a radiofrequency energy device to ablate tumor in situ in patients undergoing R1/R2 resections for locally advanced pancreatic ductal adenocarcinoma where vascular reconstruction was not feasible.ResultsThere was neither postoperative mortality nor significant morbidity. Each time the ablation lasted less than 15 minutes. Following radiofrequency ablation it was observed that the tumor remnant attached to the vessel had shrunk significantly. In four patients this allowed easier separation and dissection of the ablated tumor from the adherent vessel leading to R1 resection. In the other two patients, the ablated tumor did not separate from vessel due to true tumor invasion and patients had an R2 resection. The ablated remnant part of the tumor was left in situ.ConclusionWhenever pancreaticoduodenectomy with R0 resection cannot be achieved, this new palliative procedure could be considered in order to facilitate resection and enable maximum destruction in remnant tumors.MethodSix patients with suspected tumor infiltration and where vascular reconstruction was not warranted underwent radiofrequency-assisted pancreaticoduodenectomy for locally advanced pancreatic ductal adenocarcinoma. Radiofrequency was applied across the tumor vertically 5–10 mm from the edge of the mesenteric and portal veins. Following ablation, the duodenum and the head of pancreas were removed after knife excision along the ablated line. The remaining ablated tissue was left in situ attached to the vessel.

Palliative home parenteral nutrition: Clinical service evaluation and identifying potential prognostic factors to assist with patient selection

Home parenteral nutrition (HPN) for palliation has little evidence supporting existing guidance. Patient selection remains challenging. We aimed to evaluate use of palliative HPN in our service against ESPEN guidance, and to identify potential prognostic indicators. Palliative care patients commenced on HPN were identified. Medical notes, computer records and HPN database were accessed to identify patient demographics, primary diagnosis and aetiology of intestinal failure, blood test results potentially associated with prognosis (eGFR, albumin, CRP, Hb), presence of ascites, and PN duration. By dichotomising blood results Kaplan-Meier survival plots were derived to identify potential associations with survival. From the HPN database of 111 patients, 20 (18%) were identified as palliative. Six were male (30%), median age (interquartile range (IQR)) 56.4 (51.5-66.8) years. Four patients commenced palliative HPN between 2000 and 2006, while 2007-2013 there were 16. The median number (IQR) of nights on HPN was 85 (19-352). The most common indication was gastro-intestinal obstruction (n=13, 65%) and short bowel syndrome following palliative surgical resection (n=4, 20%). Kaplan-Meier survival plots identified worse prognosis on HPN if the presenting albumin was ≤30g/L p=0.016. The use of HPN in palliative care is increasing. Current patient selection meets with ESPEN guidance with respect to aetiology of intestinal failure and length of survival on PN. We suggest that a low albumin (not a marker of malnutrition) may help to predict those who are likely to survive less long on palliative HPN. A multi-centre prospective study, also examining quality of life would help define improved guidance.

Is third-line chemotherapy routine practice in recurrent or metastatic gastric cancer?

e15558 Background: Patients (pts) with recurrent or metastatic gastric cancer eventually experience disease progression during or after completion of first-line chemotherapy. Second-line therapy is generally recommended in the current guidelines. Although third-line therapy is often performed in daily practice in some countries, there are few reports about the benefit of third-line therapy. Methods: A retrospective review was conducted on 683 pts who underwent at least first-line palliative chemotherapy for recurrent (n = 297) or primary metastatic (n = 386) gastric cancer. Clinicopathological characteristics and overall survival (OS) were analyzed according to the lines of chemotherapy as well as for all study pts. Results: One hundred and forty-nine pts (21.8%) underwent third- or further-line therapy. Third- or further-line therapy was more frequently performed in pts with young age ( &lt; 70) (p &lt; 0.0001), ECOG PS 0 or 1 (p &lt; 0.0001) at the initiation of first-line therapy, first-line combination regimen (p = 0.006), and palliative surgical resection before first-line therapy (p = 0.029). The median follow-up duration was 62 months (24-151 months) for the survivors. The median OS for pts after first- and third-line therapy was 10 and 6 months, respectively. The median OS of pts who received third-line therapy was significantly longer than that of pts who received second- or lesser-line therapy (18 vs. 8 months, p &lt; 0.0001). Multivariate analysis revealed that third- or further-line therapy was independently associated with favorable OS (hazard ratio = 0.56, p &lt; 0.0001) along with surgical resection (p &lt; 0.0001) and first-line combination regimen (p = 0.008), whereas signet ring cell histology (p = 0.002) and peritoneal metastasis (p = 0.027) were independent prognostic factors of poor OS. Conclusions: This study suggests that recurrent or metastatic gastric cancer pts may benefit from third-line chemotherapy, although careful selection is essential.

