Postoperative Pathological Stage Research Articles

A polymorphism within the mismatch repair gene predicts prognosis and adjuvant chemotherapy benefit in gastric cancer patients.

3025 Background: Radical surgery with subsequent adjuvant chemotherapy was effective treatment for early-stage gastric cancer (GC) patients. Unfortunately, after optimal multimodality therapy, up to 30% to 40% of patients undergoing resection will relapse within 5 years. There are no validated prognostic and predictive biomarkers for GC patients who receive adjuvant chemotherapy, and current patient selection is based mainly on postoperative pathological staging. Defective mismatch repair (MMR) or microsatellite instability (MSI) may affect GC outcome. Polymorphisms of MMR genes with a low-penetrant effect can cause heterogeneous MMR capability among individuals. It is not known about the impact of these polymorphisms on GC outcome. Methods: The polymorphisms rs1800734 in MLH1, rs2303428 and rs3732183 in MSH2, rs735943 in EXO1, and rs11797 in TREX1 were selected and analyzed in independent discovery and validation sets that included 167 and 593 patients, respectively. MSI was determined. Results: In the discovery set, both the rs2303428 TC+CC and the rs11797 GA+AA genotypes significantly correlated with poor overall survival (OS; P < 0.05). In the validation set, we confirmed the prognostic association for the rs2303428 TC+CC genotype (P = 0.036) but not for the rs11797 GA+AA genotype (P = 0.737). Furthermore, the prognostic role of the rs2303428 TC+CC genotype was observed in non-cardia (P = 0.005) but not in cardia GC (P = 0.934). The multivariate model showed that the rs2303428 TC+CC genotype was an independent predictor for OS in non-cardia patients (HR = 1.54; 95% CI: 1.02-2.32; P = 0.040). Moreover, fluoropyrimidines-based adjuvant chemotherapy significantly improved OS (HR = 0.29; 95% CI: 0.15-0.58; P < 0.001) for non-cardia patients with the rs2303428 TC+CC genotype but not for those with the rs2303428 TT genotype. The rs2303428 genotypes were not associated with MSI frequency. Conclusions: The rs2303428 TC+CC genotype may predict prognosis and adjuvant chemotherapy benefit in non-cardia GC patients independent of MSI. To our knowledge, our study is the first to report the prognostic and predictive roles of MMR genotype in GC. Although prospective validation is necessary, our findings have the potential to improve patient selection for adjuvant chemotherapy and spare large numbers of GC patients’ unnecessary therapy.

Robotic radical prostatectomy in 93 cases: Outcomes of the first ERUS robotic urology curriculum trained surgeon in Turkey.

This study presents the surgical, oncological, and functional outcomes of the first 93 robotic radical prostatectomy (RARP) procedures performed in Erzurum, Turkey. These procedures were performed by a single surgeon who had completed the European Association of Urology Robotic Urology Section (ERUS) RARP curriculum in an ERUS-certified training center in Ankara. The study present the results of 93 RARP procedures performed by a single surgeon. The surgeon performing the operations completed an ERUS training program structured for RARP by two robotic surgeons holding ERUS training certificates in an ERUS-approved academic robotic surgery training center in Ankara. The RARP cases performed by the surgeon after completion of the training between April 2016 and August 2018 were retrospectively evaluated. The mean patient age was 63.62±7.04 years, and the mean preoperative serum prostate-specific antigen level was 8.34±4.96 ng/mL. Preoperatively, 82 and 4 patients had prostate biopsy Gleason scores of 3+3 and 4+3, respectively. Bilateral neurovascular bundle (NVB) sparing, unilateral NVB-sparing, and non-NVB-sparing surgery were performed in 21, 13, and 59 cases, respectively. The mean prostate weight was 85.34±47.57 g. Posterior rhabdosphincter reconstruction was performed in 60 (64.5%) cases. Mean console time, intraoperative blood loss, duration of hospital stay, and urethral catheter removal time were 170.49±36.50 min, 100.70±34.08 cc, 6.84±2.28 days, and 7.40±3.11 days, respectively. During the perioperative period (0-30 days), five minor (prolonged drain output, n=3; rectocele, n=1; gout arthritis, n=1) and six major (inguinal hernia, n=1; incisional hernia, n=2; anastomotic urinary leakage, n=2; myocardial infarction, n=1) complications were identified. No complication was detected during postoperative days 31-90. Postoperative pathological stages included pT2a, pT2b, and pT2c disease in 77 (82.8%), 9 (9.7%), and 7 (7.5%) patients, respectively. The positive surgical margin (SM) rate was 10.7% (n=10), including patients with pT2a (n=6) and pT2c (n=2) diseases. Eleven (11.8%) patients underwent pelvic lymph node (LN) dissection. The mean LN yield was 16.45±4.29. The mean length of follow-up was 11.17±8.01 months. Biochemical recurrence was observed in two patients, one of whom received maximal androgen blockage (MAB), and the other one received pelvic radiotherapy+MAB. All the patients with at least one-year follow-up (n=48, 51.6%) were fully continent (0 pads/day). Of the 40 (43%) patients with no preoperative erectile dysfunction (ED) and with at least three-month follow-up, 18 (45%) had no ED, with or without any additional medication including phosphodiesterase-5 (PDE5) inhibitors. RARP is a safe minimally invasive procedure with acceptable morbidity, excellent operative, pathological and oncological outcomes, and satisfactory functional results. The ERUS RARP curriculum provides effective and sufficient training.

