Repeat Resection Research Articles

The Impact of Surgery on the Survival of Patients with Recurrent Glioblastoma.

Objective:The purpose of this study was to investigate the possible benefit of repeat surgery on overall survival for patients with recurrent glioblastoma multiforme (GBM).Methods:We performed a retrospective analysis of data from patients who presented with recurrent GBM over a 5-year period (n = 157), comparing baseline characteristics and survival for patients who had at least 1 new tumor resection followed by chemotherapy (reoperation group, n = 59) and those who received medical treatment only (no-reoperation group, n = 98) for recurrence.Results:The baseline characteristics of the two groups differed in terms of WHO performance status (better in the reoperation group), mean age (60 years in the reoperation group vs. 65 years in the no-reoperation group), mean interval to recurrence (3 months later in the reoperation group than in the no-reoperation group) and more gross total resections in the reoperation group. Nevertheless, the patients in the reoperation group had a higher rate [32.8%] of sensorimotor deficits than those of the no-reoperation group [14.2]. There was no significant difference in sex; tumor localization, side, or extent; MGMT status; MIB-1 labeling index; or Karnofsky Performance Status [KPS] score. After adjustment for age, the WHO performance status, interval of recurrence, and extent of resection at the first operation, multivariate analysis showed that median survival was significantly better in the reoperation group than in the no-reoperation group (22.9 vs. 14.61 months, P < 0.05). After a total of 69 repeat operations in 59 patients (10 had 2 repeat surgeries), we noted 13 temporary and 20 permanent adverse postoperative events, yielding a permanent complication rate of 28.99% (20/69). There was also a statistically significant (P = 0.029, Student's t-test) decrease in the mean KPS score after reoperation (mean preoperative KPS score of 89.34 vs. mean postoperative score of 84.91).Conclusion:Our retrospective study suggests that repeat surgery may be beneficial for patients with GBM recurrence who have good functional status (WHO performance status 0 and 1), although the potential benefits must be weighed against the risk of permanent complications, which occurred in almost 30% of the patients who underwent repeat resection in this series.

The Role of Neoadjuvant Chemotherapy in Repeat Local Treatment of Recurrent Colorectal Liver Metastases: A Systematic Review and Meta-Analysis.

Simple SummaryUp to 85% of patients with colorectal liver metastases develop distant intrahepatic recurrence after curative intent local treatment. (Inter)national guidelines and scientific societies consider repeat local treatment, comprising repeat thermal ablation and/or repeat resection, the standard of care to treat recurrent new colorectal liver metastases. This systematic review and meta-analysis assessed the potential additive value of neoadjuvant chemotherapy before repeat local treatment. The addition of neoadjuvant chemotherapy prior to repeat local treatment was suggested by merely all authors, though supporting evidence is lacking. The results do not substantiate the routine use of neoadjuvant chemotherapy. We are currently constructing a phase III randomized controlled trial directly comparing upfront repeat local treatment with neoadjuvant chemotherapy followed by repeat local treatment (COLLISION RELAPSE trial).The additive value of neoadjuvant chemotherapy (NAC) prior to repeat local treatment of patients with recurrent colorectal liver metastases (CRLM) is unclear. A systematic search was performed in PubMed, Embase, Web of Science, and an additional search in Google Scholar to find articles comparing repeat local treatment by partial hepatectomy and/or thermal ablation with versus without NAC. The search included randomized trials and comparative observational studies with univariate/multivariate analysis and/or matching as well as (inter)national guidelines assessed using the AGREE II instrument. The search identified 21,832 records; 172 were selected for full-text review; 20 were included: 20 comparative observational studies were evaluated. Literature to evaluate the additive value of NAC prior to repeat local treatment was limited. Outcomes of NAC were often reported as subgroup analyses and reporting of results was frequently unclear. Assessment of the seven studies that qualified for inclusion in the meta-analysis showed conflicting results. Only one study reported a significant difference in overall survival (OS) favoring NAC prior to repeat local treatment. However, further analysis revealed a high risk for residual bias, because only a selected group of chemo-responders qualified for repeat local treatment, disregarding the non-responders who did not qualify. All guidelines that specifically mention recurrent disease (3/3) recommend repeat local treatment; none provide recommendations about the role of NAC. The inconclusive findings of this meta-analysis do not support recommendations to routinely favor NAC prior to repeat local treatment. This emphasizes the need to investigate the additive value of NAC prior to repeat local treatment of patients with recurrent CRLM in a future phase 3 randomized controlled trial (RCT).

Ocular surface squamous neoplasia: outcomes following primary excision with 2 mm margin and cryotherapy.

