Patients Underwent R0 Resection Research Articles

Results of surgical resection after induction chemoradiation for Pancoast tumours †.

Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach. Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation. Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis. This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death.

Nodal Stage of Surgically Resected Non-Small Cell Lung Cancer and Its Effect on Recurrence Patterns and Overall Survival

Current National Comprehensive Cancer Network guidelines recommend postoperative radiation therapy (PORT) for patients with resected non-small cell lung cancer (NSCLC) with N2 involvement. We investigated the relationship between nodal stage and local-regional recurrence (LR), distant recurrence (DR) and overall survival (OS) for patients having an R0 resection. A multi-institutional database of consecutive patients undergoing R0 resection for stage I-IIIA NSCLC from 1995 to 2008 was used. Patients receiving any radiation therapy before relapse were excluded. A total of 1241, 202, and 125 patients were identified with N0, N1, and N2 involvement, respectively; 161 patients received chemotherapy. Cumulative incidence rates were calculated for LR and DR as first sites of failure, and Kaplan-Meier estimates were made for OS. Competing risk analysis and proportional hazards models were used to examine LR, DR, and OS. Independent variables included age, sex, surgical procedure, extent of lymph node sampling, histology, lymphatic or vascular invasion, tumor size, tumor grade, chemotherapy, nodal stage, and visceral pleural invasion. The median follow-up time was 28.7 months. Patients with N1 or N2 nodal stage had rates of LR similar to those of patients with N0 disease, but were at significantly increased risk for both DR (N1, hazard ratio [HR] = 1.84, 95% confidence interval [CI]: 1.30-2.59; P=.001; N2, HR = 2.32, 95% CI: 1.55-3.48; P<.001) and death (N1, HR = 1.46, 95% CI: 1.18-1.81; P<.001; N2, HR = 2.33, 95% CI: 1.78-3.04; P<.001). LR was associated with squamous histology, visceral pleural involvement, tumor size, age, wedge resection, and segmentectomy. The most frequent site of LR was the mediastinum. Our investigation demonstrated that nodal stage is directly associated with DR and OS but not with LR. Thus, even some patients with, N0-N1 disease are at relatively high risk of local recurrence. Prospective identification of risk factors for local recurrence may aid in selecting an appropriate population for further study of postoperative radiation therapy.

Resection after neoadjuvant chemotherapy in advanced carcinoma of the gallbladder: a retrospective study.

Although rare over most of the world, Gallbladder cancer is very common in northern india. A delayed presentation, aggressive nature,lack of randomised trials and a poor prognosis have all contributed to the nihilistic halo encircling gallbladder cancer. None of the advances in oncology have been exploited enough to shatter the nihilistic halo. In this background we sought to analyze if the addition of neoadjuvant chemotherapy had any impact on the resectability, overall and disease free survival in patients with advanced carcinoma of the gallbladder. We reviewed the records of all patients who underwent surgery for carcinoma of the gall bladder from 2004 to 2010 at our institute retrospectively. Twenty-one patients received neoadjuvant chemotherapy and subsequently taken up for surgery. Outcome analysis of these 21 patients were done by Kaplan meier method and graphs plotted. Out of the 21 patients who were taken up for surgery after neoadjuvant chemotherapy, fourteen patients underwent R0 resection (Group 1). Seven patients had been rendered inoperable on exploration (Group 2). Thus about 66.67% of patients deemed resectable after neoadjuvant chemotherapy on imaging underwent R0 resection. The mean overall survival of the group 1 was 42.8months versus 6.6months of group 2(Hazard Ratio: 3.42). Neoadjuvant chemotherapy improves resectability in some patients with unresectable gall bladder cancer. Resection after neoadjuvant chemotherapy is feasible and may improve survival in a select group of patients. However randomized studies are required to establish its definitive role.

Risk factors for peritoneal recurrence in serosa-negative gastric cancer.