American Joint Committee on Cancer eighth edition human papilloma virus positive oropharyngeal cancer staging system: Discordance between clinical and pathological staging systems

The American Joint Committee on Cancer (AJCC) eighth edition introduces a staging system specific for human papilloma virus positive oropharyngeal cancer with separate clinical (AJCC 8c) and pathological (AJCC 8p) criteria. In this retrospective cohort study, preoperative imaging and pathology reports were used to stage patients based on the AJCC 8c and AJCC 8p criteria, respectively. The primary endpoint was agreement between AJCC 8c and AJCC 8p. A total of 213 patients met inclusion criteria. Kappa statistics showed poor agreement (κ = 0.3275) between AJCC 8c and AJCC 8p. In total, 30.3% of patient's preoperative AJCC 8c stage changed based on the postoperative pathologic staging (AJCC 8p) with 73.4% of those being upstaged. These data suggest that disagreement exists between AJCC 8c and AJCC 8p, in part due to the separate clinical and pathological staging criteria. This discrepancy should be considered as the new system is implemented.

Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation for Bladder Cancer: Experience in Ninety-Eight Cases

Aim: To report the outcomes of robot-assisted radical cystectomy (RARC) with bilateral extended pelvic lymph node dissection (BEPLND) and intracorporeal Studer pouch formation for bladder cancer. Materials and Methods: Overall 98 patients (92 males, 6 females) were included. Patient demographics, operative and postoperative variables, pathological parameters, complications, and functional outcomes were evaluated. Results: Mean age and American Society of Anesthesiologists score and body mass index were 60.9 years, 1.7 and 26 kg/m2, respectively. Neoadjuvant chemotherapy was given to 18 patients. Mean operation time, intraoperative estimated blood loss, and mean lymph node (LN) yield were 8.22 hours, 314.6 mL, and 28.3, respectively. Mean hospitalization time was 13.6 days. There were one perioperative and one postoperative deaths, both due to cardiac arrest on postoperative 21st and 60th days. Drains were removed at a mean of 10 days. Surgical margins were positive in two patients. Postoperative pathological stages were reported as pT0 (n = 21), pTis (n = 7), pT1 (n = 7), pT2a (n = 14), pT2b (n = 14), pT3a (n = 15), pT3b (n = 11), and pT4a (n = 9). Positive LNs were found in 21 patients. Prostate cancer was incidentally detected in 23 patients. Twenty-five patients received adjuvant chemotherapy. At a mean follow-up period of 25.1 months, 13 patients died from metastatic disease and 7 from cardiac disease. According to the modified Clavien-Dindo system, 30 minor and 20 major complications were identified in the perioperative (0-30 days) period, and 6 minor and 7 major complications were detected in the postoperative (31-90 days) period. According to the available data of the 60 patients, 37 were fully continent, 14 had mild, 6 had moderate, and 4 had severe daytime incontinence. Conclusions: Due to our experience, RARC with BEPLND and intracorporeal Studer pouch reconstruction procedures are complex procedures with acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results.

Clinicopathological features and prognosis of chromophobe renal cell carcinoma and papillary renal cell carcinoma

Objective To analyze the clinicopathological features and prognostic factors of common subtypes of non-transparent renal cell carcinoma. Methods Retrospective analysis of 115 patients with pathologically confirmed non-transparent renal cell carcinoma from January 2003 to December 2017, including 67 males and 48 females, with a male to female ratio of 1.4∶1. The average age is (51.2±13.4) years old. 71 cases were asymptomatic renal cancer, 44 cases had clinical symptoms, including 10 cases of gross hematuria, 28 cases of low back pain, 4 cases of hematuria with low back pain, and 2 cases of abdominal mass. There were 49 open surgery and 66 laparoscopic surgery. 58 patients underwent radical nephrectomy and 57 underwent partial nephrectomy. Of the 115 patients, 17 (14.9%) had abnormal hemoglobin (Hb), 22 (19.1%) had abnormal platelet (PLT) count, 18 (15.7%) had abnormal alkaline phosphatase, and abnormal lactate dehydrogenase 16 cases (13.9%). The Kaplan-Meier survival analysis method was used to calculate the survival rate of patients, and the Cox proportional regression risk model was used to analyze the prognostic factors. Results The postoperative pathological stage was 57 cases in T1a stage, 38 cases in T1b stage, 12 cases in T2a stage, 8 cases in T2b stage, 2 cases of regional lymph node positive, and 113 cases negative; no distant metastasis. Pathological types: 42 cases of renal chromophobe cell carcinoma, 37 cases of papillary renal cell carcinoma type Ⅰ, 36 cases of type Ⅱ. The average follow-up time was 38.6 months, and the rate of loss of follow-up was 3.5% (4/115). The 1, 3, and 5 year overall survival rates of 115 patients with common subtypes of non-transparent renal cell carcinoma were 99.1%, 95.8%, and 81.1%, respectively. Multivariate Cox regression analysis found that the pathological type (OR=4.625, P=0.014), four indicators ≥3 abnormalities (OR=30.853, P=0.024), lymph node metastasis (OR=35.663, P=0.006) were the group. An independent factor in the survival time of patients with common subtypes of non-transparent renal cell carcinoma. Conclusions Compared with papillary renal cell carcinoma type Ⅰ and renal chromophobe cell carcinoma, papillary renal cell carcinoma type Ⅱ has a higher degree of malignancy and a poor prognosis. The pathological types of the common subtypes of non-transparent renal cell carcinoma, four indicators (Hb, PLT count, alkaline phosphatase, and lactate dehydrogenase)≥3 abnormalities and lymph node metastasis are independent prognostic factors for overall survival. Key words: Non-transparent renal cell carcinoma; Renal chromophobe cell carcinoma; Papillary renal cell carcinoma; Prognosis

