Positive Surgical Resection Margins Research Articles

Defining Facility Volume Threshold for Optimization of Short- and Long-Term Outcomes in Patients Undergoing Resection of Perihilar Cholangiocarcinoma

BackgroundWe determined the minimum threshold (Tmin) of annual facility case volume to optimize outcomes for patients with resected perihilar cholangiocarcinoma. MethodsWe identified patients with localized perihilar cholangiocarcinoma who underwent resection within the National Cancer Database (2010–2017). We used marginal structural logistic regression models to estimate the average treatment effect of receiving care in facilities meeting/exceeding Tmin on 90-day mortality and other postoperative outcomes. ResultsA total of 2471 patients underwent resection for perihilar cholangiocarcinoma at 471 facilities. There was no effect of total hepatopancreatobiliary, surgical hepatopancreatobiliary, total hepatobiliary, surgical hepatobiliary, or total perihilar cholangiocarcinoma case volume on 90-day mortality. A Tmin of seven perihilar cholangiocarcinoma resections/year resulted in lower odds of 90-day mortality (IP-weighted OR = 0.49, 95% CI: 0.66–0.87). A total of two facilities met the Tmin. Patients receiving treatment at Tmin facilities had lower odds of length of stay ≥ 7 days (IP-weighted OR = 0.85, 95% CI: 0.75–0.97) and positive surgical resection margins (IP-weighted OR = 0.40, 95% CI: 0.47–0.55). Additionally, undergoing surgery at Tmin facilities resulted in higher (≥ 4 nodes) lymph node yields (IP-weighted OR = 1.94, 95% CI: 1.21–3.11) but no change in the odds of nodal positivity. There was no effect of undergoing surgery at Tmin facilities on 30-day mortality or re-admission. ConclusionsResection of perihilar cholangiocarcinoma is infrequently performed at a high number of facilities. A Tmin of ≥ 7 resections/year resulted in lower 90-day mortality and improved postoperative outcomes. Our data suggest that regionalization of care for patients with perihilar cholangiocarcinoma could potentially improve outcomes in the USA.

Clinicopathological Significances of Positive Surgical Resection Margin after Radical Prostatectomy for Prostatic Cancers: A Meta-Analysis.

Background and Objectives: This study aims to elucidate the positive rate and the clinicopathological significance of surgical margin after radical prostatectomy (RP) through a meta-analysis. Materials and Methods: This meta-analysis finally used 59 studies, including the information about the positive surgical margin (PSM) and those clinicopathological significances after RP. The subgroup analysis for the estimated rates of PSM was evaluated based on types of surgery, grade groups, and pathological tumor (pT) stages. We compared the clinicopathological correlations between positive and negative surgical margins (NSM). Results: The estimated PSM rate was 25.3% after RP (95% confidence interval [CI] 21.9–29.0%). The PSM rates were 26.0% (95% CI 21.5–31.1%) 28.0% (95% CI 20.2–37.5%) in robot-assisted RP and nerve-sparing RP, respectively. The PSM rate was significantly higher in high-grade groups than in low-grade groups. In addition, the higher pT stage subgroup had a high PSM rate compared to the lower pT stage subgroups. Patients with PSM showed significantly high PSA levels, frequent lymphovascular invasion, lymph node metastasis, and extraprostatic extension. Biochemical recurrences (BCRs) were 28.5% (95% CI 21.4–36.9%) and 11.8% (95% CI 8.1–16.9%) in PSM and NSM subgroups, respectively. Patients with PSM showed worse BCR-free survival than those with NSM (hazard ratio 2.368, 95% CI 2.043–2.744%). Conclusions: Our results showed that PSM was significantly correlated with worse clinicopathological characteristics and biochemical recurrence-free survival. Among the results in preoperative evaluations, grade group and tumor stage are useful for the prediction of PSM.