To assess margins and the rate of local recurrence of ocular surface squamous neoplasia after excision with a 2 mm margin and cryotherapy at a single ophthalmic oncology center. (1) Conjunctival margin were assessed as positive, negative, or indeterminate margins. (2) Feasibility of repair without a graft. (3) Local recurrence. Retrospective chart review of histologically proven conjunctival intraepithelial neoplasia and invasive squamous cell carcinoma cases that underwent excision with a 2 mm margin and cryotherapy. Eighty cases met inclusion criteria for the quantitative analysis. The margin was positive in six cases (7.5%), four of which were treated with post-op topical immunotherapy/chemotherapy. Of the six positive margin cases, there was one recurrence which occurred in the patient who did not receive post-op topical adjuvant therapy, however resolved after starting topical treatment. Conjunctival repair without use of a graft was feasible in 74 (93%) cases with a mean basal diameter of 6.4 mm. Total number of local recurrence was seen in three cases (4%), which were successfully treated with adjuvant topical treatment (one positive margin case, one indeterminate margin case) or repeat resection followed by episcleral plaque brachytherapy (one negative margin case). Excision with 2 mm margin of OSSN is not associated with high rates of positive surgical margins. Even those with positive margins, when treated with adjuvant topical therapy did not develop recurrence. While achieving low rates of local recurrence, the conjunctiva is conserved, thereby minimizing the need for amniotic membrane or free conjunctival grafts for conjunctival repair.

Robotic redo hepatectomy: resection SG 4B seven years after open right hemihepatectomy

Purpose: Evidence shows that repeat liver resection is often the best treatment option for recurrent colorectal liver metastases. Although repeat resections can be complex due to adhesion and altered liver anatomy, laparoscopic liver resection has been shown to be feasible in selected patients, and has been associated with shorter operative time, less blood loss, and shorter hospital stay. Compared to laparoscopy, robotic liver surgery has the advantage of 3D visualization and a larger range of motion thanks to endowrist technology. This video aims to demonstrate the experience of a hepatopancreaticobiliary surgeon with robotic redo hepatectomy. Methods: This report describes a robotic segment 4B resection, seven years after open right hemihepatectomy, in a patient with a solitary colorectal liver metastasis. Surgical risk was assessed by the Southampton laparoscopic liver resection difficulty score, and was classified as extremely high-risk. The patient was placed in supine position with 12 degrees anti-Trendelenburg. Four robotic 8 mm ports were placed, and one assistant 12 mm port. Extensive adhesiolysis was performed with monopolar scissors and a bipolar sealing device. Intraoperative ultrasound was used to demarcate the transection line. The Pringle maneuver was applied by the Huang loop technique. Liver parenchyma transection was done by a bipolar sealing device. Locking polymer clips, hemostatic matrix and fibrillar absorbable haemostat were used to counter blood loss. Results: The Pringle maneuver was performed for 18 minutes. Operative time was 170 minutes, and blood loss was 30 cc. Pathology confirmed a R0 resection of the colorectal liver metastasis. There were no intraoperative complications encountered. The postoperative course was uneventful, and the patient was discharged on postoperative day 2. Conclusion: Robotic redo hepatectomy is feasible after previous open extensive liver surgery for repeat metastatic liver disease in selected patients.

Laparoscopic caudate lobe re-resection in an obese patient with cirrhosis: a himalayan approach

We present the video of a laparoscopic caudate lobe repeat resection for a bifocal hepatocellular carcinoma (HCC) recurrence in a 67-year-old male with a history of HBV-, HCV- and metabolic-related cirrhosis, obesity, type-II diabetes, hypertension. The patient had previously undergone a partial laparoscopic resection of the caudate process with cholecystectomy in 2016 for a 55 mm G2 HCC. After four years, follow up CT and MRI showed a bifocal HCC recurrence of 22 and 10 mm in the paracaval portion of the remaining caudate process. After extensive adhesiolysis and caval exposure, the lesser omentum and accessory left hepatic artery were sectioned to expose the caudate lobe, which was then detached from the plane of the inferior vena cava by sectioning the Spigelian veins. During this maneuver, a clip on a 4mm Spigelian vein fell, causing a bleeding that was controlled with forceps and repaired with a 3/0 Polyglactin running suture. Half-way through the parenchymal transection, the pneumoperitoneum was interrupted due to insufflation problems. At reinsufflation, the patient went into cardiac arrest. CPR was performed, with return of spontaneous circulation after one minute. Cardiolpulmonary events were excluded but, due to worsening acidosis, the operation was interrupted and the patient was taken to the ICU for monitoring and stabilization. The next day, after a night of bivouac and lactate clearance, the operation was concluded as a hand-assisted procedure. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Histological examination showed a bifocal pT2 G1 HCC.