Impact of diverse shapes of prostatic apex on positive apical margin rate and biochemical recurrence following laparoscopic radical prostatectomy

Objective: To explore the effects of various forms of prostatic apex on positive apical margin rate (PAM) and biochemical recurrence (BCR) after laparoscopic radical prostatectomy. Methods: A retrospective analysis of 309 patients (aging (65±6) years) who were experienced laparoscopic radical prostatectomy from January 2010 to December 2016 at the Department of Urology, First Affiliated Hospital of Fujian Medical University. According to the relationship between prostate apex and membrane urethra at the mid-sagittal plane of preoperative MRI, all patients were classified into 4 categories. There were 31 patients for type 1, apex covering both anterior and posterior aspects of membranous urethra, 139 patients for type 2, apex covering anterior side of membranous urethra, 63 patients for type 3, apex covering posterior aspect of membranous urethra, 76 patients for type 4, apex not covering membranous urethra. PAM and BCR after operation were compared between this four groups respectively. The χ(2) test was used to compare PAM among the 4 types. Logistic regression analysis were undertaken to analyze the factors affecting PAM. Cox's proportional hazards regression model was undertaken to identify the variables influencing BCR. Results: There was no significant difference in the 4 groups concerning age, body mass index, prostate volume, preoperative prostate-specific antigen (PSA) value, postoperative Gleason score and pathological stage (P>0.05).The median follow-up time was 32 months (ranged from 12 to 60 months).The data showed that the apical type 3 patients has the highest PAM. There was statistical difference among the 4 groups in PAM (χ(2)=15.592, P=0.001). Preoperative level of PSA (OR=20.356, 95% CI: 2.440 to 169.810, P=0.005), postoperative Gleason score (OR=4.113, 95% CI: 1.911 to 8.849, P=0.001), pathological stage (OR=3.422, 95% CI: 1.600 to 7.319, P=0.002) and apical type 3 (OR=6.134, 95% CI: 2.196 to 17.132, P=0.001) were independent relactive factors of PAM. Preoperative level of PSA (HR=1.362, 95% CI: 1.006 to 1.843, P=0.045), postoperative Gleason score (HR=1.920, 95% CI: 1.384 to 2.665, P=0.001), pathological stage (HR=1.476, 95% CI: 1.098 to 1.983, P=0.010), PAM (HR=3.497, 95% CI: 2.407 to 5.081, P=0.001)and apical type 3 (HR=1.828, 95% CI: 1.266 to 2.639, P=0.001) were independent prognosis factors of BCR. Conclusion: Prostate apical type 3 could be a significant independent predictor of PAM, and an independent prognosis factor for BCR.

Accuracy of Magnetic Resonance Imaging in Staging Rectal Cancer with Multidisciplinary Team: A Single-Center Experience.

Purpose: To investigate the accuracy of magnetic resonance imaging (MRI) in preoperative staging diagnosis for rectal cancer with multidisciplinary team (MDT) discussion.Methods: The retrospective study included 377 patients of rectal cancer with preoperative MRI staging from February 2015 to April 2018, in which 137 patients (36 received MDT discussion) received neoadjuvant therapy, 240 did not (97 received MDT discussion) and direct surgery was given. With postoperative pathological stage as the standard, the accuracy of MRI in preoperative staging for rectal cancer with MDT discussion was compared with non-MDT.Results: For direct surgery group, 21 out 97 (21.6%) patients changed their therapy strategy due to the change of the stage assessment after MDT. The accuracy of MRI for the diagnosis of preoperative N stage with MDT was significantly higher than those without MDT (56.2% vs. 42.1%, P=0.021). And for those without lymph node metastasis, the accuracy of MRI was higher after MDT (61.2% vs. 37.8%, P=0.009). For neoadjuvant therapy group, 7 out of 36 (19.4%) patients altered their therapy after MDT because of the changed stage. MDT improved the accuracy of restaging N stage with MRI (70.0% vs. 33.3%, P=0.003). The accuracy of MRI in staging T stage seemed not improved after MDT in both groups.Conclusions: In conclusion, MDT discussion increased the accuracy of MRI in preoperative staging diagnosis for rectal cancer. This mode could give a more accurate clinical stage of patients, which was in favor of choosing a preferable therapy strategy.