Can CA 19-9 predict inferior surgical and pathological outcomes for resectable pancreatic cancer?

e16228 Background: Previous data have established that patients with pancreatic surgical specimens showing lymphovascular invasion (LVI) and positive surgical resection margins are associated with poor survival outcomes. However, there are no biomarkers to identify these high-risk patients preoperatively. In this study, we hypothesized that increased carbohydrate antigen 19-9 (CA 19-9) levels could be used to predict high-risk resectable pancreatic cancer features, including LVI and positive residual margins, thereby guiding the surgical decision-making process. Methods: We sampled the National Cancer Database for patients undergoing pancreatic cancer resection between 2004-2018. Logistic regression analysis was performed to analyze sociodemographic and disease characteristics associated with elevated CA 19-9 levels (> 98 U/ml) versus low CA 19-9 levels (< 98 U/ml). Additionally, Cox regression analyses were used to compare hazard ratios for demographic and disease characteristics. A p < 0.05 was considered statistically significant. Results: 12208 patients (50.76% males) with pancreatic cancer were sampled. Pathological findings of LVI (n = 5963), microscopic residual tumor margins (R1) (n = 1547), and residual margins (R), not otherwise specified (NOS) (n = 885) had a stronger association with high preoperative CA 19-9 levels when compared to those with low CA 19-9 levels (LVI: OR 1.212, 95% CI 1.125–1.305, p < 0.001, R1: OR 1.260, 95% CI 1.129–1.408, p = 0.001 and R NOS: OR 1.212, 95% CI 1.052–1.395, p = 0.008). Macroscopic residual margins (R2) (n = 85) were also associated with high CA 19-9 but statistically not significant (OR 1.242, 95% CI 0.802–1.924, p = 0.332) probably due to the low sample size for this subpopulation. Furthermore, all the factors listed below were independently associated with poor prognosis: (A) Elevated CA 19-9 levels: HR 1.411, 95% CI 1.350–1.475, p < 0.001, (B) LVI: HR 1.333, 95% CI 1.275–1.394, p < 0.001, (C) R NOS: HR = 1.517, 95% CI = 1.401–1.643, p < 0.001, (D) R1: HR 1.594, 95% CI 1.499–1.695, p < 0.001, (E) R2: HR 2.015, 95% CI 1.597–2.543, p < 0.001. Conclusions: Elevated CA 19-9 can be used as a biomarker to identify a subset of pancreatic cancer patients with high-risk surgical pathological features such as LVI or residual tumor margins. In these patients, perhaps neoadjuvant chemotherapy can facilitate downstaging and provide superior surgical and oncological outcomes.

Comparison of Recurrence Rate Between Re-Excision With Radiotherapy and Radiotherapy-Only Groups in Surgical Margin Involvement of In Situ Carcinoma.

PurposeSurgical margin status is a surrogate marker for residual tumors after breast-conserving surgery (BCS). A comparison of ipsilateral breast tumor recurrence (IBTR) rates between re-excision combined with radiotherapy (excision with RTx) and RTx alone, following the confirmation of ductal carcinoma in situ (DCIS) in the resection margin after BCS, has not been reported previously. Therefore, in the present study, the clinical characteristics of DCIS involvement in the surgical resection margin between excision with RTx and RTx alone were investigated, and the IBTR rate was compared.MethodsWe analyzed 8,473 patients treated with BCS followed by RTx between January 2013 and December 2019. Patients were divided into 2 groups based on surgical resection margin status in permanent pathology, and superficial and deep margins were excluded. Patients who underwent re-excision with DCIS confirmed in the resection margin were identified and the IBTR rate was examined.ResultsAmong 8,473 patients treated with BCS, 494 (5.8%) had positive surgical resection margins. The median follow-up period was 47 months. Among the 494 patients with a positive resection margin, 368 (74.5%) had residual DCIS at the surgical resection margin in the final pathology. Among those with confirmed DCIS at the resection margin, 24 patients (6.5%) were re-excised, and 344 patients (93.5%) underwent RTx after observation. The IBTR rates were 4.2% and 1.2% in the re-excision and observation groups, respectively. IBTR-free survival analysis revealed no significant difference between the excision with RTx and RTx-only groups (p = 0.262).ConclusionThe IBTR rate did not differ between the excision with RTx and RTx-only groups when DCIS was confirmed at the resection margins. This suggests that RTx and close observation without re-excision could be an option, even in cases where minimal involvement of DCIS is confirmed on surgical resection.

