Patients Underwent Staging Laparoscopy Research Articles

457. EVALUATING THE ACCURACY OF CLINICAL SIEWERT CLASSIFICATION, A RETROSPECTIVE REVIEW OF 807 PATIENTS

Abstract Background Adenocarcinoma of the gastro-esophageal junction (GEJ) is increasingly common in Western societies. GEJ tumours are typically categorized using the Siewert classification, which divides the tumours in to 3 types based on location relative to the GEJ. Studies have shown that there is improved survival with a proximal surgical resection such as esophagectomy for type 1 tumours while type 3 tumours have improved survival when managed as other gastric cancers with a total or extended total gastrectomy. This requires accurate clinical classification. This study aims to evaluate the accuracy of commonly used staging modalities in the clinical classification of GEJ tumours. Methods A review of 807 consecutive patients undergoing curative resection for GEJ cancer was performed. Patient data was obtained from a prospectively maintained database between February 2010 and April 2023. Siewert type was established clinically as part of the staging process. The standard staging modalities used for every patient included computerized tomography (CT) and endoscopy, with most patients also undergoing positron emission tomography (PET). Endoscopic ultra-sonography (EUS) and staging laparoscopy was also used selectively. Accuracy was determined by comparing clinical classification to pathological classification following surgery. Results 807 patients were included [319 type 1, 401 type 2, 87 type 3]. Clinical classification was the same as pathological classification in 59.5% of cases [69.6% for type 1, 48.6% for type 2, 71.3% for type 3 (p<0.001). The use of different staging modalities for each sub-type is presented in table 1. For patients that underwent EUS, Siewert type was accurate in 59.4% of cases overall. The failure rate for EUS was 2.9%. For patients undergoing staging laparoscopy Siewert type was accurate in 69.3% and for patients that underwent PET, EUS and staging lap the accuracy was 74.4%. Conclusion Accurately determining Siewert type clinically is challenging. This is particularly relevant for type 2 tumours which had the least accurate comparison of clinical to pathological type. The use of additional modalities including EUS, and staging laparoscopy improves accuracy but may not be feasible in all patients.

Clinical outcomes of conversion surgery following immune checkpoint inhibitors and chemotherapy in stage IV gastric cancer with peritoneal metastasis.

281 Background: Although anti-PD-1 antibody in combination with chemotherapy and/or targeted therapy has shown promising antitumor activity in advanced gastric adenocarcinoma (GC), the evidence of conversion therapy for initially GC with peritoneal metastasis is limited. This study aimed to clarify the clinical outcomes of conversion therapy for such patients. Methods: In this retrospective single institution cohort study, we analyzed 83 GC patients with peritoneal metastasis who received first-line anti-PD-1 antibody and chemotherapy and/or target therapy (trastuzumab) between November 2019 and June 2023. In patients who respond well to treatment, when preoperative imaging studies, multidisciplinary team discussions, and staged laparoscopy indicated the absence of peritoneal metastasis and the possibility of R0 resection, patients were offered conversion surgery. In this study, palliative surgery was not included. Patients were divided into two groups: conversion therapy group and palliative therapy group. Results: All patients underwent staging laparoscopy at their initial visit and underwent at least 2 treatment cycle, with a median follow-up time of 20.3 (16-24.6) months. Of the 83 patients, 32 patients presented a clinical response and underwent re-laparoscopy. Negative peritoneal metastasis and peritoneal cytology were confirmed in 25 patients who proceeded to undergo the conversion surgery. Compared with palliative therapy group, surgery group had a significantly better median progression-free survival (PFS) (20.3 vs 5.1 months; p < 0.001) and a prolonged median overall survival (OS) (33.4 vs 11.7 months; p < 0.001). In the surgery group, 24 (96%) of 25 patients were performed laparoscopic gastrectomy radical laparoscopic gastrectomy with more than D2 lymph node dissection (only one patient underwent open gastrectomy), 19 (76%) patients achieved R0 resection, 2 (8%) patients achieved pathologic complete response (pCR) and 4 (16%) patients reached tumor regression grade (TRG) 0-1. It was observed that patients with PCI score ≤ 2 experienced a longer median OS in comparison to those with PCI scores > 2 ( unreached vs 28.5 months, P < 0.031). And multivariate analysis associated with PFS among surgery cases identified signet ring cell carcinoma as an independent adverse prognostic factor (HR 4.66; 95% CI 1.19–18.22; p = 0.027). No serious treatment-related adverse events resulted in termination of treatment or death. Conclusions: Conversion surgery following first-line anti-PD-1 antibody in combination with chemotherapy and/or targeted therapy represented a promising treatment strategy for GC patients with peritoneal metastasis. When immunochemotherapy is effective, active second-look staging laparoscopy should be performed to clarify the possibility of conversion surgery.