19 Background: Peritoneal recurrence is often observed in gastric cancer patients without serosal invasion. It is difficult for pathologists to evaluate whether tumor cells penetrate serosa or not, because the subserosa layer is very thin. We evaluated the incidence and risk factors of peritoneal recurrence in serosa -negative gastric cancer patients to clarify the mechanism of peritoneal recurrence in these patients. Methods: A total of 1,745 gastric cancer patients underwent R0 resection from 2002 to 2009 were enrolled. The incidence of peritoneal recurrence according to tumor depth was analyzed. In serosa-nagative patients, the univariate and multivariate analysis were performed to identify the risk factors for peritoneal recurrence. Results: Peritoneal recurrence was observed in 64 (3.7 %) out of 1,745 patients. The incidence of peritoneal recurrence according to depth of tumor invasion was in 0 / 466 in T1a, 5 / 567 (0.88 %) in T1b, 4 / 187 (2.1 %) in T2, 31 / 360 (7.9 %) in T3, 20 / 108 (15.9 %) in T4a, and 4 / 12 (25 %) in T4b, respectively (p&lt;0.001). As for the risk factor for peritoneal recurrence in T3 patients, histologically undifferentiated type, negative lymphatic invasion, scirrhous type, invasive infiltrating growth pattern were the significant factors identified by univariate analysis. Only the invasive infiltrating growth pattern (OR3.44 p0.038) was selected as significant independent risk factor for peritoneal recurrence by multivariate analysis. In T1b / T2 patients, massive lymph node metastasis (N3a, 3b), scirrhous type were the significant factor for peritoneal recurrence by univariate analysis. Only massive lymph node metastasis (OR25.1 p&lt;0.001) was selected as the significant independent risk factor by multivariate analysis. Conclusions: The incidence of peritoneal recurrence increases in proportion to the tumor depth. Invasive infiltrating growth pattern was selected as an independent risk factor for peritoneal recurrence in T3 patients, while it was massive lymph node metastasis in T1b / T2 patients. The results suggest the possibility that microscopic serosal invasion in T3 tumor and lymphatic progression in T1b / T2 tumor may contribute to peritoneal recurrence in gastric cancer.

Intraoperative Surgical Margin Re-resection for Colorectal Liver Metastasis: Is It Worth the Effort?

ObjectiveThis study was conducted to evaluate recurrence and survival among patients who underwent intraoperative margin re-resection for colorectal cancer liver metastases (CRLM). BackgroundAmong patients who receive intraoperative margin re-resection, the relation between final margin status, pattern of recurrence, and survival is largely unknown. MethodsThree hundred thirty-two patients who underwent hepatic resection for CRLM between 2000 and 2013 were identified. Demographics, operative data, pathologic margin status, site of recurrence, and long-term survival data were collected and analyzed. Patients were stratified in three groups based on their margin status: R0, R1, and R1 → R0. ResultsR0 resections were achieved in 247 (74.4 %) patients, 61 (18.4 %) patients had an R1 resection, whereas 24 (7.2 %) had an R1 → R0. Median survival for patients undergoing R0 resections was 50.2 (95 % confidence interval (CI) 49.2–66.2) months versus 63.0 (95 % CI 50.3–70.5) months for patients undergoing R1 resections versus 49.2 (95 % CI 29.9—NA) months for patients undergoing intraoperative margin re-resection (P > 0.05). Differences in recurrence rate and pattern were not significant between the three groups (P > 0.05). ConclusionIn the era of modern systemic chemotherapy, it seems that the impact of margin status on outcomes may be minimal compared to that of patient and tumor factors. In this scenario, margin re-resection to achieve R0 status does not improve long-term outcomes.

297. Multimodal approach to stage IV rectal cancer treatment

297. Multimodal approach to stage IV rectal cancer treatment

Long-term survival outcomes of advanced gastric cancer patients who achieved a pathological complete response with neoadjuvant chemotherapy: a systematic review of the literature.

A pathologic complete response (pCR) can sometimes be induced by intensive or long-term neoadjuvant chemotherapy (NAC). This prognostic research study based on a systematic review of the literature evaluated the impact of a pCR on the long-term survival of gastric cancer (GC) patients. Articles were extracted from PubMed and the Japanese medical search engine "Ichu-shi," using the terms "GC," "NAC," and "pCR." Articles were selected based on the following criteria: (1) full-text case report, (2) R0 resection following NAC for locally advanced GC, and (3) pathological complete response in both the primary stomach and in the lymph nodes. A questionnaire regarding the patients' prognoses was sent to the corresponding authors of the articles selected in July 2013. Twenty-four articles met the criteria. Twenty authors responded to the questionnaire. Finally, 22 patients from 20 articles were entered into the present study. The median follow-up time (range) of the survivors was 76 (range 13-161) months. Tumors that were stage III/IV (86%: 19/22) and of an undifferentiated histology (61.9%: 13/21) were dominant. An S1-based regimen was frequently selected for the NAC. All patients underwent R0 resection and D2/D3 lymphadenectomy. The overall survival and recurrence-free survival rates at 3 and 5 years were 96% and 85% and 91% and 75%, respectively. Although a pCR was a relatively rare event, a high pCR rate would be helpful to select the regimen and courses of NAC, especially when the pathological response rates are similar.