SURG-16. SURGICAL TECHNIQUES TO AVOID COMPLICATIONS DURING REPEAT RESECTIONS FOR PEDIATRIC BRAIN TUMORS

Complications due to repeat resection for recurrent pediatric brain tumors remain unclear. The present study focused on surgical techniques to avoid surgical morbidities during repeat resections for pediatric brain tumors. This study included 57 consecutive repeat resections for 28 pediatric patients under the age of 15 with recurrent brain tumors. Resections were performed 2–14 times for each patient by the senior author (TK). Reviewed factors were wound-related complications, bleeding/ischemic complications, and Eastern Cooperative Oncology Group performance status (PS) before and after surgery. No patients presented any complications to decrease PS, postoperatively. No wound-related complications were worthy of special mention. Surgical techniques to prevent wound-related complications are as follows: 1) shaving the hair around the previous skin incision just before the surgery; 2) washing and disinfecting around the skin incision using chlorhexidine soap and an alcohol swab, followed by Povidone-Iodine solution; 3) after craniotomy, removing all granulation tissues, residual titanium plates, and screws; 4) brushing all surgical fields and a bone flap before opening the dura mater using Povidone-Iodine solution followed by normal saline; 5) maintaining a bone flap in normal saline with antibiotics; 6) changing all the surgical instrument and gloves; 8) closing the dura mater completely to prevent CSF leakage, and 8) using postoperative antibiotics for six days. Meticulous dissecting postsurgical adhesion of brain and dura mater, arteries and nerves; usage of neuronavigation system and neuromonitoring to understand the anatomy radiologically and functionally; applying papaverine hydrochloride for spastic arteries, are important to avoid complications during the intracranial procedure.

PEDT-02 Clinical usage of NCC Oncopanel/FoundationOne CDx for pediatric/AYA patients with recurrent malignant brain tumors

Backgrounds: Analyses of somatic mutations in malignant brain tumors have been used to make effective treatment strategies. NCC Oncopanel and FoundationOne CDx are custom targeted next-generation sequencing (NGS) panels. The cost for this analysis is 560,000 yen covered by National Health Insurance in Japan since June 2019. These methods can be applied for the solid cancers with no established therapies and relapsed after the standard therapies. Following these inclusion criteria, most malignant brain tumors, especially recurrent malignant brain tumors in pediatric/AYA generations, can be included. Object: To report the results of our initial experiences. Methods: In the last one year, we utilized these NGS panels for five patients with recurrent malignant brain tumors in this generations: 2 epithelioid glioblastomas; 1 anaplastic meningioma; 1 diffuse astrocytoma (gliomatosis cerebri); 1 atypical choroid plexus papilloma. Results: Final recommended treatments are as follows: BRAF/MEK inhibitors, bevacizumab, or anti-PD-1 antibody for one epithelioid glioblastoma; MEK inhibitor for another epithelioid glioblastoma previously treated by BRAF inhibitor and bevacizumab; ERK1/2 inhibitors for anaplastic meningioma. The diffuse astrocytoma had IDHR132H mutation. There was no clinical trial using IDH inhibitor for recurrent diffuse astrocytoma; thus, the final recommendation for this case was rechallenge of temozolomide. To date, only one NGS for a choroid plexus papilloma has been reported (Arch Pathol Lab Med, 2017). Our case had multiple actionable gene alterations, including TERT mutation and amplification of various genes. Unfortunately, there was no druggable gene alteration among them. Conclusions: Insurance-covered cancer gene panel tests could represent effective treatment options for some malignant brain tumors in pediatric/AYA generations. If the relapse is local and can be treated by repeat resections, we think the surgery is the first-line choice. But, in another situation, information from NGS panels should be obtained positively. Efforts to increase the utility of off-label use of drugs are encouraged.

Long-term outcomes in the treatment of pediatric skull base chordomas in the endoscopic endonasal era.

Pediatric skull base chordoma is a rare entity that is traditionally considered to display aggressive behavior with an increased risk of recurrence. There is an absence of literature examining outcomes in the pediatric population in general and using the endoscopic endonasal approach (EEA). The authors retrospectively reviewed all patients with skull base chordomas presenting by the age of 18 years to the Children's Hospital of Pittsburgh or the University of Pittsburgh Medical Center from 2004 to 2019. Clinical outcomes, the number and location of recurrences, and progression-free survival time were determined. Twenty patients met the study criteria. The most common presenting complaints were diplopia (n = 7), headache (n = 6), and swallowing difficulty (n = 4). Three cases were incidentally discovered. Twelve patients underwent single-stage EEA alone, 2 patients had two-stage EEA, and 6 patients had combined EEA with open far-lateral or extreme-lateral approaches. Fourteen patients underwent gross-total resection (GTR), and 6 patients had near-total resection. Larger tumors were more likely to require staging or a combined approach (86% vs 7%) and were less likely to receive GTR (33% vs 86%) but had comparable recurrence and mortality rates. Five patients developed CSF leaks requiring reoperation, 2 patients developed a permanent abducens nerve palsy, 1 patient suffered an internal carotid artery injury, 1 patient developed an epidural hematoma, and 1 patient developed a subdural empyema. Four (20%) patients had recurrence during follow-up (mean radiographic follow-up 59 months and mean time to local recurrence 19 months). Two patients with recurrence underwent further resection, and 1 patient elected to stop treatment. Both patients who underwent repeat resection experienced a second recurrence, one of whom elected to stop treatment. Both patients who died had an elevated Ki-67 (p = 0.039), one of whom developed de-differentiated histology. A third patient died of progressive spinal metastases without local recurrence and is one of 2 patients who developed postoperative spinal metastases. Both patients whose tumors became de-differentiated progressed from tumors with an initial Ki-67 of 15 or greater (p = 0.035) and received prior radiotherapy to the bulk tumor (p = 0.03). The majority of pediatric skull base chordomas, when managed at a specialized center with a goal of GTR, may have a better outcome than traditionally believed. Elevated Ki-67 rates may predict poor outcome and progression to de-differentiation.