OGC P47 Yield of staging laparoscopy in upper GI cancer; post COVID

Abstract Background Staging laparoscopy is a useful adjunct in preoperative staging process of oesophago-gastric cancer. NICE recommends use of staging laparoscopy in oesophageal cancer cases where it is likely to guide further management. In cases of gastric cancer there is strong evidence to suggest a high specificity of staging laparoscopy in detection of peritoneal metastasis. During COVID very selective use of staging laparoscopy was adopted by our unit. In this study we aimed to evaluate yield of staging laparoscopy in context of gastric and selective oesophageal cancers in our unit during post-COVID period Methods Retrospective analysis of our prospectively kept database in patients undergoing staging laparoscopy between January 2022 to May 2023 in upper GI tertiary cancer centre was performed. Age, sex, tumour grade, nodal status on radiology, histologic type, differentiation, and site of tumour was assessed against positive cytology and presence of peritoneal or occult visceral metastasis. Multivariate logistic regression was applied to identify independent factors associated with findings. Statistical analysis was carried out using EXCEL® and MedCalc® software. Results Among 104 patients, 69 had oesophageal cancer (OC) and 35 had gastric cancer (GC). In OC group cytology was positive in 4 (5.8%), peritoneal metastasis was present in 7 (10.1%) patients. In GC group positive cytology in 8 (22.8%), peritoneal metastasis was found in 8 (22.8%) patients. On multivariate analysis differentiation, T3+ tumour, lower third cancer, male sex was linked with positive findings in OC group. In GC group poor differentiation, T4 disease, mid body tumour, nodal status of N3 were associated positive findings. Yield of laparoscopy was found to be 17.6% and 34.6% in OC and GC groups respectively. Conclusions Despite of recent advances in radiological modalities, staging laparoscopy remains a useful adjunct in diagnosing peritoneal disease. With negligible complication rates and its relatively high yield in lower third and junctional oesophageal cancer it can be utilised to guide further management and reduce unnecessary laparotomies. Mid gastric body site and T4 cancers in our cohort were strong predictors of peritoneal disease further multi centre research on site of tumour is needed to affirm any such association.

OGC P58 Clinical Rationale for Staging Laparoscopy in Oesophagogastric cancers: A high-volume tertiary centre study

Abstract Background Oesophagagogastric cancers are characterised by their propensity to spread to the locoregional lymph nodes or to distant sites by transcoelomic migration. Accurate staging is imperative to select patients for treatment according to the likelihood of clinical benefit; sparing patients with advanced disease aggressive treatment which would most likely be futile. Staging laparoscopy combined with peritoneal cytology is usually employed as a method to detect peritoneal metastases which would not detected by other staging modalities. Our study focuses on stage migration following staging laparoscopy in patient with oeophagogastric cancers and thus analyses the clinical rationale for staging laparoscopy in these patients. Methods Data from all patients undergoing staging laparoscopy by a standardised procedure for oesophagogastric cancer between January 2013 and December 2022 was studied retrospectively using a prospectively maintained database. Patient demographics, tumour location, preoperative staging, laparoscopy findings, cytology, histopathology and subsequent treatment decisions at multi-disciplinary meetings were analysed. Results A total of 317 patients were identified. Of these 103 (32.5 %) were female. Median age was 69 (33-88) years. The site of tumour was oesophageal for 108 (34%) patients, junctional including gastric cardia for 56 (18%) and gastric (fundus to pylorus) for 153 (48%). Positive peritoneal cytology was identified in 38 (11.9%) patients. There was no significant difference between findings of metastases between primarily oesophageal and primarily gastric tumours (p=0.14). cTNM staging for metastatic disease at laparoscopy was most commonly T3N2 and T3N3 with 10 patients (26.3%) each. Only 5 (13.5%) of patients declared metastatic had been staged as cT4. Conclusions The yield for staging laparoscopy was found to be similar for oesophageal and gastric tumour locations independent of stage. Evidently, while the procedure remains a valuable tool in the staging and management of patients with clinically resectable oesophagogastric cancer,it is essential that the staging laparoscopy procedure be standardised in practice to allow comparisons across regional or national institutes. This stands to impact both the clinical benefit and the cost-effectiveness of the procedure in the long run.