Oxaliplatin-Based Adjuvant Chemotherapy for Rectal Cancer after Preoperative Chemoradiotherapy (ADORE): Long-Term Results of an Open-Label, Multicentre, Phase 2, Randomised Controlled Trial

Background: Oxaliplatin-based adjuvant chemotherapy for rectal cancer patients after preoperative chemoradiotherapy (CRT) is currently based on extrapolated results from colon cancer patients. We evaluated the role of oxaliplatin as adjuvant chemotherapy in rectal cancer patients who received preoperative CRT with fluoropyrimidine monotherapy and total mesorectal excision (TME). Methods: The ADORE is a multicentre, randomised trial in patients with postoperative ypStage II (ypT3-4N0) or III (ypTanyN1-2) rectal cancer after fluoropyrimidine-based preoperative CRT and TME. Patients were randomly assigned (1:1) to receive adjuvant chemotherapy either with FL (5-fluorouracil 380 mg/m², leucovorin 20 mg/m²) or FOLFOX (oxaliplatin 85 mg/m², leucovorin 200 mg/m², 5-fluorouracil bolus 400 mg/m² on day 1, 5-fluorouracil infusion 2400 mg/m² for 46 hours). Stratification factors included ypStage and participating centre. Investigators were not blinded to the group assignment. Primary endpoint was disease-free survival (DFS), analysed according to the intention-to-treat principle (ClinicalTrials.gov registration number: NCT00807911). Findings: A total of 321 patients were enrolled between November 19, 2008, and June 12, 2012. The 6-year DFS rates were 68·2% in the FOLFOX arm vs 56·8% in the FL arm, with a stratified hazard ratio (HR) of 0·63 (95% CI, 0·43-0·93, p=0·018) by intention-to-treat analysis. In the subgroup analysis for DFS, FOLFOX was favourable to FL in patients with ypStage III, ypN1b, ypN2, high-grade histology, minimally regressed tumour, and absence of lymphovascular or perineural invasion. The 6-year overall survival (OS) rate was 78·1% in the FOLFOX arm vs 76·4% in the FL arm (HR 0·73 [0·45-1·19], p=0·21). In the subgroup analysis for OS, FOLFOX was favourable to FL in patients with ypN2 and minimally regressed tumour. Interpretation: Adjuvant FOLFOX improved DFS in rectal cancer patients with ypStage II/III after preoperative CRT. Adjuvant FOLFOX should be chosen based on the postoperative pathologic stage in those received preoperative CRT and TME. Trial Registration Number: ClinicalTrials.gov registration number: NCT00807911 Funding: Sanofi-Aventis, Republic of Korea Declaration of Interest: TWK received research funding from Sanofi-Aventis, Taiho, and Roche. YSH received research funding from Bayer. All other authors have no conflicts of interest to declare. Ethical Approval: All patients provided written informed consent, and the study protocol was approved by the institutional review boards of all participating institutions.

Are the indications for postoperative radiotherapy in the NCCN guidelines for patients with gastric adenocarcinoma too broad? A study based on the SEER database

BackgroundThe types of patients with gastric adenocarcinoma (GA) for whom postoperative radiotherapy can improve the disease-specific survival rate (DSS) remain controversial. This study aims to explore the ideal indications.MethodsPatients in the Surveillance, Epidemiology, and End Results (SEER) database with T3–4Nx or TxN+ GA from January 1988 to December 2012 were included and divided into a postoperative chemoradiotherapy group (Group R) and a postoperative chemotherapy group (Group C). We established a nomogram to predict DSS and then divided entire patient cohort into low-risk and high-risk groups based on the DSS predicted by the nomogram.ResultsThe Cox multiple regression analysis demonstrated that various risk factors affected DSS for Group R. Based on these risk factors, a nomogram for predicting DSS was established. The decision curve indicated that the best clinical effect could be obtained when the threshold probability was 0–58%. The patients were then divided into low-risk (< 69 points) and high-risk (≥ 69 points) groups according to the five-year DSS predicted. DSS was significantly better for Group R than for Group C for high-risk patients (P < 0.001) but was similar for low-risk patients (P = 0.732).ConclusionAt present, the National Comprehensive Cancer Network (NCCN) guidelines may include an overly broad range of indications for postoperative radiotherapy for patients with GA. For intestinal GA patients with a postoperative pathologic stage of T1 N1 who are younger than 65 years, have had more than 15 lymph nodes dissected, and have received postoperative chemotherapy, postoperative radiotherapy should not be recommended.

Clinicopathologic analysis of prostatic cancer with single positive core biopsy after radical prostatectomy

