Conversion surgery (CS) in patients with stage IV gastric cancer (GC) who respond to chemotherapy is a promising strategy, but its prognostic value remains unclear. In this study, clinical outcomes were evaluated, and prognostic factors were identified in patients who underwent CS. We retrospectively analyzed 443 consecutive patients who were diagnosed with stage IV GC and treated at the University of Toyama Hospital between January 2002 and January 2023. Patients were categorized into the following treatment groups: chemotherapy alone (CA), upfront surgery (US), and CS. Prognostic factors for overall survival (OS) in the CS group were examined using univariate and multivariate analyses. Among the 443 patients, 343 underwent CA, 62 underwent US, and 34 underwent CS. The 5-year OS rates and median survival times were 8.1% and 11.7 months (CA), 21.4% and 16.2 months (US), and 37.1% and 33.5 months (CS) for the CA, US and CS groups, respectively, and significant differences were observed among the groups. Distant metastasis was less frequent in the CS group. A univariate analysis revealed a high preoperative lymphocyte count (≥1600/μl) and R0 resection as favorable factors. A multivariate analysis confirmed that a lymphocyte count ≥1600/μl [hazard ratio (HR)=0.37; p<0.05] and R0 resection (HR=0.04; p<0.01) were independent predictors of improved OS. CS is effective for select patients with stage IV GC, especially those with R0 resection, preserved lymphocyte counts, and low tumor burden (≤pT4, Yoshida category).

Thymoma is the most common anterior mediastinal neoplasm in adults and often requires surgical resection for curative treatment. Traditional approaches, including open surgery and multiportal thoracoscopic techniques, are associated with significant morbidity. The uniportal subxiphoid approach offers a minimally invasive, patient-friendly alternative, with potential benefits in operative efficiency and post-operative recovery. This technique may be particularly advantageous in low-resource settings, given its simplicity and reduced need for specialized equipment or personnel. This study included 27 patients who underwent uniportal subxiphoid thymectomy at our institution between January 2022 and December 2024. The technique involves pre-operative planning based on tumour staging, with resections possible for tumours up to 15 cm. The patient is placed supine, with no carbon dioxide insufflation or epidural anaesthesia used. An incision below the xiphoid process provides access for tumour dissection, utilizing a thoracoscope. The thymoma is carefully removed through the incision, followed by a mediastinal drain placement. In 27 patients, tumour sizes ranged from 2 to 15 cm. The mean operative time was 106.9 min, with minimal blood loss (46.7 mL). All procedures were R0 resections, with no conversions to open surgery. Post-operative pain was minimal, and the mean hospital stay was 2.6 days. The uniportal subxiphoid thymectomy is an effective, minimally invasive technique, offering excellent outcomes in terms of operative time, blood loss, and recovery. It provides a safe, efficient, and cost-effective alternative, especially for low-resource settings.

The outcomes of salvage surgery for previously irradiated recurrent head and neck squamous cell carcinoma (HNSCC) remain suboptimal. This phase II trial evaluated the effects of preoperative tislelizumab (an anti-programmed cell death protein 1 monoclonal immunoglobulin G4 antibody) plus chemotherapy followed by salvage surgery and adjuvant tislelizumab in this setting. Eligible patients (n = 34) with resectable recurrent HNSCC after radiotherapy received preoperative tislelizumab (200 mg), albumin-bound paclitaxel (260 mg/m2), and cisplatin (60-75 mg/m2) every 3 weeks for 2 cycles, followed by salvage surgery and 6 cycles of adjuvant tislelizumab. The primary endpoint was major pathologic response (MPR). Secondary endpoints included pathologic complete response (pCR), the objective response rate (ORR), 2-year event-free survival (EFS), 2-year overall survival (OS), and safety. The ORR was 35.3% (12/34). Of 26 surgical patients, R0 resection was achieved in 19 (73.1%). The MPR rate was 19.2% (5/26), with a pCR rate of 15.4% (4/26). At a median follow-up of 32 months, 2-year EFS was 39.6% and 2-year OS was 54.8%. All MPR patients remained disease free. Grade 1 to 2 adverse events were common; one grade 3 hyperglycemia occurred. High baseline B-cell receptor (BCR) repertoire diversity and clonal abundance (top 1%/10%) correlated with poor prognosis, with top 1% clonality showing strong prognostic power (AUC = 0.910; P = 0.006). Preoperative chemoimmunotherapy followed by surgery and adjuvant immunotherapy was feasible with encouraging survival in previously irradiated recurrent HNSCC. Baseline BCR repertoire characteristics may serve as a noninvasive prognostic biomarker.