OGC P11 Outcomes in patients with gastric cancer and positive peritoneal washings

Abstract Background The presence of positive cytological washings in the absence of overt peritoneal disease (P0C1) represents metastatic disease. Most centres advocate for neoadjuvant chemotherapy and full restaging including repeat laparoscopy and washings, with resection offered to those in whom restaging is negative. This approach was implemented at our institute in 2012 and when evaluated in 2015 was found to have very good results with 63% of patients resected and 90% 2-year survival. Since this time chemotherapy regimens have changed meaning this earlier approach requires additional scrutiny. Methods A retrospective review of a prospectively maintained database of all upper GI cancer patients treated at the Northern Oesophago-Gastric Unit (NOGU) was undertaken. All patients with adenocarcinoma of the stomach or gastroesophageal junction without metastases on imaging and who underwent staging laparoscopy between August 2012 and August 2022 were identified. Patients who had positive cytological washings without evidence of overt peritoneal disease were included in the analysis. Data were extracted including demographics, treatment data and oncological outcomes. Survival data were collected and patterns of recurrence determined. Results 630 patients underwent staging laparoscopy. Resectable P0C1 disease occurred in 55/630 (8.7%), and 48/55 commenced chemotherapy. Restaging occurred in 45/48 (93.8%) and 21/45 (46.7%) went on to have definitive surgery where 15/45 (33%) were resected. Recurrence occurred in 8/15 patients, 3 of which had peritoneal metastases. Median time to recurrence was 16 months (range: 6-34). A total of 9 patients died during follow up which occurred at a median of 14 months (range: 5 to 43). Overall median survival of the cohort was 28 months (range: 5 – 111), with survival of 60% and 25% at 2 and 5 years, respectively. Conclusions This study demonstrated 60% 2-year survival in patients treated with curative intent who initially had positive peritoneal cytology. We were not able to demonstrate a predominate pattern of peritoneal recurrence. Furthermore, 25% of patients survived for at least 5 years after surgery, indicating that this remains an acceptable approach to the management of P0C1 disease with current best practice chemotherapy regimens.

ThTP2.3 Value of staging laparoscopy in patients with oesophageal and junctional cancers – Single centre retrospective observational study

Abstract Introduction The role of staging laparoscopy in oesophageal and junctional cancer remains controversial due to lack of robust evidence leading to heterogenous practice nationally and globally. The purpose of this study was to identify the value of staging laparoscopy in patients with oesophageal and junctional cancer. Methods A retrospective review of all consecutive patients who underwent staging laparoscopy for oesophageal and junctional cancer over 7-year period at Royal Derby Hospital, Derby was conducted using hospital database. Patient demographics, histology, staging, location, and findings of staging laparoscopy were analysed. Results A total of 278 of patients underwent staging laparoscopy from July 2015 to September 2022 were included. All patients with gastric cancer histology were excluded. Majority of the patients were having adenocarcinoma histology (N=248, 89.2%) and 236 (84.8%) cancers were involving lower oesophagus/ GOJ. Additionally, nearly three-quarters of patients (N=203, 73%) were having T3 staging before the procedure. Overall, staging laparoscopy had changed the management in 22 patients (7.9%) due to positive cytology (N=12, 4.3%) and other findings (N=10, 3.5%) such as cirrhosis liver, large bulky tumour, and peritoneal deposits. Out of patients who were having positive cytology, all had adenocarcinoma histology, located in the lower oesophagus, and had T3 or above pre-operative staging. Conclusion This study identified the value of staging laparoscopy in patients with certain risk factors who are at risk of having peritoneal disease. Therefore, selective approach would be more appropriate when selecting patients for staging laparoscopy in oesophageal and junctional cancer.