Objective To evaluate the clinical and pathological features of patients with prostate cancer who were diagnosed by single positive core biopsy and treated by radical prostatectomy (RP). Methods Between July 2012 and June 2016, 164 patients with prostate cancer diagnosed by single positive core biopsy underwent RP.The mean age was 66.3 years old (ranged 41-82 years old), and the mean PSA level was 12.3 ng/ml (ranged 0.6-59.5 ng/ml). The biopsy Gleason score showed 6 scores in 113 cases, 3+ 4=7 scores in 21 cases, 4+ 3=7 scores in 18 cases, ≥8 scores in 12 cases.Clinical stage was cT1 in 71 cases, cT2 in 92 cases, and cT3 in 1 case. The patients were divided into subgroups according to age, preoperative PSA level, biopsy Gleason score and clinical stage, and the pathological results were compared among these subgroups. Results Of the 164 patients, 67 cases had Gleason score ≤6, 52 cases Gleason score 3+ 4=7, 24 case Gleason score 4+ 3=7, and 11 cases Gleason score ≥8. Ten patients had pT0 disease according to the RP specimen, 3 had extraprostatic extensions, 5 had seminal vesicle invasions, and 24 had positive surgical margins. Compared to the biopsy, the Gleason score of RP specimens was higher in 53 cases, concordant in 77 cases, and lower in 24 cases. There was no significant difference in the postoperative pathological features between the age group 7 was significantly increased in PSA ≥10 ng/ml group [41.4%(36/87) vs. 66.2%(51/77), P<0.05]. When the biopsy Gleason score was divided into four groups (6, 3+ 4=7, 4+ 3=7, ≥8), there were significant differences in postoperative pathological stages among the four groups (P<0.05), and the patients with biopsy Gleason score 6 were more likely to have no residual cancer (stage T0) when compared with other Gleason scores [8.8%(10/113) vs. 0, P=0.09]. The probability of no residual cancer in clinical T1 stage patients was significantly higher than that in T2 stage [11.3%(8/71) vs. 2.8%(2/92), P=0.02], while the probability of Gleason score upgrading was significantly lower [23.9%(17/71) vs. 39.1%(36/92), P<0.05]. Conclusions Most single core prostate cancer have clinically significant disease. The treatment plan must be evaluated individually for patients with single core prostate cancer. Key words: Prostatic neoplasms; Biopsy; Single positive core; Pathological stage

Application value of single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer

Objective To explore the application value of single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer. Methods The retrospective descriptive study was conducted. The clinicopathological data of 27 patients who underwent single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer in the General Hospital of Ningxia Medical University between September 2016 and April 2018 were collected. The surgical operators were divided into neck operation group and abdomen operation group. A Y tube was used to inflate the abdomen and mediastinum simultaneously with CO2, and the gas pressure was 12-16 mmHg (1 mmHg=0.133 kPa). Bilateral exchange free and join forces with the esophagus and xiphoid process operating small incision, the severed esophagus cardia; residual stomach was made into a 3-5 cm tubular stomach and was sutured at the top point; at the same time, esophagus was brought up from the neck, with a pouch suture between upper esophageal and stapling head; the tubular stomach through mediastinum-esophagus bed was pulled to the left neck and then gastroesophageal anastomosis manually or instrument was performed. Observation indicators: (1) surgical and postoperative recovery; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to May 2018. The measurement data with normal distribution were represented as ±s. The measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery: all the 27 patients underwent successful single-port inflatable mediastinoscopic and laparoscopic radical resection of esophageal cancer, with complete tumor resection and without conversion to open surgery. There was no arrhythmia or myocardial ischemia through intraoperative electrocardiography. Among 27 patients, 5 had intraoperative rupture of the pleura and 3 stopped intermittently inflation with CO2 due to obvious hemodynamic changes. The operation time and volume of intraoperative blood loss were (121±21)minutes and (100±30)mL. Twenty-seven patients had no thoracic incision, obviously decreased postoperative pain and out-of-bed activity at day 1 postoperatively. The volume of postoperative mediastinal drainage was (40±10)mL. The mediastinal drainage-tube was removed at 1 week after regular food intake. Of 27 patients, 5 with pleural effusion were cured by puncture drainage; 2 were complicated with anastomotic leakage, 1 of them with a small amount of subcutaneous gas under neck incision at 12 days postoperatively was cured spontaneously through oral food intake, without special treatment, and the other had a small amount of subcutaneous gas under neck incision after solid food intake at 1 month postoperatively and then was cured after 1-week fluid food intake; 1 with anastomotic stenosis was improved after dilation treatment. The squamous cell carcinoma was confirmed by postoperative pathological examination, without cancer cell infiltration in the upper and lower margins. The numbers of mediastinal lymph node dissected, abdominal lymph nodes dissected and positive lymph node, postoperative pathological staging and duration of hospital stay were respectively 9.5±2.2, 8.2±2.5, 1 (range, 0-12), T1-3N0-1M0 and 13 days (range, 11-21 days). (2) Follow-up and survival situations: 27 patients were followed up for 1-20 months, with a median time of 10 months. During the follow-up, there was no recurrence or metastasis and death. Conclusion The single-port inflatable mediastinoscopy combined with laparoscopy in the radical resection of esophageal cancer is safe and effective, and it is especially suitable for patients with partial respiratory failure and closed thoracic cavity. Key words: Esophageal neoplasms; Combined operation; Radical resection; Mediastinoscopy; Laparoscopy