Meta-Analysis of Prognostic Factors for Recurrence of Resected Well-Differentiated Pancreatic Neuroendocrine Tumors

Introduction: Well-differentiated pancreatic neuroendocrine tumors (WDPNETs) are a group of rare and heterogeneous tumors. However, the prognostic factors for recurrence after curative resection still remain controversial. We aim to illustrate the prognostic factors for recurrence of resected WDPNETs. Methods: All relevant articles published through June 2020 were identified via PubMed, Embase, Web of Science, and Cochrane Library. Articles that examined the prognostic factors of WDPNETs were enrolled. Results: Ten articles were finally included in this study. From 1993 to 2018, 2,863 patients underwent curative resection and 358 patients had recurrence, and the combined recurrence rate was 13%. Furthermore, the pooled data indicated that patients with G2, positive lymph node and surgical resection margin, vascular invasion, and perineural invasion had a decreased disease-free survival for WDPNETs. However, gender, function, and tumor size had no significant relationship with WDPNETs recurrence. Conclusion: These findings demonstrated that G2, positive lymph node and surgical resection margin, vascular invasion, and perineural invasion could be prognostic factors for recurrence of resected WDPNETs, indicating that patients with these high-risk factors need closer postoperative follow-up and may benefit from adjuvant therapy.

Prognosis and Circumferential Margin in Patients with Resected Hilar Cholangiocarcinoma.

Resection margin status is a known prognosticator in patients who undergo resection for hilar cholangiocarcinoma. However, the influence of an isolated positive circumferential margin on clinical outcome is unclear. Patients with resected de novo hilar cholangiocarcinoma from two European hepatobiliary centres (Medical University of Vienna and Aintree University Hospital, 2006-2016) were classified according to resection margin status (negative, surgically positive, isolated circumferentially positive) and investigated with respect to overall survival (OS), recurrence-free survival (RFS) and recurrence pattern. Eighty-three (48 male/35 female) patients were enrolled. The median age was 64years (range 33-80). The median follow-up was 21.7months (range 0.3-92.4). Forty (48%) patients had negative resection margins, 25 (30%) had an isolated positive circumferential margin and 18 (22%) had a positive surgical margin. The 5-year OS rates in patients with negative, isolated positive circumferential and positive surgical resection margins were 47%, 33% and 0%, respectively. Median OS was 45.6, 32.7 and 14.5months, respectively (log rank, P = 0.011). Upon multivariable Cox regression analysis, resection margin status and lymph node status remained statistically significant (P < 0.05). No difference with respect to RFS and recurrence pattern was found between the groups (P > 0.05). Our data show that these three resection margin types were associated with different clinical outcomes. Circumferential margin status may therefore serve as a novel prognostic biomarker.

Searching for novel multimodal treatments in oligometastatic pancreatic cancer

BackgroundMetastatic pancreatic cancer has a median overall survival of less than 12 months, even if treated with chemotherapy. Selected patients with oligometastatic disease could benefit from multimodal treatments connecting chemotherapy and surgical treatment or radiofrequency ablation (RFA) of metastases.Case presentationWe present a patient with oligometastatic pancreatic cancer recurrence who was successfully treated with a multimodal therapeutic approach.A 57-year-old male initially presenting with resectable pancreatic cancer underwent pancreatoduodenectomy. The histopathological diagnosis revealed ductal pancreatic adenocarcinoma with positive surgical resection margins and negative lymph nodes. He completed six cycles of adjuvant therapy with gemcitabine (1000 mg/mq 1,8,15q 28), followed by external radiotherapy (54 Gy in 25 fractions) associated with gemcitabine 50 mg/mq twice weekly. Three years later, the patient developed multiple liver metastases, and he started FOLFIRINOX (oxaliplatin 85 mg/mq, irinotecan 180 mg/mq, leucovorin 400 mg/mq and fluorouracil 400 mg/mq given as a bolus followed by 2400 mg/mq as a 46 h continuous infusion,1q 14) as a first-line treatment.The CT scan showed a partial response after 6 cycles. After multidisciplinary discussion, the patient underwent a laparotomic metastasectomy of the three hepatic lesions. After additional postsurgical chemotherapy with 4 cycles of the FOLFIRINOX schedule, the patient remained free of recurrence for 12 months. A CT scan showed a new single liver metastasis, which was treated with radiofrequency ablation (RFA). A second radiofrequency ablation was performed when the patient developed another single liver lesion 12 months after the first RFA; currently, the patient is free from recurrence with an overall survival of 6 years from the diagnosis.ConclusionsOur case has benefited from successful multimodal treatment, including surgical and local ablative techniques and systemic chemotherapy. A multimodal approach may be warranted in selected patients with oligometastatic pancreatic cancer and could improve overall survival. Further research is needed to investigate this approach.