The role of staging laparoscopy in pancreatic adenocarcinoma and its effect on patients’ survival

BackgroundPrompt and accurate staging of pancreatic cancer is essential to distinguish patients to benefit from resection with curative intent and those with unresectable disease. A staging laparoscopy is used preoperatively to identify macroscopic or occult metastases not identified on imaging. This single-institution study aims to evaluate the role of staging laparoscopy in patients with pancreatic adenocarcinoma and its effect on overall survival.MethodClinicopathologic data were evaluated for all patients undergoing staging laparoscopy for pancreatic adenocarcinoma from July 2014 to December 2019. The study identified 155 patients eligible for analysis. All patients were followed for at least 2 years. Clinical backgrounds, survival curves and prognostic factors were investigated.ResultsResectability status among the cohort was 62 (40%) upfront resectable, 53 (34%) borderline resectable and 40 (26%) locally advanced disease. The median age was 69, with 44% male patients. Median CA19-9 value was 125 kU/L, and median CA125 value was 22 kU/L. Staging laparoscopy resulted in upstaging nine (15%) upfront resectable patients, five (9%) borderline resectable patients and ten (25%) locally advanced patients. There was positive cytology in 19 (12%), peritoneal deposits in six (4%) and peritoneal liver deposits in seven (5%) patients. Overall, the number needed to treat (NNT) to avoid an unnecessary laparotomy was eight patients.ConclusionStaging laparoscopy continues to be a valuable investigation of pancreatic adenocarcinoma. In this institution, one in every eight patients undergoing a staging laparoscopy was upstaged to metastatic disease, thus avoiding an unnecessary laparotomy or a non-curative resection.

Early postoperative outcomes of staging laparoscopy for peritoneal metastases with or without pressurized intra-peritoneal aerosol chemotherapy (PIPAC)

BackgroundPressurized intraperitoneal aerosol chemotherapy (PIPAC) has been introduced for palliative treatment of peritoneal surface malignancies (PSM) and is currently tested also in the neoadjuvant and prophylactic setting. The aim was therefore to compare safety and tolerance of staging laparoscopy with or without PIPAC.MethodsThis retrospective analysis compared consecutive patients undergoing staging laparoscopy alone for oesogastric cancer with patients having PIPAC for suspected PSM of various origins from January 2015 until January 2020. Safety was assessed by use of the Clavien classification for complications and CTCAE for capturing of adverse events. Pain and nausea were documented by use of a visual analogue scale (VAS: 0–10: maximal intensity).ResultsOverall, 25 PIPAC procedures were compared to 24 staging laparoscopies. PIPAC procedures took a median of 35 min (IQR: 25–67) longer. Four patients experienced at least one complication in either group (p = 0.741). No differences were noted for postoperative nausea (p = 0.961) and pain levels (p = 0.156). Median hospital stay was 2 (IQR: 1–3) for PIPAC and 1 (IQR: 1–2) for the laparoscopy group (p = 0.104).ConclusionsThe addition of PIPAC did not jeopardize safety and postoperative outcomes of staging laparoscopy alone. Further studies need to clarify its oncological benefits.

Intraperitoneal Paclitaxel Treatment for Patients with Pancreatic Ductal Adenocarcinoma with Peritoneal Dissemination Provides a Survival Benefit.

Simple SummaryPancreatic ductal adenocarcinoma (PDAC) with peritoneal dissemination is a highly lethal disease. Recently, promising activity of intraperitoneal chemotherapy with paclitaxel (i.p.-PTX) has been observed in patients with peritoneal dissemination. We conducted a retrospective comparative study to evaluate the clinical efficacy of i.p.-PTX combined with systemic chemotherapy versus standard systemic chemotherapy in PDAC patients with peritoneal dissemination. The median survival time was 10.2 months for patients in the standard therapy group and 17.9 months in the i.p.-PTX group; the difference between groups was statistically significant (p = 0.006). We have performed surgical resection (defined as conversion surgery) to responders to treatment. Conversion surgery was planned for 26% in the i.p.-PTX group and 8% in the standard therapy group. The median survival time (27.4 months) from initial treatment in patients who underwent conversion surgery was significantly longer than that in patients who did not undergo conversion surgery (11.3 months, p < 0.0001). Implementation of the i.p.-PTX regimen may improve survival in patients with PDAC with peritoneal dissemination.Background: Intraperitoneal chemotherapy using paclitaxel (i.p.-PTX) is expected to be a new therapeutic strategy for patients with pancreatic ductal adenocarcinoma (PDAC) and peritoneal dissemination. We evaluated the survival benefit of i.p.-PTX compared with standard systemic chemotherapy. Methods: Clinical data of 101 consecutive PDAC patients with peritoneal dissemination between 2007 and 2018 were analyzed. All patients were determined to have no other sites of distant organ metastasis to the lung, bone, or liver on contrast-enhanced CT imaging. Patients underwent staging laparoscopy or open laparotomy to confirm pathological evidence of peritoneal dissemination, and to exclude occult liver metastasis. Survival curves were estimated using the Kaplan–Meier method, and differences were compared using the log-rank test. Results: Forty-three patients were treated with i.p.-PTX (i.p.-PTX group) and forty-nine patients received standard systemic chemotherapy (Ctrl group). Nine patients did not receive any treatment (BSC group). The median survival time (MST) in the i.p.-PTX group was significantly longer than that in the Ctrl group (17.9 months vs. 10.2 months, p = 0.006). Negative peritoneal washing cytology was observed in 24 out of 43 patients in the i.p.-PTX group. The i.p.-PTX group tended to have a higher proportion of clinical responses than the Ctrl group (30% vs. 18%, p = 0.183). Conversion surgery was performed in 10 patients in the i.p.-PTX group and 2 patients in the Ctrl group after confirming disappearance of peritoneal dissemination with staging laparoscopy or open laparotomy (p = 0.005). The MST in patients who underwent surgical resection was significantly longer than that in patients who did not (27.4 months vs. 11.3 months; p < 0.0001). Conclusion: i.p.-PTX therapy provided improved survival in PDAC patients with peritoneal dissemination, and conversion surgery enhanced it in patients with favorable responses to chemotherapy. i.p.-PTX might become one of the treatment options to PDAC patients with peritoneal dissemination.