230P - Prognostic Impact of Tumoral and/or Peri-Tumoral Sparc Expressions After Surgery in Patients with Biliary Tract Cancer

ABSTRACT Aim: SPARC (secreted protein acidic and rich in cysteine) is a member of matricellular glycoproteins, which modulate interactions between tumoral cells and the peri-tumoral stroma. It was demonstrated that SPARC not only induced proliferation and invasion in vitro, but also became a poor prognostic marker in different cancers, including three gastro-intestinal cancers; stomach, colon, and pancreas. Herein, we evaluated the prognostic significance of tumor and peri-tumoral SPARC expression in patients with biliary tract cancer (BTC) after surgery. Methods: We examined immunohistochemical patterns of SPARC expression in 110 resected specimens and evaluated the prognostic significance using a prospectively collected database. Results: 93 patients underwent R0 resection, and 54 patients suffered from lymph node metastasis. Overall survival at 5-year after surgery was 34.2%. SPARC expressed at 46 tumoral cells (42%) and at 65 peri-tumoral stroma (59%). Tumoral SPARC did not relate to major patients characteristics; however, peri-tumoral stromal SPARC expressed highly, related to lymph node metastasis, stage, and tumor location. Patients whose peri-tumoral stroma expressed SPARC (MST, 24.5 months) had a significantly worse prognosis than patients whose peri-tumoral stroma did not express SPARC (MST, 69.2 months; p = 0.0001). Moreover, the expression of SPARC in tumoral cells was also associated with a poor prognosis and was a less significantly predictor of prognosis than the positive SPARC expression in peri-tumoral stroma (p = 0.0487). In multivaliate analysis, controlling for other prognostic factors (UICC stage, pathological type, lymph nodes metastasis, margin status, perineural invasion and vascular invasion), the hazard ration for patients whose peri-tumoral stroma expressed SPARC compared with those whose peri-tumoral stroma did not was 2.74 (95% CI, 1.64 to 4.76). The expression of tumoral SPARC was unrelated to an independent predictor of poor prognosis (HR, 1.45; 95% CI, 0.89 to 2.37). Conclusions: The expression of SPARC at peri-tumoral stroma portends a poor prognosis for patients with BTC after surgery. Disclosure: All authors have declared no conflicts of interest.

Surgical treatment of non-early gastric remnant carcinoma developing after distal gastrectomy for gastric cancer.

The optimal surgical procedure for gastric remnant carcinoma (GRC) remains debatable. The aim of this study was to retrospectively evaluate the surgical treatments for T2-4 GRC developing after distal gastrectomy for gastric cancer. Between 1970 and 2012, a total of 50 patients underwent R0 resection for T2-4 GRC. The clinicopathologic features, therapeutic methods, and follow-up data of these patients were reviewed. The tumor was located at a non-anastomotic site of the remnant stomach in 43 of the 50 patients. Total gastrectomy was performed in 48 patients and partial gastrectomy was in two patients. Lymph node metastasis was found in 19 patients. Major postoperative complications occurred in 16 patients. The overall 1-, 3-, and 5-year survival rates of the 50 patients were 90%, 66%, and 44%, respectively. Presence of small intestinal or esophageal infiltration and postoperative complications was independently associated with poorer survival. Dissection of the perigastric and splenic hilar/artery nodes was found to have potential therapeutic benefit. Surgical resection for T2-4 GRC developing after distal gastrectomy for gastric cancer can be invasive, but is feasible and effective. Total gastrectomy with splenectomy is one of the recommendable procedures for this disease.

ALK expression is absent in pancreatic ductal adenocarcinoma.