Hook-wire localization versus lipiodol localization for patients with pulmonary lesions having ground-glass opacity

ObjectivesAccurate and safe preoperative localization is useful for video-assisted thoracic surgery of small pulmonary lesions with ground-glass opacity (GGO). However, the optimal localization method is unclear. The aim of this study was to compare the usefulness and safety of the lipiodol and hook-wire localization techniques for video-assisted thoracic surgery of GGO lesions. MethodsThis prospective, non-randomized comparative study was conducted between April 2014 and December 2016 at 8 qualifying university teaching hospitals. Two-hundred-fifty patients with pulmonary lesions having GGO were included. Patients were assigned in a 1:1 ratio to either the lipiodol (n = 125, 4 hospitals) or hook-wire group (n = 125, 4 hospitals) for preoperative localization procedures. Participants underwent preoperative localization via the lipiodol or hook-wire technique followed by thoracoscopic surgery. The primary endpoint was the procedure success rate. ResultsThe procedure success rates (hook-wire vs lipiodol group) were 94.40% versus 99.16% (P = .08). Localization-related complications occurred in 53.60% versus 48.33% of patients (P = .49). Hemorrhage rates were significantly greater in the hook-wire group than in the lipiodol group (21.6% vs 5.83%, P < .001). The lipiodol procedure time was significantly longer than that of the hook-wire technique (20.69 ± 9.34 vs 17.15 ± 7.91 minutes, P = .001). The initially positive surgical resection margin was significantly greater in the hook-wire group than in the lipiodol group (10.89% vs 2.38%, P = .02). ConclusionsThere was no significant difference in success rate between the hook-wire and lipiodol methods. However, the hemorrhage rate was significantly greater in the hook-wire group, whereas the hook-wire group showed greater initially positive surgical resection margins.

Analysis of outcomes and predictors of long-term survival following resection for retroperitoneal sarcoma

BackgroundRetroperitoneal sarcomas (RPS) include a heterogeneous group of rare malignant tumours, and various treatment algorithms are still controversially discussed until today. The present study aimed to examine postoperative and long-term outcomes after resection of primary RPS.Patients and methodsClinicopathological data of patients who underwent resection of primary RPS between 2005 and 2015 were assessed, and predictors for overall survival (OS) and disease-free survival (DFS) were identified.ResultsSixty-one patients underwent resection for primary RPS. Postoperative morbidity and mortality rates were 31 and 3%, respectively. After a median follow-up time of 74 months, 5-year OS and DFS rates were 58 and 34%, respectively. Histologic high grade (5-year OS: G1: 92% vs. G2: 54% vs. G3: 43%, P = 0.030) was significantly associated with diminished OS in univariate and multivariate analyses. When assessing DFS, histologic high grade (5-year DFS: G1: 63% vs. G2: 24% vs. G3: 22%, P = 0.013), positive surgical resection margins (5-year DFS: R0: 53% vs. R1: 10% vs. R2: 0%, P = 0.014), and vascular involvement (5-year DFS: yes: 33% vs no: 39%, P = 0.001), were significantly associated with inferior DFS in univariate and multivariate analyses.ConclusionsHigh-grade tumours indicated poor OS, while vascular involvement, positive surgical resection margins, and histologic grade are the most important predictors of DFS. Although multimodal treatment strategies are progressively established, surgical resection remains the mainstay in the majority of patients with RPS, even in cases with vascular involvement.

Comparison of tumor characteristics and survival between esophageal and other gastroenteropancreatic neuroendocrine neoplasms.