Is surgical resection beneficial in recurrent or metastatic gastric cancer?

4043 Background: Although chemotherapy is currently established as a standard treatment in recurrent or metastatic gastric cancer, the role of palliative surgical resection is still controversial. We investigated the survival benefit of surgical resection in patients (pts) with recurrent or metastatic gastric cancer who received systemic chemotherapy. Methods: A retrospective review was conducted on 698 pts who received palliative chemotherapy for recurrent (n = 307) or primary metastatic (n = 391) gastric cancer. Overall survival (OS) of pts who underwent surgical resection followed by chemotherapy was compared to that of pts who received chemotherapy alone. Results: Among 140 pts (primary metastatic: 97, recurrent: 43) with surgical resection, gastrectomy, metastasectomy, and gastrectomy with metastasectomy were performed in 83 (primary metastatic: 81), 44, and 13 pts, respectively. Higher surgical resection rate was observed in pts with young age ( &lt; 70) (p = 0.010), ECOG PS 0 or 1 (p = 0.010), primary metastatic (p &lt; 0.0001), absence of liver metastasis (p = 0.002), and signet ring cell histology (p = 0.002). The median OS of pts who underwent surgical resection before chemotherapy was significantly longer than that of pts who received chemotherapy alone (19 vs. 9 months, p &lt;0.0001). The OS benefit of surgical resection was consistent across subgroups in terms of baseline characteristics including age, ECOG PS, disease status (primary metastatic vs. recurrent), peritoneal metastasis, and first-line chemotherapy regimen (single vs. combination). In multivariate analysis, surgical resection was independently associated with favorable OS (hazard ratio = 0.41, p &lt; 0.0001) along with ≥second-line chemotherapy (p &lt; 0.0001), whereas ECOG PS 2 or 3 (p = 0.013), signet ring cell histology (p &lt; 0.0001), and peritoneal metastasis (p = 0.046) were independent prognostic factors of poor OS. Conclusions: The present study suggests that judicious use of surgical resection before chemotherapy in recurrent or metastatic gastric cancer pts may result in favorable outcome, although large scale phase III trials are essential to establish this treatment approach as a standard practice.

Clinicopathological Characteristics and Survival of Male Veterans With Colorectal Adenocarcinoma: An Updated Experience Over Ten Years