Liver resection (LR) and orthotopic liver transplantation (OLT) are therapeutic options for locally advanced perihilar cholangiocarcinoma (pCCA) requiring hepatic artery reconstruction (HAR). This study aimed to compare short- and long-term outcomes of LR and OLT. Outcomes were major vascular complications, 90-day mortality, overall survival (OS) and recurrence-free survival (RFS). A cohort of patients undergoing LR with HAR from 10 Western centres was compared with an OLT cohort comprising patients who received or did not receive neoadjuvant chemoradiotherapy (NACR). 109 patients, 60 LR and 49 OLT (22 OLT no-NACR and 27 OLT NACR) were included. LR patients were older and had fewer Bismuth type 4 tumours (38.3% vs. 69.4%, p = 0.009). Positive margins (49.2% vs. 6.5%, p < 0.001) and lymph nodes (54.2% vs. 32.4%, p = 0.058) were found more frequently in LR patients. No differences were found between LR and OLT in major (40% vs. 46.9%, p = 0.56) and vascular complications (23.3% vs. 28.6%, p = 0.66); NACR was an independent prognostic factor for vascular complications (OR 2.63, 95% CI 1.03-6.70, p = 0.043). 90-day mortality (15% for LR vs. 10.2% for OLT, p = 0.57) and 5-year OS (HR 0.68, 95% CI 0.40-1.17, p = 0.17) were similar. Median OS after LR versus OLT was higher but not significant (24 vs. 40 months, p = 0.13). OLT had better 5-year RFS (HR 0.52, 95% CI 0.29-0.96, p = 0.035) than LR. R1 resection (HR 2.07, 95% CI 1.03-4.18, p = 0.041) and perineural invasion (HR 3.64, 95% CI 1.09-12.16, p = 0.035) were independent prognostic factors for RFS. LR and OLT for locally advanced pCCA had similar rates of major complications and post-operative mortality, but NACR was associated with increased vascular complications. Survival was difficult to compare in the groups due to their heterogeneity, but OLT, especially with NACR, seems to give better results than LR.

Chemoradiotherapy has proven effective in enabling conversion surgery (CS). However, the priority of immunochemotherapy compared with chemoradiotherapy as induction therapy for initially unresectable cT4 esophageal squamous cell carcinoma (ESCC) remains unclear. We aimed to compare the survival outcomes of CS following induction immunochemotherapy (iICT) versus induction chemoradiotherapy (iCRT) in these patients. This multi-institutional retrospective cohort study included initially unresectable cT4 ESCC patients who underwent CS after iICT or iCRT between 2019 and 2022. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method and the log-rank-test. Univariable and multivariable analyses for prognostic factors were performed. In total, 118 patients were included: 43 in the iICT group and 75 in the iCRT group. There were no significant differences between the two groups in terms of pathological complete response rates (P = 0.637) or R0 resection rates (P = 0.885). The iICT group had a lower rate of postoperative overall recurrence (P = 0.005) and distant metastasis (P = 0.015) than the iCRT group. The OS (1-year: 90.4% vs. 76.0%; 3-year: 77.3% vs. 54.9%, P = 0.027) and DFS (1-year: 85.4% vs. 58.7%; 3-year: 73.1% vs. 39.0%, P = 0.001) rates were significantly higher in the iICT group than in the iCRT group. Multivariable Cox analysis demonstrated that the iICT regimen was independently associated with improved OS and DFS. iICT combined with CS was a safe and manageable treatment option and was associated with improved OS and DFS in patients with initially unresectable cT4 ESCC.