e15556 Background: Neuroendocrine neoplasms (NEN) of esophagus are extremely rare. Limited information is available on survival of these tumors. The objective of this study was to define the clinicopathologic predictors of overall survival (OS) in esophageal NEN, and to compare them with the other gastroenteropancreatic NEN (GEP-NEN). Methods: Esophageal NEN were selected from the National Cancer Database (2004–2013). Multivariable analysis and Kaplan–Meier method were performed. The prognostic factors for GEP-NEN were derived from literature including WHO classification and AJCC TNM classification. Results: Of 802 selected patients with esophageal NEN, 97.5% were NEC and only 2.5% typical NET. The median age for NET was 58 vs. 66 for NEC (p = 0.007). NET more commonly presented in females (60%) compared to NEC wherein 68% patients were male. Most of the NEC were grade III/IV and &gt; 4 cm, while most NET were grade I/II and &lt; 4 cm. They most frequently metastasized to the liver. 10.7% of patients with esophageal NEN underwent esophagectomy while 86.5% had no surgery; 68.5% had adjuvant and 6.6% neoadjuvant therapy. Multivariable analysis showed that tumor &gt; 4 cm (hazard ratio (HR) 1.45; P = 0.013), stage III and IV (HR 2.27; p = 0.030, and HR 4.02; P &lt; 0.001, respectively) were associated with significantly worse OS, while esophagectomy (HR 0.30; P = 0.019) and neoadjuvant therapy (HR 0.35; p = 0.006) were predictors of better OS. The 5-year OS rate was 12% for all esophageal NEN (95% CI, 10-15): 89% for NET and 9% for NEC. Pancreatic NET are generally &gt; 2 cm and NEC have an average size of 4 cm. The factors associated with worse prognosis in pancreatic NEN include positive surgical resection margins, lymph node metastases, advanced TNM stage, vascular invasion and distant metastasis. The 5-year OS for patients with pancreatic NET and NEC is 65% and 16%, respectively. NET of ileum are &lt; 2 cm in 47% of cases, and the 5-year OS is about 60%. Tumor stage is the most important predictor of survival. The malignant potential is retained for ileal NET &gt; 1 cm. Only Stage III vs. Stage IV has a better OS. The G3 NEC and mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) have poor OS and variable median survival time reported up to 40 months. Conclusions: Using the largest dataset of esophageal NEN to date, the major independent predictors of OS include tumor size, stage, esophagectomy, and chemotherapy. The majority of esophageal NEN are NEC. Their OS is similar or slightly higher in comparison to ileal NEC but poor in comparison to similar tumors presenting in the pancreas.

Influence of African American race on the association between preoperative biopsy grade group and adverse histopathologic features of radical prostatectomy.

The current study was performed to evaluate the influence of race on the association between biopsy grade group (GrGp) and the risk of detectable prostate-specific antigen (PSA) and adverse histopathological outcomes after radical prostatectomy (RP). Data regarding 4073 men (1344 African American men; 33%) who were treated with RP were categorized based on the 5-tiered GrGp system. Logistic regression was used to test the association between biopsy GrGp and PSA nadir (<0.1ng/mL) after RP as well as adverse pathological features among all patients and stratified by race. Those patients with a higher biopsy GrGp were found to have lower odds of achieving a PSA nadir <0.1ng/mL after RP on unadjusted and multivariable analysis (both P<.001). On unadjusted and multivariable analysis, higher GrGp was associated with increased odds of each of the adverse pathological features, namely, GrGp ≥3, extraprostatic extension, seminal vesicle invasion, positive surgical resection margin, and positive lymph nodes (all P<.001). Race had no significant interaction with biopsy GrGp in the prediction of PSA nadir after RP (P=.91) or any adverse pathological features (all P>.06) except positive lymph nodes. When the models were stratified by race, the associations between preoperative biopsy GrGp and having a PSA nadir <0.1ng/mL, high-grade final pathology, or other adverse histopathologic features were similar in both races except as noted for positive lymph nodes. Higher preoperative biopsy GrGp is associated with increased odds of adverse histopathological findings as well as lower odds of a PSA nadir <0.1ng/mL after RP. These associations are largely independent of race, suggesting that GrGp is an accurate tool for risk stratification in both black and white men.

Adjuvant Therapy for Resected Biliary Tract Cancer: ASCO Clinical Practice Guideline.

To develop an evidence-based clinical practice guideline to assist in clinical decision making for patients with resected biliary tract cancer. ASCO convened an Expert Panel to conduct a systematic review of the literature on adjuvant therapy for resected biliary tract cancer and provide recommended care options for this patient population. Three phase III randomized controlled trials, one phase II trial, and 16 retrospective studies met the inclusion criteria. Based on evidence from a phase III randomized controlled trial, patients with resected biliary tract cancer should be offered adjuvant capecitabine chemotherapy for a duration of 6 months. The dosing used in this trial is described in the qualifying statements, while it should be noted that the dose of capecitabine may also be determined by institutional and regional practices. Patients with extrahepatic cholangiocarcinoma or gallbladder cancer and a microscopically positive surgical resection margin (R1 resection) may be offered chemoradiation therapy. A shared decision-making approach is recommended, considering the risk of harm and potential for benefit associated with radiation therapy for patients with extrahepatic cholangiocarcinoma or gallbladder cancer. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines .

The role of regional lymphadenectomy in surgical treatment of nonfunctional pancreatic neuroendocrine tumors

Objective To analyze the prognostic importance of lymph node metastasis and the significance of regional lymphadenectomy in surgical treatment of nonfunctional pancreatic neuroendocrine tumors(NF-PanNET). Methods The clinical and pathological data of patients who underwent resection of NF-PanNET in Tianjin Medical University Cancer Institute and Hospital from January 2000 to December 2013 were retrospectively studied. The data included age, sex, tumor location, tumor size, lymph node metastasis, surgical resection margins, pathological grades and followed-up visits. Results Of 75 patients in this study, 16 (21.3%) had lymph node metastases. Patients with larger tumors (>3 cm) and higher tumor gradings (G3) had higher rates of lymph nodal metastasis. The overall 3- and 5-year disease-free survival (DFS) were 92.0% and 89.2% respectively. The 5-year DFS for patients with and without nodal metastasis were 75.0% and 93.0% (P 3 cm), high pathological gradings (G3) and positive surgical resection margins (all P<0.05). Multivariable analysis showed that lymph nodal metastasis and surgical resection margin were independent factors associated with DFS (all P<0.05). Conclusions Patients with NF-PanNET with lymph node metastasis had significantly higher risks of recurrence and metastasis. Patients with large tumor sizes (>3 cm) had a higher rate of lymph node metastasis, and radical surgery with lymph node dissection is recommended for these patients. Key words: Pancreatic neoplasms; Neuroendocrine tumors; Lymph metastasis; Surgical procedures, operative

Five-year results of post-prostatectomy patients administered a hydrogel rectal spacer implant in conjunction with dose escalated external beam radiation therapy

This study reports on the 5-year biochemical-relapse free survival (bRFS), and late gastrointestinal (GI) and genitourinary (GU) toxicities of patients who underwent a prostatectomy and received high dose (> 72 Gy) radiation therapy with an absorbable polyethylene glycol (PEG) rectal spacer implant. From January 2010 to October 2013, 21 radical prostatectomy patients received a PEG spacer. GI and GU toxicities were scored using the National Cancer Center Institute Common Terminology Criteria for Adverse Events v4.0 grading scheme. bRFS was tallied and segregated into risk groups according to the National Cancer Comprehensive Network (NCCN) guidelines version 1.2016. Cox regression multivariate analysis was performed to elicit disease risk factors. The mean follow-up time was 59 months (SD 12, range 40–97). Our GI toxicities for acute, 3 months, and after 6 months are as follows: grade 0 (57%, 86%, 86%), grade 1 (43%, 14%, 14%), and grade 2 (0%, 0%, 5%). Our GU toxicities for acute, 3 months, and after 6 months are as follows: grade 0 (43%, 48%, 62%), grade 1 (48%, 43%, 24%), and grade 2 (10%, 5%, 14%). There were no late grade 3 GI/GU toxicities. The 5-year overall bRFS rate was 62.2% (95% CI 42.6–90.9%, SE 12.0%). Multivariate logistic regression analysis revealed positive surgical resection margins to be predictive (p = 0.00037) for decreased biochemical control. Hydrogel rectal spacer implants in patients who previously had a prostatectomy is well tolerated long term with reduced incidence of GI and GU toxicities, and bRFS rates consistent with previous reports in the literature.

A meta-analysis of Prognostic factor of Pancreatic neuroendocrine neoplasms

Pancreatic neuroendocrine neoplasms (pNENs) are a group of clinically rare and heterogeneous diseases of the pancreas. However, the prognostic factors for this disease in patients still remain controversial. The purpose of our study is to evaluate the predictive roles of those prognostic factors for pNENs. All related articles published until Sep 17, 2017 were identified via PubMed, EMBASE, Web of Science, Ovid and the Cochrane Library. Studies that examined the prognostic factors of pNENs were enrolled. 17 articles (2822 patients) were finally included in this study. The pooled data suggested that patients with positive surgical resection margin and lymph node, advanced G stage and TMN stage, organ metastasis, vascular invasion and the necrosis of specimens had a decreased overall survival for pNENs. Similarly, patients with functional tumors might have a poor prognosis. However, age, gender, surgical type and size of tumor could not be regarded as prognostic factors for pNENs. Our analytic data demonstrated that surgical resection margin, G stage, TMN stage, lymph node, metastasis, vascular invasion and the necrosis could be prognostic factors for pNENs. Our study may assist doctors to screen patients with different prognosis more efficiently during follow-up and select appropriate treatment measures.