Introduction: We performed an updated analysis of clinicopathological characteristics and survival of male veterans with colorectal cancer (CRC). Methods: A retrospective study of male CRC patients (pts) diagnosed between 2003 and 2012 at a VA medical center was conducted. Survival analysis was performed with Kaplan-Meier estimator and Cox proportional hazards model using SPSS (v22). Results: 279 pts with colorectal adenocarcinoma were included. Median (M) age at diagnosis was 68 years (yrs, range 27-92). There were 155 Caucasians, 108 African Americans, 14 Hispanics and 2 others. Tumor location was left-sided in 118, right-sided in 83 and rectum in 78 pts. Grade was 1-2 in 214, 3-4 in 53 and unknown in 12 pts. Stage was I in 80, II in 62, III in 62, IV in 52 and unknown in 23 pts. At M follow-up of 50.4 months (mo, range 0.2-142.2), M overall survival (OS) was 72.9 mo (95% CI 53.7-92.3) and 5- and 10-yr survival rates were 53.4% and 34.4%, respectively. M OS by stage was Stage I 114.0, II 82.2, III 79.4 and IV 13.7 mo. The 5-yr survival rates by stage were Stage I 75.5%, II 60.6%, III 52.3% and IV 6.6%. The 10-yr survival rates by stage were Stage I 44.2%, II 41.7%, III 43.9% and IV 3.3%. Pts 65 yrs or younger had longer M OS (103.3 vs 54.9 mo, P=0.014). Pts with left-sided colon cancer had longer M OS than those with right-sided (94.5 vs 51.6 mo, P=0.011). Younger age, left-sided location and an earlier stage were associated with better OS in both univariate (P=0.014, 0.010 and 0.000) and multivariate (P=0.004, 0.012 and 0.000) analyses. Race and grade were not associated with OS. In stage I-III pts, surgical resection improved OS (P=0.029). Pts diagnosed through screening colonoscopy had earlier stage (P=0.000) and better OS (P=0.000) than pts who presented with anemia/positive guaiac or cancer related symptoms. Disease recurrence/progression occurred in 60 pts and was significantly associated with stage (P=0.000). Recurrence/progression and progression-free survival (PFS) were not associated with tumor grade after adjusting for stage. In stage III pts, chemotherapy significantly improved PFS (P=0.004) and OS (P=0.000). In stage IV pts, chemotherapy improved OS (P=0.000), and palliative surgical resection also offered an OS benefit that was not significant (P=0.152). Conclusion: These data provide insights into the clinical epidemiology of CRC. Survival of male veterans with CRC is favorably influenced by preventive, surgical and medical interventions.

Abstract 5237: Monitoring minimal residual disease by urinary or plasma circulating tumor DNA of KRAS mutation burden in colorectal cancer patients with resectable liver metastases

Abstract Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the third leading cause of cancer deaths. Over half of patients with CRC will develop liver metastases. Surgical resection, in combination with systemic therapies, greatly improves long-term outcomes, and around 40% of patients with resected liver limited disease are alive 5 years after diagnosis. While tumor staging and radicality of surgery are commonly used for prognostic assessment, better non-invasive markers are needed for monitoring chemo-responsiveness, following minimal residual disease (MRD), and guiding complex treatment decisions in these patients. This study evaluated the utility of quantitating KRAS mutation burden in urinary and plasma ctDNA as a means of monitoring MRD in surgical CRC patients with liver limited metastases. Methods: We developed a novel, NGS-based method for enrichment and quantitative detection of KRAS mutations in urinary and plasma ctDNA. A blinded retrospective study was conducted on 20 Stage I-IV CRC patients, 15 of whom had undergone curative or palliative intent surgical resection of primary tumor or liver metastases in combination with various systemic therapies. Results: Archived, matched urine and plasma samples were collected from 20 patients with KRAS positive primary tumor. For operable patients, specimens were collected prior to surgery, during and immediately after surgery, plus additional time points post-surgery. A total of 193 plasma and urine samples archived for 3-5 years were tested. All 101 of 101 plasma samples (100%) and 79 of 92 urine samples (86%) had sufficient DNA and were deemed evaluable. In a blinded analysis, a correct KRAS mutation that correlated with KRAS mutation in tissue was identified in 95% of evaluable baseline plasmas (19 of 20) and 92% of evaluable baseline urines (11 of 12). In one patient, a KRAS mutation distinct from that identified in the tumor biopsy was detected consistently across all serial ctDNA samples. Overall, we observed a clear correlation and highly comparable fold change between plasma and urinary ctDNA KRAS levels on treatment. Significantly, in all patients with curative intent surgery, ctDNA KRAS levels were undetectable in urine or plasma after surgery. In contrast, in 8 of 10 patients with incomplete, palliative surgery, the ctDNA KRAS signal remained detectable or increased after surgery. Further correlation between ctDNA KRAS and clinical outcomes will be discussed. Conclusion: We demonstrate for the first time that quantitative changes of mutational KRAS burden in plasma and urinary ctDNA are highly correlated. We further demonstrate clinical applicability of urinary ctDNA KRAS analysis for monitoring quantitatively, with single molecule sensitivity, the MRD post-surgery for CRC patients with liver resectable metastases. Supported by Grant no. 13660. Citation Format: Vlada Melnikova, Jason C. Poole, Cecile Rose T. Vibat, Lucie Benesova, Barbora Belsanova, Saege Hancock, Latifa Hassaine, Errin Samuelsz, Timothy T. Lu, Mark G. Erlander, Marek Minarik. Monitoring minimal residual disease by urinary or plasma circulating tumor DNA of KRAS mutation burden in colorectal cancer patients with resectable liver metastases. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5237. doi:10.1158/1538-7445.AM2015-5237