It has not yet been clearly defined whether anaplastic lymphoma kinase (ALK) expression can be detected in pancreatic ductal adenocarcinoma (PDAC). Within a retrospective study, archival PDAC surgical specimens were screened for ALK expression in tumor and normal tissue by immunohistochemistry (IHC) with the use of a specific ALK detection kit on a tissue microarray (TMA). PDAC tumor tissue was available from 99 resected cases: fifty-eight out of 99 patients (59%) had nodal-positive disease, and 80 patients (81%) had pT3 tumors. Forty-nine patients underwent R0 resection, and in 48 cases, resection status was classified R1. Regarding ALK expression, five cases showed faint immunoreactivity on TMA, which was negative on whole mount sections. All other 94 cases showed no ALK expression. In 99 PDAC cases, no ALK expression was detected by IHC; ALK thus may not serve as a relevant drug target in PDAC.

Patterns of recurrence after resection of gallbladder cancer without routine extrahepatic bile duct resection

ObjectiveRoutine extrahepatic bile duct (EBD) resection in non-jaundiced patients with gallbladder cancer (GBC) is controversial. The aim of this study was to retrospectively analyse patterns of recurrence in patients who underwent resection of GBC without routine EBD resection. MethodsThis analysis referred to 58 patients who had undergone explorative laparotomy for GBC during 2000–2012 at a single, tertiary referral centre. Overall survival, time to recurrence, and patterns of recurrence were assessed in patients who underwent conventional negative-margin (R0) resection without routine EBD resection. ResultsOf 58 patients submitted to explorative laparotomy for GBC, 26 (45%) patients underwent R0 resection without EBD resection (tumour stage T1b in five patients, T2 in 17, T3 in three, and T4 in one). The 3-year survival rate among these patients was 78% at a median follow-up of 33months (range: 13–127 months). Seven patients developed recurrent disease at a median of 9 months (range: 2–25 months) after resection. No patients developed isolated recurrent disease at the EBD. ConclusionsOf 26 patients resected for GBC, none developed isolated recurrent disease at the EBD after conventional resection of GBC without EBD resection. This finding suggests that routine EBD resection is of no additional value.

Clinicopathological features and surgical outcomes of adenosquamous carcinoma of the pancreas: a retrospective analysis of patients with resectable stage tumors

Adenosquamous carcinoma of the pancreas is a rare subtype of pancreatic cancer. We herein describe the clinicopathological features of surgically resected cases of adenosquamous carcinoma of the pancreas. From 2001 to 2011, 132 patients underwent R0 resection for Stage IIA or IIB pancreatic cancer. The survival rate, pathological features and recurrence status were reviewed. Out of 132 patients, 121 patients had tubular adenocarcinoma, and only seven had adenosquamous carcinoma (ASC). The incidence of ASC increased with the tumor size. The overall survival and disease-free survival periods of the patients with ASC were significantly shorter than those of patients with tubular adenocarcinoma (p = 0.0153 and p = 0.0045). The histological findings revealed more marked venous invasion in ASC compared to tubular adenocarcinoma (G1, G2 and G3). The proportion of v3 cases, which denotes the most severe venous invasion, was 31.3 % in G1, 47.3 % in G2, 60.0 % in G3 and 71.4 % in ASC cases, respectively. Other factors, including lymphatic and nerve invasion, were not correlated with the histological subtypes. The incidence of ASC was 11.1 % in the tumors more than 6 cm in diameter, and 0 % in those less than 2 cm in diameter. We revealed that adenosquamous carcinoma of the pancreas is associated with a poor outcome, and also clarified its clinicopathological features.

Clinical implications of quantitative pathological and immunohistochemical markers for lymph node metastasis in esophageal cancer patients based on preoperative treatment status

Whether the prognostic abilities of markers of lymphatic spread are affected by preoperative chemotherapy or chemoradiotherapy for esophageal cancer has not been clarified. The purpose of this study was to determine significant prognostic predictors related to lymphatic spread in potentially curable esophageal cancer according to preoperative treatment status. The prognostic significance of quantitative pathological and immunohistochemical markers of lymphatic spread was determined in 80 esophageal cancer patients undergoing R0 resection with or without preoperative treatment. Univariate analysis revealed that the presence or absence of immunohistochemical nodal micrometastasis (iNM), number of pathological nodal metastases (pNM) and iNM, and the ratios of pNM and iNM to removed nodes were significant prognostic predictors in patients undergoing esophagectomy without preoperative treatment. In contrast, only the presence or absence of pNM, number of pNM, and pNM ratio were significant prognostic indicators in patients undergoing esophagectomy after preoperative treatment. Multivariate analysis revealed that the number of iNM, a novel prognostic indicator found in the present study, was the only independent prognostic predictor in the former patients, whereas the number of pNM was the only independent prognostic predictor in the latter patients. In esophageal cancer, the prognostic values of factors related to lymphatic spread depend on the patient’s preoperative treatment status. Two or more pNM indicated poor prognosis after esophagectomy in patients undergoing preoperative treatment for advanced disease. However, 2 or more iNM indicated poor prognosis after esophagectomy in patients undergoing upfront esophagectomy for less advanced disease.