TP6.2.15 Staging Laparoscopy and Peritoneal Cytology for Gastric and Gastro-oesophageal Junction Malignancy: an Audit from a Single Oesophagogastric Resection Centre

Abstract Aims AUGIS recommends staging laparoscopy in all gastric cancers and selected gastro-oesophageal junction (GOJ) cancers. We previously audited our practice of staging laparoscopy and peritoneal cytology and found that in a cohort of 158 consecutive patients, no tumours less than T3 with negative nodes had positive cytology, resulting in change in practice to selectively use peritoneal cytology in patients with a T-stage of 3 and above or N+ disease. Our aim was to assess the impact of this audit on current practice. Methods We retrospectively reviewed the notes of patients undergoing staging laparoscopy and oesophagogastroduodenoscopy (OGD) identified by MDT from January 2019 to December 2019. Patients who underwent resection on the same day were excluded. Results 63 patients underwent staging laparoscopy and OGD, 54 for GOJ and 9 for gastric disease. The majority were staged as T3 or T4a (81%). As a result of staging laparoscopy and OGD, 4 (6%) patients were changed from curative to palliative pathway, 2 (3%) of whom had positive cytology. No patients had positive peritoneal cytology for a T stage of 2 and below with no positive nodes, further demonstrating the safety of the recommendation. Conclusions Peritoneal cytology has a low yield in changing the clinical course of patients but can upstage up to 6% of patients. The re-audit backs up the previous guidance in the safety of using our current threshold for recommending peritoneal cytology and potentially prevents delaying treatment while waiting for cytology results.

The Role of Open Diagnostic Peritoneal Lavage in the Evaluation of Peritoneal Cytology for Advanced Gastric Cancer: An Old Diagnostic Modality with New Usage

Background: Positive peritoneal cytology is a critical factor in prognosis. Peritoneal lavage is associated with long-term survival in patients with gastric cancer. Diagnostic peritoneal lavage (DPL) is a method for diagnosing visceral injury in trauma patients. This study aimed to investigate the usage of DPL in staging the work-up of patients with gastric cancer. Method: In this prospective study, we enrolled gastric cancer patients referring to Cancer Institute; they underwent DPL and washing specimen was sent for cytology review. After DPL, all patients underwent staging laparoscopy (SL) via the same abdominal incision. Results: DPL and SL were successful in all patients. There were six (11%) cases of peritoneal seeding discovered in SL; all of these patients had positive peritoneal cytology on DPL. Also, four patients showed positive cytology in the absence of positive SL. Thus, sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of DPL were 100 % (95% CI: 54.1-100), 91.6 % (95%: 79.2-97.5), 100 % (95%CI: 85.3-100), and 60 % (95%CI: 37-79.3). The accuracy of DPL in determining the peritoneal dissemination of gastric cancer was 92.31% (95% CI: 81.5-97.9). Conclusion: DPL had an excellent ability to find peritoneal dissemination in a gastric cancer patient, which is of great value in the setting of low-resource countries.

MicroRNA-593-3p Expression in Peritoneal Lavage Fluid as a Prognostic Marker for Pancreatic Cancer Patients Undergoing Staging Laparoscopy.