Multimodality management of borderline resectable pancreatic adenocarcinoma.

Patients with borderline resectable pancreatic adenocarcinoma have primary tumors within the pancreas that involve the mesenteric vasculature to a limited degree. Their tumors are nonetheless at high-risk for a microscopically positive surgical resection margin and/or early treatment failure when pancreatectomy is performed de novo. The optimal treatment strategy for these patients has not been established; however, relatively favorable outcomes can be achieved with systemic chemotherapy and radiation therapy (RT) prior to intended resection. In this article, we discuss the modalities used to stage localized pancreatic cancer, the concept of borderline resectable pancreatic cancer (BRPC), the rationale for the use of preoperative therapy, and review recent publications, placing special emphasis on the necessity of appropriate patient selection and coordinating multimodality management to maximize outcomes.

Midterm outcomes of four-port extraperitoneal laparoscopic radical prostatectomy for high-risk prostate cancer within Asian population

ObjectiveAsian patients tend to have higher stage prostate cancer at diagnosis compared with patients of other races. This article aims to investigate the use of four-port extraperitoneal laparoscopic radical prostatectomy (EPLRP) as the first step in a multimodality treatment strategy for Asian patients with high-risk prostate cancer (HRPC). Materials and methodsA cohort of 202 patients underwent EPLRP between January 2006 to January 2016, of whom 122 (60.3%) had HRPC as defined by D'Amico classification: clinical T stage ≥ cT2c or PSA level ≥ 20 ng/mL or biopsy Gleason sum ≥ 8). All patients underwent proper preoperative staging. The median age was 68 years (48–82), PSA level 17.8 ng/mL (3.3–191.1), and biopsy Gleason sum 7 (6–10). All patients underwent pelvic lymphadenectomy, and some underwent neurovascular bundle preservation according to their risk category. ResultsPerioperative outcomes included a median operative time of 185 min (65–380), total blood loss 150 ml (30–500), postoperative hospitalization 10 days (6–25), and urethral catheterization time 7 days (4–22). No patient was converted to open surgery. Median specimen weight was 42 g (19–124), lymph node yield was 10 (0–35) with 11.5% positivity and a positive surgical resection margin rate of 28.7%. The median follow-up period was 37 months (6–129). 96.7% of patients achieved continence and 53.8% of the 39 potent patients prior to surgery maintained their sexual potency at one year after EPLRP. The 5-year cancer-specific, overall, and biochemical recurrence-free survival rates were 98.8%, 92.2%, and 68.7%, respectively. ConclusionExtraperitoneal laparoscopic radical prostatectomy has low morbidity, and can provide fair functional and oncological outcomes as the first step of a multimodality treatment strategy for high-risk prostate cancer in Asian.

Lymphovascular invasion and extracapsular invasion are risk factors for distant recurrence after preoperative chemoradiotherapy and oesophagectomy in patients with oesophageal squamous cell carcinoma.

Patients with oesophageal squamous cell carcinoma have a high risk of disease recurrence even after trimodality treatments, which include preoperative chemoradiotherapy and oesophagectomy. We aimed to identify the histological factors that are associated with loco-regional and distant recurrence. A retrospective review of a prospectively established database identified patients who received preoperative chemoradiotherapy and oesophagectomy for squamous cell carcinoma. The impact of histological factors, including surgical resection margins, lymphovascular invasion (LVI), perineural invasion (PNI), extracapsular invasion (ECI) and tumour regression grade (TRG), on disease recurrence was analysed. A total of 116 patients treated between 2009 and 2015 were included. Sixty-one patients developed disease recurrence, including 25 loco-regional and 49 distant recurrences, with a median disease-free interval of 6 months. Positive histological surgical resection margins were significantly associated with loco-regional recurrence, whereas pre-treatment N stage, ypT stage, ypN stage, positive surgical resection margins, TRG, LVI, PNI, ECI and TRG were significant prognostic factors for distant recurrence. Upon multivariate analysis, cN stage [hazard ratio (HR): 4.049; 95% confidence interval (CI): 1.242-13.200, P = 0.020], LVI (HR: 3.658; 95% CI: 1.891-7.078, P < 0.001) and ECI (HR: 2.393; 95% CI: 1.202-4.763, P = 0.013) remained independent factors for distant recurrence. The 1- and 3-year freedom from distant recurrence rates were 71.8 and 65.6%, respectively, when both LVI and ECI factors were absent, compared to 17.6 and 14.1% when either or both were present ( P < 0.001). Patients with lymphovascular invasion and extracapsular invasion are at a high risk of distant recurrence after preoperative chemoradiotherapy and oesophagectomy. Effective systemic therapy and intensive surveillance are necessary in this group of patients.