PTH-122 Home Parenteral Nutrition In Palliative Care: A Retrospective Study To Identify Potential Prognostic Indicators

IntroductionThe use of home parenteral nutrition (HPN) in the palliative setting is less common in the UK than in Europe and the USA. It remains controversial with little evidence base...

Curative versus palliative surgical resection of liver metastases in patients with neuroendocrine tumors: a meta-analysis of observational studies.

The role of surgical therapy in patients with liver metastases from neuroendocrine tumors (NETs) is unclear. In this study, the results obtained with curative or palliative resection, by reviewing recent literature and performing a meta-analysis, were examined. A systematic review and meta-analysis of observational studies published between January 1990 and October 2013 were performed. Studies that evaluated the different survival between patients treated by curative or palliative surgical resection of hepatic metastases from NETs were considered. The collected studies were evaluated for heterogeneity, publication bias, and quality. To calculate the pooled hazard ratio (HR) estimate and the 95% confidence interval (95% CI), a fixed-effects model was applied. After the literature search, 2,546 studies were found and, among 38 potentially eligible studies, 3 were considered. We did not find a significant longer survival in patients treated with curative surgical resection of hepatic metastases when compared to palliative hepatic resection HR 0.40 (95% CI: 0.14-1.11). In one study, palliative resection of hepatic metastases significantly increased survival when compared to embolization. Curative and also palliative surgery of NETs liver metastases may improve survival outcome. However, further randomized clinical trials are needed to elucidate this argument.

Prognostic Implications of Primary Tumor Resection in Stage IVB Colorectal Cancer in Elderly Patients.

PurposeThe aim of this study was to identify prognostic factors in stage IVB colorectal cancer in elderly patients, focusing on the influence of treatment modalities, including palliative chemotherapy and primary tumor resection.MethodsA cohort of 64 patients aged over 65 years who presented with stage IVB colorectal cancer at the Gangneung Asan Hospital between July 1, 2001, and December 31, 2009, was analyzed. Demographics, tumor location, tumor grade, performance status, levels of carcinoembryonic antigen (CEA), level of aspartate aminotransferase (AST), and distant metastatic site at diagnosis were analyzed. Using the treatment histories, we analyzed the prognostic implications of palliative chemotherapy and surgical resection of the primary tumor retrospectively.ResultsThe cohort consisted of 30 male (46.9%) and 34 female patients (53.1%); the median age was 76.5 years. Primary tumor resection was done on 28 patients (43.8%); 36 patients (56.2%) were categorized in the nonresection group. The median survival times were 12.43 months in the resection group and 3.58 months in the nonresection group (P < 0.001). Gender, level of CEA, level of AST, Eastern Cooperative Oncology Group performance status, tumor location, and presence of liver metastasis also showed significant differences in overall survival. On multivariate analysis, male gender, higher level of CEA, higher AST level, and no primary tumor resection were independent poor prognostic factors. In particular, nonresection of the primary tumor was the most potent/poor prognostic factor in the elderly-patient study group (P = 0.001; 95% confidence interval, 2.33 to 21.99; hazard ratio, 7.16).ConclusionIn stage IVB colorectal cancer in elderly patients, resection of the primary tumor may enhance survival.