P-0272 - Neoadjuvant Chemotherapy Capecitabine and Oxaliplatin (XELOX) Combined with Bevacizumab for High-Risk Localized Rectal Cancer

Introduction: Neoadjuvant Chemoradiotherapy followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. Although this approach decreases the risk of local recurrence, pelvic radiation is associated with long-term morbidity and delays systemic treatment. We conducted this study to evaluate the feasibility of neoadjuvant capecitabine and oxaliplatin (XELOX) plus bevacizumab as a treatment for high-risk localized rectal cancer. Methods: Patients with T4 or lymph node-positive rectal cancer were treated with three cycles of XELOX plus bevacizumab, and one additional cycle of XELOX. This was followed by TME performed 3–8 weeks after the last chemotherapy session. Results: Twenty-five patients were recruited between December 2009 and November 2011. In seven of the patients (28.0%), grade 3-4 adverse events occurred. After preoperative chemotherapy, the frequency of tumor (T) downstaging was 69.6%, and that of lymph node (N) downstaging was 78.9%. Seven patients discontinued the treatment after 2-3 cycles of XELOX plus bevacizumab. The frequency of subsequent surgery was 92%, and all patients underwent R0 resections. Postoperative complications occurred in six patients (26.1%). One patient achieved a pathological complete response (pCR) for the primary tumor and lymph nodes, whereas an additional four patients achieved near-pCR. After a median follow-up of 31 months, five patients displayed metastatic progression, including one who suffered local recurrence. Conclusion: XELOX plus bevacizumab followed by TME is feasible for high-risk localized rectal cancer, as it achieves good tumor regression and causes manageable toxicity.

The preoperative neutrophil-lymphocyte ratio predicts recurrence and survival among patients undergoing R0 resections of adenocarcinomas of the esophagogastric junction.

Elevated preoperative neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) predict survival rates among patients with several types of cancer. The current study sought to clarify whether NLR and PLR are clinically useful independent prognostic indicators of adenocarcinomas of the esophagogastric junction (AEG) among patients undergoing curative resections (i.e., R0 resections). A total of 327 patients who underwent R0 resections for AEG were enrolled in the study. Data concerning demographic parameters, laboratory analyses, histopathology, and survival time were collected and analyzed. A total of 123 patients (37.6%) had elevated preoperative NLR (≥ 5). The median follow-up duration was 24.7 months (range = 2-39 months). NLR was significantly related to histology (P = 0.035), pTNM stage (P < 0.0001) and tumor recurrence (P = 0.022). Univariate analyses revealed that NLR were significantly associated with disease-free survival (DFS) and overall survival (OS; both P < 0.0001). Multivariable analyses revealed that elevated NLR independently predicted poorer DFS (hazard ratio [HR] = 2.551, P < 0.0001) and OS (HR = 2.743, P < 0.0001). However, PLR did not significantly predict DFS or OS. The present study indicates that elevated preoperative NLR (≥ 5) is a useful marker of tumor recurrence and independently predicts poorer disease-free and overall survival among patients with AEG undergoing R0 resections.