Laparoscopic posterior sectionectomy (LPS) is a challenging liver resection procedure often requiring advanced techniques and equipment to ensure precision. This video demonstration highlights a cost-effective, resource-efficient technique for LPS using a single-energy device approach, showcasing safe and precise liver resection while emphasizing meticulous surgical techniques. An 81-year-old male patient presented with a solitary lesion in segment VII of the liver, close to the hepatocaval confluence. Preoperative imaging confirmed a well-circumscribed lesion without vascular invasion. LPS was performed using Ligasure, which served a dual purpose: 'Kelly-clysis' for parenchymal dissection while simultaneously sealing and dividing vascular structures. Key procedural steps included precise anatomical exposure, isolation of major vascular structures, and systematic parenchymal transection under continuous inflow control. Critical aspects of the technique were highlighted, including real-time intraoperative ultrasound guidance for vascular mapping and ensuring minimal blood loss. The procedure was completed successfully without intraoperative complications. Operative time was 220minutes, and estimated blood loss was 60mL. Cumulative Pringle clamp time was 72minutes. The postoperative course was uneventful, with the patient discharged on postoperative day 5. Histopathological analysis confirmed R0 resection. The video highlights critical operative strategies to mitigate challenges typically encountered during LPS without cavitron ultrasonic surgical aspirator, demonstrating the feasibility of this technique in resource-limited settings. This video highlights the feasibility of laparoscopic posterior sectionectomy using a cost-effective, resource-efficient, single-energy device approach, offering a practical alternative for surgeons. Proper planning, expertise, and use of conventional tools can ensure safe and effective outcomes, even in resource-constrained environments.

Perihilar cholangiocarcinoma (PHCC) often presents challenges with intraoperatively detected distal bile duct margin (DM) positivity. We evaluated the safety and oncological impact of performing an additional pancreatoduodenectomy (ad-PD) for converting R1 to R0 resection. We retrospectively reviewed 272 patients (1990-2024) who underwent major hepatectomies for PHCC. Patients with positive DM were divided into an ad-PD group (n = 8) and a hepatectomy alone group (DMpos-HA, n = 10). A manalysis identified lymph node metastasis, non-R0 resection, vascular resection, and CA19-9 > 90 U/mL as independent predictors of a poor overall survival (OS) in the entire cohort (n = 272). Regarding the DM-positive subgroup, the ad-PD group achieved a 100% R0 rate, whereas the DMpos-HA group had a 0% rate (p < 0.001). The 5-year OS rate tended to be higher in the ad-PD group (50.0% vs. 20.0%, p = 0.396), although the difference was not statistically significant. Major complications (Clavien-Dindo ≥IIIa) occurred in 38% of the ad-PD group and 20% of the DMpos-HA group (p = 0.613). Importantly, the in-hospital mortality rate was 0% in both groups. In carefully selected patients, concomitant ad-PD is a feasible option that achieves a high R0 rate and suggests a trend toward an improved long-term survival without increasing mortality.

The Kirsten rat sarcoma viral oncogene homolog (KRAS) is defined as frequently mutated oncogenes in colorectal cancer. We aimed to clarify the clinical impact of KRAS mutation status on recurrence patterns, the surgical management of recurrent lesions, and prognostic outcomes after curative hepatectomy for colorectal liver metastases (CRLM). The subjects of this retrospective study were 190 patients who underwent curative (macroscopic R0 resection) hepatectomy for CRLM and had wild-type (62.1%) or mutant (37.9%) KRAS status. KRAS mutations were associated with significantly worse overall survival (OS) and recurrence-free survival (RFS), as well as more aggressive recurrence patterns. Multivariate analysis identified KRAS mutation as an independent predictor of poor OS and RFS, whereas CEA ≥ 5 ng/mL was independently associated with OS but not RFS. Notably, patients from the mutant KRAS and wild-type KRAS groups who underwent local therapy (as repeat resection or ablation) for local recurrence had comparable OS. Conversely, among the patients who did not receive local therapy, those from the mutant KRAS group had significantly worse OS than those from the wild-type KRAS group. KRAS mutations are associated with aggressive recurrence patterns and a poor prognosis for patients with CRLM. However, survival following local therapy for recurrence appeared less pronounced regardless of KRAS status.

Laparoscopic versus open surgery for locally advanced gastric gastrointestinal stromal tumors following neoadjuvant imatinib therapy: a multicenter propensity-weighted cohort study.