Some presumed resectable pancreatic cancer patients harbor radiographically occult metastases that are incidentally identified at the time of abdominal exploration. This study aims to identify novel diagnostic or predictive microRNA (miRNA) markers for subclinical peritoneal dissemination in patients with pancreatic cancer undergoing abdominal exploration. Peritoneal lavage fluid samples were harvested from 74 patients with pancreatic cancer at the time of staging laparoscopy. Microarray analysis was performed using peritoneal lavage fluids with positive and negative cytology. Candidate microRNA expression was quantified and validated by droplet-digital PCR assays. In the miRNA array analysis, miR-593-3p showed significant upregulation in peritoneal lavage fluids with positive cytology. Of the 74 patients validated, peritoneal lavage fluids with positive cytology had significantly higher expression of miR-593-3p than those with negative cytology (P < 0.001). Even in cases with no peritoneal dissemination and negative cytology, multivariate analysis revealed that elevated miR-593-3p expression was significantly correlated with worse overall survival than those with low expression (hazard ratio: 3.474, P = 0.042). Of the 48 patients who underwent pancreatectomy, multivariate analysis also demonstrated that higher expression of miR-593-3p in peritoneal lavage was the only significant poor prognostic marker influencing both overall survival (hazard ratio: 23.38, P = 0.005) and recurrence-free survival (hazard ratio: 5.700, P = 0.002). Elevated miR-593-3p expression in peritoneal lavage suggests the presence of subclinical micrometastasis even in cases with localized pancreatic cancer, and miR-593-3p could be a useful prognostic predictor for pancreatic cancer patients undergoing staging laparoscopy.

Staging Laparoscopy in Patients with Intrahepatic Cholangiocarcinoma: Is It Still Useful?

Background: The role of staging laparoscopy in patients with intrahepatic cholangiocarcinoma remains unclear. Despite extensive preoperative imaging, approximately 25% of patients are deemed unresectable at laparotomy due to metastasized disease. The aim of this study was to evaluate the frequency of unresectable disease found at staging laparoscopy and to identify predictors for detecting metastasized intrahepatic cholangiocarcinoma. Methods: We retrospectively collected records of all patients with intrahepatic cholangiocarcinoma, presenting at our institution from 2008 to 2017. Staging laparoscopy was performed on the suspicion of distant metastases and on indication in larger tumors. The yield and sensitivity of staging laparoscopy was calculated. Reasons for unresectability at staging laparoscopy or laparotomy were recorded. Results: Among a total of 80 patients with potentially resectable intrahepatic cholangiocarcinoma, 35 patients underwent staging laparoscopy on the suspicion of distant metastases. Unresectable disease was found at staging laparoscopy in 15 patients. Reasons for unresectability were liver metastasis (n = 6), peritoneal metastasis (n = 4), severe cirrhosis (n = 2), locally advanced tumor with satellite lesions (n = 1), and distant lymph node metastasis (n = 2). Considering optimal preoperative imaging, the true yield of staging laparoscopy was 20% (7/35). Two patients did not undergo laparotomy due to progression after staging laparoscopy. Of the remaining 18 patients who underwent laparotomy, 6 patients (30%) had unresectable disease, mostly because of distant metastasis (n = 4). Conclusions: The role of staging laparoscopy to detect unresectable intrahepatic cholangiocarcinoma is highly dependent on the quality of preoperative imaging. Currently, no accurate selection criteria on imaging exist to select patients with intrahepatic cholangiocarcinoma who potentially benefit from staging laparoscopy.

Staging laparoscopy and peritoneal cytology in patients with early stage gastric adenocarcinoma