A Nomogram to Predict Long-term Survival After Resection for Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a primary cancer of the liver that is increasing in incidence, and the prognostic factors associated with outcome after surgery remain poorly defined. To combine clinicopathologic variables associated with overall survival after resection of ICC into a prediction nomogram. We performed an international multicenter study of 514 patients who underwent resection for ICC at 13 major hepatobiliary centers in the United States, Europe, and Asia from May 1, 1990, through December 31, 2011. Multivariate Cox proportional hazards regression modeling with backward selection using the Akaike information criteria was used to select variables for construction of the nomogram. Discrimination and calibration were performed using Kaplan-Meier curves and calibration plots. Surgical resection of ICC at a participating hospital. Long-term survival, effect of potential prognostic factors, and performance of proposed nomogram. Median patient age was 59.2 years, and 53.1% of the patients were male. Most patients (74.7%) had a solitary tumor, and median tumor size was 6.0 cm. Patients were treated with an extended hepatectomy (202 [39.3%]), a hemihepatectomy (180 [35.0%]), or a minor liver resection (<3 segments) (132 [25.7%]). Most patients underwent R0 resection (87.9%), and 35.7% of patients had N1 disease. Using the backward selection of clinically relevant variables, we found that age at diagnosis (hazard ratio [HR], 1.31; P < .001), tumor size (HR, 1.50; P < .001), multiple tumors (HR, 1.58; P < .001), cirrhosis (HR, 1.51; P = .08), lymph node metastasis (HR, 1.78; P = .01), and macrovascular invasion (HR, 2.10; P < .001) were selected as factors predictive of survival. On the basis of these factors, a nomogram was created to predict survival of ICC after resection. Discrimination using Kaplan-Meier curves, calibration curves, and bootstrap cross-validation revealed good predictive abilities (C index, 0.692). On the basis of an Eastern and Western experience, a nomogram was developed to predict overall survival after resection for ICC. Validation revealed good discrimination and calibration, suggesting clinical utility to improve individualized predictions of survival for patients undergoing resection of ICC.

A multicentre retrospective cohort study of patients with gastrointestinal stromal tumors in Shandong Province

To investigate the clinicopathological features and prognosis of patients with gastrointestinal stromal tumor(GIST) after surgery in Shandong Province. Clinicopathological data of GIST patients undergoing surgery from January 2001 to June 2013 in four university teaching hospitals in Shandong Province were reviewed. Pathology results were rechecked. Patients were followed up. The prognostic factors were evaluated by univariate and multivariate analyses with Log-rank test and Cox proportional hazard model. A total of 1039 GIST cases were enrolled, including 509 males and 530 females, with age from 18 to 87 years(median, 58). Ninety-three patients died of GIST during follow-up. The 1-, 3-, 5-year survival rates were 94.6%, 91.7% and 87.8%, respectively. Patients undergoing R0 resection had a higher 5-year overall survival rate than those undergoing R1 resection(88.8% vs 69.0%, P<0.05). For patients with intermediate risk of recurrence after surgery, the 5-year overall survival rate was 94.4% and 89.2% respectively in imatinib and non-imatinib intervention groups(P>0.05). For patients with high risk of recurrence after surgery, the 5-year overall survival rate was 76.8% and 67.7% respectively(P<0.05). Multivariate analysis revealed that tumor size(P<0.01, RR=1.988, 95%CI:1.497-2.641), mitotic count(P<0.01, RR=2.326, 95%CI:1.686-3.208) and tumor rupture(P<0.01, RR=3.032, 95%CI:1.732-5.308) were independent prognostic factors. Tumor size, mitotic count and tumor rupture affect the prognosis of patients after resection of primary GIST independently. The standard treatment of localized GIST is R0 resection. Adjuvant imatinib therapy can improve overall survival of patients with high risk of recurrence after surgery. The efficacy of imatinib for patients with intermediate risk of recurrence remains to be verified.

Efficacy and prognosis of different treatments on 63 patients with small intestinal gastrointestinal stromal tumors