Extent of liver resection for incidental gallbladder cancer: Anatomic versus nonanatomic approaches in T2-T3 disease.

Outcomes of endoscopic submucosal dissection for superficial esophageal squamous neoplasms: a multicenter North American experience.

Phase II randomized trial of 41.4Gy vs. 50.4Gy in neoadjuvant chemoradiotherapy for resectable esophageal cancer.

Surgery for bilobar colorectal liver metastasis: from staged resections to liver transplantation. A systematic review of the outcomes of the different strategies.

Trends in surgical outcomes for perihilar cholangiocarcinoma: Insights from a Western tertiary center.

ELECLA trial: final results of perioperative chemotherapy with fluoropyrimidine and oxaliplatin in mismatch repair proficient locally advanced colon cancer.

The optimal approach between perioperative chemotherapy (CT) versus preoperative chemoradiotherapy (CRT) for esophageal carcinoma remains debated. This meta-analysis compares the safety and efficacy of CT versus CRT in resectable esophageal and gastroesophageal junction carcinoma. Electronic databases were systematically searched for eligible randomized controlled trials (RCTs) that enrolled adult patients (aged ≥ 18 years) with histologically confirmed, resectable esophageal or gastroesophageal junction carcinoma, directly compared perioperative CT with preoperative CRT, and reported at least one outcome of interest. Meta-analysis was conducted using RevMan 5.4 with a random-effects model. Hazard Ratios (HRs) were pooled for time-to-event outcomes, and risk ratios (RR) for dichotomous endpoints. Eight RCTs were included. Compared with CRT, CT had significantly reduced R0 resection rates (RR 0.94, 95% CI 0.89, 0.99) and a lower pathologic complete response (RR 0.27, 95% CI 0.13, 0.58). No statistically significant differences were observed in overall survival, progression-free survival, postoperative mortality, or severe adverse events. There was a trend toward greater benefit of CRT in squamous cell carcinoma; however, the test for subgroup differences did not attain statistical significance. This meta-analysis suggests that CRT improves local tumor control by increasing R0 resection rates and complete response rates, but without a clear survival advantage over CT. This meta-analysis further highlights the need for an updated multidisciplinary framework and highlights the importance of biomarker-driven strategies in future research.

Real-world evidence regarding surgery for clinical T4 (cT4) nonsmall cell lung cancer (NSCLC) is limited. We evaluated outcomes and prognostic factors of cT4 NSCLC using the 9th edition TNM classification. This multi-institutional retrospective study included patients who underwent pulmonary resection for cT4N0-2bM0 NSCLC between 2010 and 2019. Prognostic factors for relapse-free survival (RFS) and overall survival (OS) were analyzed in patients who achieved R0 resection. OS was compared across cT4 subgroups and cN categories. Among 165 patients, 71 were classified as cT4 owing to invasion of neighboring organs. Clinical nodal status was cN0 in 97, cN1 in 40, cN2a in 21, and cN2b in 7. Preoperative therapy was administered in 44 patients. Postoperative complications occurred in 48%, with 90-day mortality of 2.4%. OS after R0 resection was significantly longer than after R1-2 resection. The 5-year RFS and OS of 149 R0-resected patients were 43 and 61%, respectively. The 5-year RFS rates were 47% for pN0-1, 28% for pN2a, and 17% for pN2b; corresponding OS rates were 63, 48, and 50%, respectively. Multivariable analysis identified pN status and preoperative therapy as independent predictors of RFS, and pN status was an independent predictor of OS. OS did not differ among cT4 subgroups (size alone, invasion alone, or both). Prognosis was similar between cT4cN0-1 and cT4cN2a, whereas cT4cN2b had significantly worse outcomes. Surgery for cT4 NSCLC can achieve favorable results when R0 resection is feasible. Tumors with dual T4 factors and selected cT4N2a disease may benefit from surgery-inclusive treatment.