BackgroundStaging laparoscopy and peritoneal cytology can detect occult metastatic disease prior to treatment of gastric cancer. The yield of peritoneal staging in patients with early stage disease is lacking. We assess the yield of peritoneal staging in early stage gastric cancer and its impact on survival.MethodsData were obtained from a prospective database of patients who underwent staging laparoscopy and peritoneal cytology for gastric cancer at our institution between July 1995 and July 2018. Clinical stage was determined by endoscopic ultrasound, and early stage was defined as cT1-2 and cN0. Rates of positive cytology and carcinomatosis at time of laparoscopy were obtained. Univariate analyses were used to compare groups, and Kaplan-Meier survival analyses were used to assess survival outcomes.ResultsEight hundred sixty-seven patients underwent staging laparoscopy and peritoneal cytology; 56 were defined as early stage. Age was 61 ± 12 years, 66.4% were male, and 62.3% were white. Of the patients with early stage disease, 17.9% had either gross carcinomatosis (10.7%) and/or positive peritoneal cytology (10.9%). All cases of peritoneal disease were in patients with cT2 disease. There were no differences in age, gender, or race based on peritoneal disease (all p > 0.05). The presence of carcinomatosis or positive cytology significantly affected overall survival (p < 0.001), regardless of clinical T or N stage.ConclusionsPeritoneal staging identifies metastatic disease in a significant number of patients with early stage disease. Given its poor prognosis and alternate therapy options, independent staging laparoscopy and peritoneal cytology should be considered in patients with early stage gastric adenocarcinoma.

Role of Staging Laparoscopy in Patients Undergoing Pancreaticoduodenectomy.

BackgroundPancreatic cancer patients undergoing curative resection need staging laparoscopy for detecting metastatic disease not picked up on standard radiological scans. Identifying these patients can help to prevent unnecessary laparotomies and early induction of palliative therapies.The aim of our study was to determine the effect of staging laparoscopy on resectable pancreatic or periampullary tumors at our hospital.MethodsPatients recommended pancreaticoduodenectomy between September 2014 and June 2018 were included in this study. Any significant finding and its impact on management was recorded.ResultsA total of 120 patients underwent staging laparoscopy. Fifteen patients had suspicious lesions and one patient had cirrhotic liver on staging laparoscopy. Out of these 15 patients nine patients had liver lesions, three patients with peritoneal nodules and three patients having both liver and peritoneal lesions. Among patients with liver lesions, four patients were found to have metastatic deposits. All of the remaining lesions were benign. Plan of curative resection was changed in five patients. Three patients who were planned for pancreaticoduodenectomy cancelled because of hepatic metastasis. One patient with hepatic metastasis showing neuroendocrine tumor considered for resection. One patient with resectable disease had cirrhotic liver on laparoscopy, so not medically fit for this major surgery.ConclusionIn patients planned for pancreaticoduodenectomy, staging laparoscopy is an important step to detect metastatic disease involving peritoneum or viscera. It is very helpful in determining the stage of disease and further management plan.

Long-term survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with peritoneal metastases of urachal cancer

IntroductionUrachal adenocarcinoma (UrAC) is a rare malignancy arising from persistent urachal remnants, which can cause peritoneal metastases (PM). Currently, patients with this stage UrAC are considered beyond cure. Our objective is to report long-term oncological outcome after cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with PM of urachal adenocarcinoma (UrAC). Materials and methodsWe identified 55 patients with UrAC treated at our hospital between 1994 and 2017. Patients were staged with CT, bone scintigraphy and/or PET/CT. From 2001 on, cN0M0 patients underwent staging laparoscopy. Ten patients had PM and were treated with CRS/HIPEC; 35 showed no metastases and underwent local treatment; 10 had distant metastases and received palliative chemotherapy.Disease-specific survival (DSS) rates were estimated using the Kaplan-Meier method and log-rank tests. Postoperative complications represent a secondary outcome. ResultsThe median follow-up was 96.8 months. Of the CRS/HIPEC patients, 5 (50%) developed a recurrence; 4 (40%) died of disease. The 2-yr and 5-yr DSS after CRS/HIPEC were 66.7% and 55.6%, respectively. DSS of the CRS/HIPEC patients did not significantly differ from DSS of patients without metastases who only underwent curative local treatment and was superior to patients with distant metastases (P = 0.012). The overall complication rate after CRS/HIPEC was 60%. Major complications (Clavien 3) constituted 20%. The study is limited by its retrospective nature and the small sample size. ConclusionCRS/HIPEC demonstrates satisfactory long-term oncological outcome for patients with PM of UrAC. It may be offered as a potentially curative treatment option for this group of patients.

Risk factors for latent distant organ metastasis detected by staging laparoscopy in patients with radiologically defined locally advanced pancreatic ductal adenocarcinoma.