PS02.081: ADVANCED PRETREATMENT STAGE IN OESOPHAGEAL CANCER NOT ASSOCIATED WITH POOR OUTCOMES

Abstract Background Following a diagnosis of oesophageal cancer UICC TNM staging guides treatment and informs prognosis. There is recognised variance between clinical staging (cTNM) and post-operative pathological staging (pTNM). T3N3 oesophageal cancers have a 5-year survival of less than 25% in most studies; given the morbidity associated with radical treatment these cancers may not be considered curable. Methods A database of patients treated in a high volume UK tertiary referral centre was interrogated for all cT3N3M0 patients. Demographics, pathological stage and outcomes were recorded. Results From 2011 to 2016 34 patients met the inclusion criteria of cT3N3M0 oesophageal cancer. 11 patients had squamous cell carcinoma, the remainder adenocarcinoma. Median age was 65. Predicted overall survival at two years was 71% with a median overall survival of 54 months. 29 patients had neoadjuvant chemotherapy. All patients had an R0 resection. In 15% of patients clinical stage equated to pathological stage, 9% were ’understaged’, 76% had a better prognostic pathological stage. Conclusion Staging is considered important to allow treatment to be tailored to the individual patient. Identifying an unfavourable clinical stage may prevent inappropriate treatment, but may disadvantage patients who are erroneously ‘overstaged’. This study highlights variance between pre-treatment clinical staging and post-operative pathological staging. Care should be taken when making treatment decisions and counselling patients who have a poor prognostic clinical stage. Disclosure All authors have declared no conflicts of interest.

Application value of multi-detector computed tomography evaluating the clinical staging of adenocarcinoma of the esophagogastric junction after neoadjuvant chemotherapy

Application value of multi-detector computed tomography evaluating the clinical staging of adenocarcinoma of the esophagogastric junction after neoadjuvant chemotherapy

External validation of a predictive model of survival after cytoreductive nephrectomy for metastatic renal cell carcinoma.

Recent trials have emphasized the importance of a precise patient selection for cytoreductive nephrectomy (CN). In 2013, a nomogram was developed for pre- and postoperative prediction of the probability of death (PoD) after CN in patients with metastatic renal cell carcinoma. To date, the single-institutional nomogram which included mostly patients from the cytokine era has not been externally validated. Our objective is to validate the predictive model in contemporary patients in the targeted therapy era. Multi-institutional European and North American data from patients who underwent CN between 2006 and 2013 were used for external validation. Variables evaluated included preoperative serum albumin and lactate dehydrogenase levels, intraoperative blood transfusions (yes/no) and postoperative pathologic stage (primary tumour and nodes). In addition, patient characteristics and MSKCC risk factors were collected. Using the original calibration indices and quantiles of the distribution of predictions, Kaplan-Meier estimates and calibration plots of observed versus predicted PoD were calculated. For the preoperative model a decision curve analysis (DCA) was performed. Of 1108 patients [median OS of 27months (95% CI 24.6-29.4)], 536 and 469 patients had full data for the validation of the pre- and postoperative models, respectively. The AUC for the pre- and postoperative model was 0.68 (95% CI 0.62-0.74) and 0.73 (95% CI 0.68-0.78), respectively. In the DCA the preoperative model performs well within threshold survival probabilities of 20-50%. Most important limitation was the retrospective collection of this external validation dataset. In this external validation, the pre- and postoperative nomograms predicting PoD following CN were well calibrated. Although performance of the preoperative nomogram was lower than in the internal validation, it retains the ability to predict early death after CN.

Total thoracoscopic high-position sleeve lobectomy of the right upper lobe of the lung.

This video demonstrates a total thoracoscopic high-position sleeve lobectomy of the right upper lobe in patients with central lung cancer. A 50-year-old male was admitted to the hospital due to a two-month history of coughing. His previous medical history was unremarkable. On admission, physical examination revealed reduced breath sounds in the right upper lung, but no significant rales were present. Chest CT scan revealed a mass in the right upper lung near the lung hilum, atelectasis of the right upper lobe, and enlarged right hilar lymph nodes. No significantly enlarged mediastinal lymph node was noted. Bronchoscopy revealed occlusion of the right upper lobe bronchus by the tumor. Pathological examination of the obtained biopsy reveled squamous cell carcinoma. The required preoperative examinations were completed, and no distant metastasis was evident. Total thoracoscopic sleeve resection of the right upper lobe was performed via the "three-port approach" in which the anterior port was the main operating port. First, the inferior pulmonary ligament was dissected to remove the lymph nodes of station 9. Next, the lymph nodes of stations 7 and 8 were removed. Third, the lymph nodes in the region between the intermediate bronchus and the right upper lobe were dissected. Then, the dissection continued superiorly to remove mediastinal lymph nodes of stations 2 and 4 followed by successful anatomic right upper lobectomy, which briefly included division of the superior pulmonary arteries and veins, skeletonization of the upper right lobular bronchus, localization via incision by a sharp blade, division of the bronchus with scissors, and anastomosis with 3-0 prolene continuous suture. The surgery was successful. The postoperative pathological stage was T4N1M0 (stage IIIA).