Detection and Clinical Significance of Intratumoral EGFR Mutational Heterogeneity in Chinese Patients with Advanced Non-Small Cell Lung Cancer

PurposeThis study evaluated occurrence and potential clinical significance of intratumoral EGFR mutational heterogeneity in Chinese patients with non-small cell lung cancer (NSCLC).Materials and MethodsEighty-five stage IIIa-IV NSCLC patients who had undergone palliative surgical resection were included in this study. Of these, 45 patients carried EGFR mutations (group-M) and 40 patients were wild-type (group-W). Each tumor sample was microdissected to yield 28–34 tumor foci and Intratumoral EGFR mutation were determined using Denaturing High Performance Liquid Chromatography (DHPLC) and Amplification Refractory Mutation System (ARMS). EGFR copy numbers were measured using fluorescence in situ hybridization (FISH).ResultsMicrodissection yielded 1,431 tumor foci from EGFR mutant patients (group-M) and 1,238 foci from wild-type patients (group-W). The EGFR mutant frequencies in group-M were 80.6% (1,154/1,431) and 87.1% (1,247/1,431) using DHPLC and ARMS, respectively. A combination of EGFR-mutated and wild-type cells was detected in 32.9% (28/85) of samples by DHPLC and 28.2% (24/85) by ARMS, supporting the occurrence of intratumoral heterogeneity. Thirty-one patients (36.5%) were identified as EGFR FISH-positive. Patients harboring intratumoral mutational heterogeneity possessed lower EGFR copy numbers than those tumors contained mutant cells alone (16.7% vs. 71.0%, P<0.05). Among 26 patients who had received EGFR-TKIs, the mean EGFR mutation content was higher in patients showing partial response (86.1%) or stable disease (48.7%) compared with patients experiencing progressive disease (6.0%) (P = 0.001). There also showed relationship between progression-free survival (PFS) and different content of EGFR mutation groups (pure wild type EGFR, EGFR mutation with heterogeneity and pure mutated EGFR) (P = 0.001).ConclusionApproximately 30% of patients presented intratumoral EGFR mutational heterogeneity, accompanying with relatively low EGFR copy number. EGFR mutant content was correlated with the response and prognosis of EGFR-TKIs.

Surgically resected gastric metastasis of pulmonary squamous cell carcinoma

Gastric metastasis of pulmonary carcinoma has been reported to range from 0.19%-5.1%. An autopsy review of cancer disclosed 1.7%-29.6% of gastric metastases, primarily from breast cancer, lung cancer and melanoma. A 71-year-old man was referred to our department because of persistent cough, sputum and sweating for 20 d. Chest posteroanterior view and chest computed tomography scan demonstrated an irregular tumor mass measuring 5.8 cm with central necrosis at the right lower lung. Bronchoscopic biopsy revealed pulmonary squamous carcinoma. Esophagogastroduodenoscopy revealed a huge bleeding ulcer at the body of the stomach and a biopsy diagnosed a metastatic lesion. We performed a palliative total gastrectomy, splenectomy and distal pancreatectomy. The patient did not receive any adjuvant chemotherapy due to his refusal. He was controlled conservatively and survived for 11 mo after surgery. Surgical resection may provide an option for safe palliative treatment. Although gastric metastasis from lung cancer is associated with dismal outcomes, a longer survival or more favorable outcome has been demonstrated in patients undergoing palliative surgical resection of the metastatic site. Considerable improvements in the understanding of metastatic diseases and therapeutic strategies are needed to improve the clinical outcome.

Aktuelle S3-Leitlinie zur Chirurgie des Magenkarzinoms

The current S3 guidelines on the diagnosis and treatment of gastric carcinoma including those of the esophagogastric junction describe optimal clinical practice based on a high level of evidence and expert consensus from different medical disciplines. Endoscopy and performance of multiple biopsies is the standard approach to detect malignant tumors in the upper gastrointestinal tract. Further diagnostic procedures are necessary to evaluate the tumor stage. With the exception of mucosal carcinomas, surgical therapy is the cornerstone of curative treatment in all potentially resectable stages. In locally advanced carcinomas perioperative chemotherapy should be carried out and in high-seated tumors preoperative radiochemotherapy might be an alternative option. Palliative surgical resection should be avoided in disseminated asymptomatic stages. In a palliative situation complications of the tumor should primarily be treated by interventional or conservative procedures.