Neoadjuvant long-course chemoradiation remains strongly favored over short-course radiotherapy by radiation oncologists in the United States.

Short-course radiotherapy (SC-RT) and long-course chemoradiotherapy (LC-CRT) are accepted neoadjuvant treatments of rectal cancer. In the current study, the authors surveyed US radiation oncologists to assess practice patterns and attitudes regarding SC-RT and LC-CRT for patients with rectal cancer. The authors distributed a survey to 1701 radiation oncologists regarding treatment of neoadjuvant rectal cancer. Respondents were asked questions regarding the number of patients with rectal cancer treated, preference for SC-RT versus LC-CRT, and factors influencing regimen choice. Of 1659 contactable physicians, 182 responses (11%) were received. Approximately 83% treated at least 5 patients with rectal cancer annually. The majority of responding radiation oncologists (96%) preferred neoadjuvant LC-CRT for the treatment of patients with locally advanced rectal cancer and 44% never used SC-RT. Among radiation oncologists using SC-RT, respondents indicated they would not recommend this regimen for patients with low (74%) or bulky tumors (70%) and/or concern for a positive circumferential surgical resection margin (69%). The most frequent reasons for not offering SC-RT were insufficient downstaging for sphincter preservation (53%) and a desire for longer follow-up (45%). Many radiation oncologists indicated they would prescribe SC-RT for patients not receiving chemotherapy (62%) or patients with a geographic barrier to receiving LC-CRT (82%). Patient comorbidities appeared to influence regimen preferences for 79% of respondents. Approximately 20% of respondents indicated that altered oncology care reimbursement using capitated payment by diagnosis would impact their consideration of SC-RT. US radiation oncologists rarely use neoadjuvant SC-RT despite 3 randomized controlled trials demonstrating no significant differences in outcome compared with LC-CRT. Further research is necessary to determine whether longer follow-up coupled with the benefits of lower cost, increased patient convenience, and lower acute toxicity will increase the adoption of SC-RT by radiation oncologists in the United States. Cancer 2017;123:1434-1441. © 2016 American Cancer Society.

Predictors of adjuvant treatment for pancreatic adenocarcinoma at the population level.

In the present study, we aimed to describe, at the population level, patterns of adjuvant treatment use after curative-intent resection for pancreatic adenocarcinoma (pcc) and to identify independent predictors of adjuvant treatment use. In this observational cohort study, patients undergoing pcc resection in the province of Ontario (population 13 million) during 2005-2010 were identified using the provincial cancer registry and were linked to administrative databases that include all treatments received and outcomes experienced in the province. Patients were defined as having received chemotherapy (ctx), chemoradiation (crt), or observation (obs). Clinicopathologic factors associated with the use of ctx, crt, or obs were identified by chi-square test. Logistic regression analyses were used to identify independent predictors of adjuvant treatment versus obs, and ctx versus crt. Of the 397 patients included, 75.3% received adjuvant treatment (27.2% crt, 48.1% ctx) and 24.7% received obs. Within a single-payer health care system with universal coverage of costs for ctx and crt, substantial variation by geographic region was observed. Although the likelihood of receiving adjuvant treatment increased from 2005 to 2010 (p = 0.002), multivariate analysis revealed widespread variation between the treating hospitals (p = 0.001), and even between high-volume hepatopancreatobiliary hospitals (p = 0.0006). Younger age, positive lymph nodes, and positive surgical resection margins predicted an increased likelihood of receiving adjuvant treatment. Among patients receiving adjuvant treatment, positive margins and a low comorbidity burden were associated with crt compared with ctx. Interinstitutional medical practice variation contributes significantly to differential patterns in the rate of adjuvant treatment for pcc. Whether such variation is warranted or unwarranted requires further investigation.