Application value of biplane transrectal ultrasonography plus ultrasonic elastosonography and contrast-enhanced ultrasonography in preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer

PurposeTo determine the accuracy of biplane transrectal ultrasonography (TRUS) plus ultrasonic elastosonography (UE) and contrast-enhanced ultrasonography (CEUS) in preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer. Materials and methodsFifty-three patients with advanced lower rectal cancer were examined before and after neoadjuvant chemoradiotherapy with use of TRUS plus UE and CEUS and were diagnosed as having T stage disease. We compared ultrasonic T stages before and after neoadjuvant chemoradiotherapy and analyzed any changes. Also, with postoperative pathological stages as the gold standard, we compared ultrasonic and pathological T stages and determined their consistency by the kappa statistic. ResultsFor patients with rectal cancer, ultrasonic T stages were lower after neoadjuvant chemoradiotherapy than before, with a statistically significant difference (P < 0.05). The posttreatment downstaging rate was 39.6% (21/53). A total of 84.9% received correct staging with use of biplane TRUS plus UE and CEUS in the evaluation of preoperative T staging after neoadjuvant chemoradiotherapy for rectal cancer, which was highly consistent with that of pathological staging (κ = 0.768, P < 0.05). Its sensitivities were 80.0%, 50.0%, 75.0%, 96.3%, and 100% in the diagnoses of stages T0 to T4 rectal cancers, respectively; the specificities were 95.4%, 97.9%, 95.1%, 88.5%, and 100% at stages T0 to T4, respectively. ConclusionBiplane TRUS plus UE and CEUS can be used to accurately perform preoperative T staging in rectal cancer after neoadjuvant chemoradiotherapy; in addition, this procedure well reflects changes in depth of rectal cancer invasion into the intestinal wall before and after neoadjuvant chemoradiotherapy. It is of great value in clinically evaluating the efficacy of neoadjuvant chemoradiotherapy, in selecting therapeutic regimens, and in avoiding overtreatment.

Effects of urethral fibrosis on urinary control after laparoscopic radical prostatectomy

Objective: To determine the influence of urethral fibrosis on the recovery of urinary continence after laparoscopic radical prostatectomy. Method: A retrospective study of 203 patients from January 2010 to January 2014 who were underwent laparoscopic radical prostatectomy for prostate cancer in the First Affiliated Hospital of Fujian Medical University. The patients were divided into 2 groups according to preoperative T2-weighted magnetic resonance imaging of fibrosis status of the urethral wall and periurethral tissue. One hundred and forty-four(≤2 grade) and 59 (≥3 grade) were classified into the no/mild and severe urethral fibrosis groups respectively. Urinary continence at 1, 3, 6, 12 months after operation were compared between this two groups respectively. Result: There was no significant difference in the two groups with respect to age, body mass index (BMI), Charlson comorbidity index (CCI), international prostate symptom score (IPSS), prostate volume, preoperative prostate-specific antigen value, nerve-sparing procedure, postoperative Gleason score and pathological stage. The operation was completed successfully in all cases. With a median follow-up time of 15 months (ranged from 12 to 24 months), there was no statistical difference between the two groups in urinary continence at 1 month after operation (P>0.05). The incidences of continence in patients with no/mild fibrosis were significantly higher at 3, 6, 12 months after operation than those with severe fibrosis. (In the no/mild fibrosis group and severe fibrosis group, the continue rate at 3 mouths was 50.0% vs 28.8% P=0.005; at 6 mouths was 91.0% vs 59.3% P<0.001; at 12 mouths was 98.6% vs 88.1% P=0.003). Conclusion: Preoperative urethral fibrosis could be a significant predictor of recovery of the long-term urinary continence status after laparoscopic radical prostatectomy. Compared with no/mild fibrosis, severe fibrosis had worse long-term continence status.

Diagnostic value of endoscopic ultrasonography in staging of rectal cancer

Objective To evaluate the diagnostic value of endoscopic ultrasonography (EUS) in staging of rectal cancer (RC). Methods From January 2015 to January 2017, the clinical data of 204 patients with RC and received EUS and surgery were retrospectively analyzed. Patients were divided into surgery alone group (155 cases) and preoperative neoadjuvant chemoradiation therapy (CRT) plus surgery group (49 cases). The preoperative staging by EUS and postoperative pathological staging of two groups were compared. Kappa test was performed for statistical analysis. Results Compared with postoperative pathologic diagnosis, the accuracy rate of EUS in the evaluation of invasion depth of RC in surgery alone group was 81.9% (127/155), and the accuracy rates in the diagnosis of Tis, T1, T2, T3 and T4 were 3/4, 11/13, 82.1%(32/39), 91.1%(41/45) and 74.1%(40/54), respectively, with a good consistency (kappa=0.751, P<0.01). However, the accuracy rate of EUS in the invasion depth of RC in CRT plus surgery group was 34.7% (17/49), and the accuracy rates in the diagnosis of T2, T3 and T4 were 1/13, 2/7 and 14/16, respectively, with a poor consistency (kappa=0.107, P=0.850). Compared with postoperative pathologic diagnosis, the diagnostic accuracy rate of EUS in evaluating regional lymph node metastasis in surgery alone group was 70.3% (109/155), and the accuracies in the diagnosis of cases with or without regional lymph node metastasis were 40.7% (24/59) and 88.5% (85/96), respectively, with a poor consistency (kappa=0.317, P<0.01). The diagnostic accuracy rate of EUS in evaluating regional lymph node metastasis of preoperative CRT plus surgery group was 51.0% (25/49), and the accuracies in the diagnosis of cases with or without regional lymph node metastasis were 5/11 and 52.6% (20/38), respectively, with a poor consistency (kappa=0.014, P=0.911). Conclusions EUS can accurately evaluate the depth of tumor invasion and lymph node metastasis in preoperative staging of RC, which may be helpful for determining clinical treatment strategy. However, for patients received CRT treatment, EUS has a limited value in diagnosing and staging the tumor. Key words: Rectal neoplasms; Endosonography; Neoplasm staging; Diagnosis