We aimed to identify risk factors for latent distant organ metastasis in patients with radiographically defined locally advanced (RDLA) pancreatic ductal adenocarcinoma (PDAC). RDLA disease was defined as unresectable disease without distant organ metastasis based on resectability status by NCCN guidelines. Between January 2005 and November 2015, 110 consecutive patients underwent staging laparoscopy to rule out latent distant metastasis. Univariate and multivariate analyses were performed to identify risk factors for latent distant organ metastasis or peritoneal metastasis (PM), defined as peritoneal dissemination and/or positive peritoneal lavage cytology (PPC). Latent distant organ metastasis was diagnosed by staging laparoscopy in 62 patients. PPC was found in 23%, peritoneal dissemination in 19%, and liver metastasis in 15%. Univariate analysis showed tumor location, preoperative CA 19-9 level and tumor size, and multivariate analysis revealed tumor size >55mm and CA 19-9 level>60IU/ml as risk factors for latent distant metastasis. Multivariate analysis showed pancreas body-tail tumors and tumor size >42mm as risk factors for PM; 65.4% of pancreas body-tail tumors >42mm had PM. Patients with large pancreas body-tail tumors and high CA 19-9 level are at greater risk for latent distant organ metastasis or PM, and should undergo staging laparoscopy routinely for accurate diagnosis (UMIN000023125).

A laparoscopic risk-adjusted model to predict major complications after primary debulking surgery in ovarian cancer: A single-institution assessment

ObjectiveTo develop and validate a simple adjusted laparoscopic score to predict major postoperative complications after primary debulking surgery (PDS) in advanced epithelial ovarian cancer (AEOC). MethodsFrom January 2006 to June 2015, preoperative, intraoperative, and post-operative outcome data from patients undergoing staging laparoscopy (S-LPS) before receiving PDS (n=555) were prospectively collected in an electronic database and retrospectively analyzed. Major complications were defined as levels 3 to 5 of MSKCC classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n=370) and was validated on the remaining one-third patients (n=185). ResultsMajor complication rate was 18.3% (102/555). Significant predictors included in the scoring system were: poor performance status, presence of ascites (>500cm3), CA125 serum level (>1000U/ml), and high laparoscopic tumor load (predictive index value, PIV ≥8). The mean risk of developing major postoperative complications was 3.7% in patients with score 0 to 2, 13.2% in patients with score 3 to 5, 37.1% in patients with score 6 to 8. In the validation population, the predicted risk of major complications was 17.8% (33/185) versus a 16.7% (31/185) observed risk (C-statistic index=0.790). ConclusionThis new score may accurately predict a patient's postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt tailored strategies on individual basis.

Staging laparoscopy improves treatment decision-making for advanced gastric cancer

To evaluate the clinical value of staging laparoscopy in treatment decision-making for advanced gastric cancer (GC). Clinical data of 582 patients with advanced GC were retrospectively analyzed. All patients underwent staging laparoscopy. The strength of agreement between computed tomography (CT) stage, endoscopic ultrasound (EUS) stage, laparoscopic stage, and final stage were determined by weighted Kappa statistic (Kw). The number of patients with treatment decision-changes was counted. A χ(2) test was used to analyze the correlation between peritoneal metastasis or positive cytology and clinical characteristics. Among the 582 patients, the distributions of pathological T classifications were T2/3 (153, 26.3%), T4a (262, 45.0%), and T4b (167, 28.7%). Treatment plans for 211 (36.3%) patients were changed after staging laparoscopy was performed. Two (10.5%) of 19 patients in M1 regained the opportunity for potential radical resection by staging laparoscopy. Unnecessary laparotomy was avoided in 71 (12.2%) patients. The strength of agreement between preoperative T stage and final T stage was in almost perfect agreement (Kw = 0.838; 95% confidence interval (CI): 0.803-0.872; P < 0.05) for staging laparoscopy; compared with CT and EUS, which was in fair agreement. The strength of agreement between preoperative M stage and final M stage was in almost perfect agreement (Kw = 0.990; 95% CI: 0.977-1.000; P < 0.05) for staging laparoscopy; compared with CT, which was in slight agreement. Multivariate analysis revealed that tumor size (≥ 40 mm), depth of tumor invasion (T4b), and Borrmann type (III or IV) were significantly correlated with either peritoneal metastasis or positive cytology. The best performance in diagnosing P-positive was obtained when two or three risk factors existed. Staging laparoscopy can improve treatment decision-making for advanced GC and decrease unnecessary exploratory laparotomy.

Prognostic Indicators in Thick Melanoma: A Review of the National Cancer Database

Allard-Picou, Ayana MD; Dove, James T.; Arora, Tania K. MD; Shabahang, Mohsen MD, FACS; Blansfield, Joseph A. MD, FACS Author Information