While neoadjuvant FOLFIRINOX is an effective regimen for pancreatic ductal adenocarcinoma (PDAC), toxicity frequently limits its use. Nanoliposomal irinotecan (nal-IRI) offers improved pharmacokinetic properties and may mitigate some of the side effects. We conducted a multi-institutional, phase II study to evaluate the safety and clinical activity of neoadjuvant NALIRIFOX (nal-IRI, 5-fluorouracil, leucovorin, and oxaliplatin) in patients with resectable and borderline resectable (R/BR) PDAC. Patients with untreated R/BR PDAC received eight cycles of neoadjuvant NALIRIFOX. The primary endpoint was the 30-day post-operative major complication rate among resected patients. Secondary endpoints included treatment completion rate, R0 resection rate, objective response rate (ORR), biochemical (CA19-9) and radiographic responses, nodal downstaging, and quality of life (QoL by FACT-G). Of the 45 enrolled patients, 73% completed all eight cycles of neoadjuvant NALIRIFOX. 34 patients (76%) underwent attempted surgery, of whom 29 (64%) had complete resection (15 BR patients and 14 R patients). The 30-day post-operative major complication rate was 10% (95% CI, 2.2-27%, p = 0.012), meeting the pre-specified threshold. R0 resection was achieved in 90% of resected patients. The radiographic ORR was 45% (95% CI, 29-62%), and the clinical benefit rate was 73% (95% CI, 58-85%). Neoadjuvant NALIRIFOX is a safe and active regimen in R/BR PDAC with a low post-operative complication rate, high treatment completion and R0 resection rates, and meaningful clinical responses. These findings support further investigation of NALIRIFOX as part of a total neoadjuvant therapy (TNT) approach in PDAC. [ClinicalTrials.gov identifier: NCT03483038].

Initial results of NUPAT-01 suggest the feasibility of multidrug neoadjuvant chemotherapy for borderline-resectable pancreatic cancer and favorable survival of patients, and we report on the long-term results of this study. In this multicenter, phase II trial (NUPAT-01), patients with borderline-resectable pancreatic cancer were randomly assigned to receive neoadjuvant chemotherapy with either FOLFIRINOX (original regimen) or gemcitabine with nab-paclitaxel (GEM/nab-PTX) and underwent subsequent surgery if feasible. The primary endpoint was the R0 resection rate. Fifty-one eligible patients were randomly assigned to FOLFIRINOX (n = 26) or GEM/nab-PTX (n = 25). Forty-three patients underwent surgery, and R0 resection was achieved in 33 patients. An Intention-to-treat (ITT) analysis revealed a 3-year overall survival of 51.0% and a 5-year overall survival of 35.3% with a median survival time of 36.5 months. No significant difference between the FOLFIRINOX group and the GEM/nab-PTX group was found in the ITT analysis or in patient survival after surgery. However, patients with a favorable response to chemotherapy had significantly better disease-free survival. These results suggest no significant difference between the benefit of FOLFIRINOX and GEM/nab-PTX as neoadjuvant chemotherapy for borderline-resectable pancreatic cancer, and the survival of patients depends not on the regimen but on the response to chemotherapy.

Surgery for locally advanced intrahepatic cholangiocarcinoma (LAICC) requires extended liver resections, often associated with vascular and/or biliary reconstruction. The benefits of these high-risk operations are still debated. The objective of this study was to analyze short, long-term outcomes, and futility after surgery for LAICC. A retrospective single-center study on the 2013-2024 period was conducted. LAICC was defined as mass-forming intrahepatic tumors 5 cm or more in size with hepatic vein/IVC contact or hepatic hilum contact or both and requiring extended liver resection (five segments or more). Futility was defined as deaths within 90 days or recurrence within 6 months of surgery. 39 consecutive patients were analyzed, including (29) 74% women with a median age of 66 years (38-83 years). In 34 (88%) patients, a trisectionectomy (H145678 or H123458) was performed. Major vascular or biliary recontruction was required in 43.5% and 67%, respectively. Overall morbidity was 56%, with severe morbidity occurring in 8 (20%). The 90-day mortality was 5%. Median overall survival and recurrence-free survival was estimated at 58 and 23 months, respectively. Overall rate of futility was 15.4%. N+ has been shown to be the main factor affecting survival (p = 0.03 for overall survival and p = 0.01 for recurrence-free survival). R1 resection had no impact of overall or recurrence-free survival. Our study supports an aggressive surgical approach for LAICC. Anticipated R1 resection by necessity should not be considered a contraindication to surgery.