To analyze the efficacy and prognosis of different treatments on small intestinal gastrointestinal stromal tumors(SIGIST). Clinical data of 63 patients with SIGIST who were admitted to the Chinese PLA General Hospital from January 2004 to December 2013 were analyzed retrospectively. According to resection procedure and postoperative use of imatinib, patients were divided into R0 resection plus imatinib group (13 cases), R0 resection without imatinib group (42 cases), non-R0 resection plus imatinib group (7 cases), non-R0 resection without imatinib group (1 case). Survival was compared among groups. Result All the patients were followed up with a median length of 24 months(3 to 120 months), and the over survival (OS) rates at 1-year, 3-year, 5-year were 97%, 94% and 80%. In R0 resection plus imatinib group, R0 resection without imatinib group, and non-R0 resection plus imatinib group, the progression free survival(PFS) time was 24, 24 and 23 months; the 1-year PFS were 100%, 97% and 83%; the 3-year PFS were 100%, 45% and 83%; the 5-year PFS were 100%, 28% and 42%. R0 resection plus imatinib group had significantly higher PFS(all P<0.05). The case of non-R0 resection without imatinib died 6 months after operation. Among 55 patients undergoing R0 resection, recurrence was found in 16 patients, whose recurrence rates of 1-year, 3-yeart and 5-year were 2%,43% and 58%. Local recurrence was found in 8 cases, hepatic recurrence in 3 cases and widespread recurrence in 5 cases, who received simple imatinib, operation plus imatinib and imatinib intervention, with median survival time of 66.5 months, 92.5 months and 48 months respectively. One patient initiatively abandoned treatment and died 17 months later. The total resection and postoperative imatinib administration can improve the prognosis and raise the progression free survival of patients with small intestinal stromal tumors.

Neoadjuvant capecitabine and oxaliplatin (XELOX) combined with bevacizumab for high-risk localized rectal cancer

Chemoradiotherapy followed by total mesorectal excision (TME) is the standard treatment for locally advanced rectal cancer. Although this approach decreases the risk of local recurrence, pelvic radiation is associated with long-term morbidity and delays systemic treatment. We conducted this study to evaluate the feasibility of neoadjuvant capecitabine and oxaliplatin (XELOX) plus bevacizumab as a treatment for high-risk localized rectal cancer. Patients with T4 or lymph node-positive rectal cancer were treated with three cycles of XELOX plus bevacizumab and one additional cycle of XELOX. This was followed by TME performed 3-8 weeks after the last chemotherapy session. Twenty-five patients were recruited between December 2009 and November 2011. In seven of the patients (28.0 %), grade 3-4 adverse events occurred. After preoperative chemotherapy, the frequency of tumor (T) downstaging was 69.6 %, and that of lymph node (N) downstaging was 78.9 %. Seven patients discontinued the treatment after 2-3 cycles of XELOX plus bevacizumab. The frequency of subsequent surgery was 92 %, and all patients underwent R0 resections. Postoperative complications occurred in six patients (26.1 %). One patient achieved a pathological complete response (pCR) for the primary tumor and lymph nodes, whereas an additional four patients achieved near-pCR. After a median follow-up of 31 months, five patients displayed metastatic progression, including one who suffered local recurrence. XELOX plus bevacizumab followed by TME is feasible for high-risk localized rectal cancer, as it achieves good tumor regression and causes manageable toxicity.

Phase 2 Trial of Induction Gemcitabine, Oxaliplatin, and Cetuximab Followed by Selective Capecitabine-Based Chemoradiation in Patients With Borderline Resectable or Unresectable Locally Advanced Pancreatic Cancer

To evaluate, in a phase 2 study, the safety and efficacy of induction gemcitabine, oxaliplatin, and cetuximab followed by selective capecitabine-based chemoradiation in patients with borderline resectable or unresectable locally advanced pancreatic cancer (BRPC or LAPC, respectively). Patients received gemcitabine and oxaliplatin chemotherapy repeated every 14 days for 6 cycles, combined with weekly cetuximab. Patients were then restaged; "downstaged" patients with resectable disease underwent attempted resection. Remaining patients were treated with chemoradiation consisting of intensity modulated radiation therapy (54 Gy) and concurrent capecitabine; patients with borderline resectable disease or better at restaging underwent attempted resection. A total of 39 patients were enrolled, of whom 37 were evaluable. Protocol treatment was generally well tolerated. Median follow-up for all patients was 11.9 months. Overall, 29.7% of patients underwent R0 surgical resection (69.2% of patients with BRPC; 8.3% of patients with LAPC). Overall 6-month progression-free survival (PFS) was 62%, and median PFS was 10.4 months. Median overall survival (OS) was 11.8 months. In patients with LAPC, median OS was 9.3 months; in patients with BRPC, median OS was 24.1 months. In the group of patients who underwent R0 resection (all of which were R0 resections), median survival had not yet been reached at the time of analysis. This regimen was well tolerated in patients with BRPC or LAPC, and almost one-third of patients underwent R0 resection. Although OS for the entire cohort was comparable to that in historical controls, PFS and OS in patients with BRPC and/or who underwent R0 resection was markedly improved.