Comparison of the application between circular stapler and linear stapler in Billroth II( anastomosis of distal gastrectomy

To compare the safety and effectiveness of circular stapler and linear stapler in Billroth II( anastomosis following distal gastrectomy for gastric cancer patients. Clinical data of gastric adenocarcinoma patients who received distal gastrectomy with Billroth II( anastomosis at Ward IIII( of Gastrointestinal Cancer Center of Peking University Cancer Hospital from January 2013 to April 2017 were collected retrospectively. (1) patients identified as stage IIII( gastric cancer by preoperative clinical and postoperative pathological staging. (2) patients undergoing emergency operation due to perforation, obstruction, or bleeding of digestive tract. (3) patients receiving chemotherapy before operation. (4) patients undergoing combined organ resection due to tumor involving other organs. (5) patients complicating with other malignancies. A total of 116 cases were enrolled and divided into circular stapler (CS, 61 cases) group and linear stapler (LS, 55 cases) group according to the application of mechanical stapler. Clinicopathological characteristics, operative conditions and postoperative recovery were compared between two groups. Differences in baseline data, such as tumor size, Lauren classification, differentiation grade, and pathologic stage, between two groups were not statistically significant (all P>0.05). The mean operative time (230 min vs. 234 min), median intra-operative blood loss (50.0 ml vs. 50.0 ml), median number of harvested lymph node (28.0 vs. 26.0) and median number of positive lymph node (1.0 vs. 2.0) between LS group and CS group were not significantly different (all P>0.05) As compared to CS group, LS group presented shorter median time to the first flatus (3.0 days vs. 4.0 days, P=0.038), shorter median time to the first liquid diet (7.0 days vs. 8.0 days, P=0.000), shorter median time to remove the first abdominal drainage tube (7.0 days vs. 9.0 days, P=0.000) and shorter median time of postoperative hospital stay (8.0 days vs. 10.0 days, P=0.000). The morbidity of postoperative complication was 11.5% and 1.8% in CS group and LS group respectively without significant difference (P=0.092). In CS group, 1 case (1.6%) developed anastomotic hemorrhage, 3 cases (4.9%) gastric emptying disorder and 3 cases (4.9%) abdominal infection after operation, who all were cured by conservative treatment without duodenal stump fistula and re-operation. In LS group, only 1 case (1.8%) developed duodenal stump fistula and was cured by re-operation. In distal gastrectomy with Billroth II( anastomosis for gastric cancer, the application of linear stapler results in faster recovery of gastrointestinal function and shorter hospital stay, indicating more advantages.

What is the accuracy of multi-parametric magnetic resonance imaging in predicting adverse pathology in patients undergoing radical prostatectomy?

139 Background: Few studies have examined the accuracy of preoperative multi-parametric magnetic resonance imaging (MP-MRI) in predicting adverse pathological features in patients undergoing radical prostatectomy (RP) for localized prostate cancer (PCa). Methods: We retrospectively analyzed the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of preoperative MP-MRI for adverse pathologic features [extracapsular extension (ECE), seminal vesicle invasion (SVI), lymph node involvement (LNI) and high Gleason score) on postoperative pathologic staging after RP in 30 patients with localized PCa . Results: The median age and preoperative PSA were 62.5 years and 8.5 ng/mL, respectively.17 patients had ECE, 5 had SVI, 5 had LNI, and 15 had high risk Gleason score (4+3, tertiary pattern 5, 4+4 or higher). The sensitivity, specificity, PPV and NPV of MP-MRI for ECE was 64.71% (95%CI 38.33 - 65.79), 92.31% (95% CI 63.97 - 99.81), 91.67% (95% CI 61.52 - 99.79), and 66.67% (95% CI 40.89 - 86.96) respectively. For the detection of SVI on MP-MRI, the sensitivity, specificity, PPV, and NPV were 60% (95% CI 14.66 - 94.73), 96% (95% CI 76.95 - 99.90), 75% (95% CI 19.41 - 99.37), and 92.31% (95% CI 74.87 - 99.05) respectively. For the detection of LNI, the sensitivity of MP-MRI was 100% (95% CI 47.82 - 100), specificity was 96% (95% CI 79.65 - 99.90), PPV was 83.33% (95% CI 35.88 - 99.58), NPV was 100% (95% CI 85.75 - 100). For detection of of high risk Gleason score the sensitivity of MP-MRI was 94.44% (95% CI 72.71 - 99.86), specificity was 66.67% (95% CI 34.89 - 90.08), PPV was 80.95% (95% CI 58.09 - 94.55), and NPV was 88.89% (95% CI 51.75 - 99.72). Conclusions: MP-MRI has a reasonable sensitivity, specificity, and NPV for the preoperative detection of adverse pathologic features at prostatectomy. This could provide assistance in the selection of patients appropriate for Active Surveillance as well as in the preoperative counseling regarding multimodality treatment for PCa.