SURG-35. INTRACRANIAL MYXOID MESENCHYMAL TUMOR WITH EWSR1-ATF1 GENE FUSION

Abstract Intracranial myxoid mesenchymal tumors (IMMT) carrying an EWSR1-CREB gene family fusion are extremely rare and have only been identified in ten relatively recent reported cases. There is some question as to whether this is a novel entity, or a myxoid variant of angiomatoid fibrous histiocytoma (AFH), given certain histopathological similarities. Despite these similarities, the increasing number of cases reported appear to demonstrate clear histological differences that indicate IMMTs are a distinct and novel entity. Previous reports have focused on histological analysis but have lacked detailed long-term clinical follow-up and recommendations regarding treatment approach. In this case, we describe a 48-year-old female who presented with a left intraventricular mass that was identified histologically as an IMMT with an EWSR1-ATF1 gene fusion. Following initial resection, the tumor demonstrated local recurrence. Repeat resection was performed followed by immediate demonstration of local, as well as distant, tumor recurrence. Subsequent histological analysis of the tumor demonstrated a myxoid mesenchymal tumor clearly distinct from AFH. Fractionated stereotactic radiation therapy was administered following the second resection and tumor control was achieved at 1 year. This case is particularly remarkable as it is only the second reported IMMT case to occur in a middle-aged adult, with all other cases occurring in children or young adults. The two middle-aged adult cases share striking similarities in clinical presentation, including a history of breast cancer. Our findings indicate that an intracranial myxoid mesenchymal tumor is a novel and rare entity that may demonstrate rapid local and distant recurrence. Given the aggressive recurrence seen with the presented case, we recommend the treatment plan to be surgical resection followed by adjuvant radiation therapy to maintain tumor control.

Diffusion Magnetic Resonance Imaging Phenotypes Predict Overall Survival Benefit From Bevacizumab or Surgery in Recurrent Glioblastoma With Large Tumor Burden.

Diffusion magnetic resonance (MR) characteristics are a predictive imaging biomarker for survival benefit in recurrent glioblastoma treated with anti-vascular endothelial growth factor (VEGF) therapy; however, its use in large volume recurrence has not been evaluated. To determine if diffusion MR characteristics can predict survival outcomes in patients with large volume recurrent glioblastoma treated with bevacizumab or repeat resection. A total of 32 patients with large volume (>20 cc or > 3.4 cm diameter) recurrent glioblastoma treated with bevacizumab and 35 patients treated with repeat surgery were included. Pretreatment tumor volume and apparent diffusion coefficient (ADC) histogram analysis were used to phenotype patients as having high (>1.24 μm2/ms) or low (<1.24 μm2/ms) ADCL, the mean value of the lower peak in a double Gaussian model of the ADC histogram within the contrast enhancing tumor. In bevacizumab and surgical cohorts, volume was correlated with overall survival (Bevacizumab: P=.009, HR=1.02; Surgical: P=.006, HR=0.96). ADCL was an independent predictor of survival in the bevacizumab cohort (P=.049, HR=0.44), but not the surgical cohort (P=.273, HR=0.67). There was a survival advantage of surgery over bevacizumab in patients with low ADCL (P=.036, HR=0.43) but not in patients with high ADCL (P=.284, HR=0.69). Pretreatment diffusion MR imaging is an independent predictive biomarker for overall survival in recurrent glioblastoma with a large tumor burden. Large tumors with low ADCL have a survival benefit when treated with surgical resection, whereas large tumors with high ADCL may be best managed with bevacizumab.

Subcuticular Sutures Versus Staples for Wound Closure in Open Liver Resection: A Randomised Clinical Trial.

Subcuticular sutures reduce wound complication rates only in clean surgeries. Repeat resection is frequently required in liver surgery, due to the high recurrence rate (30-50%) of liver cancers. The aim of this study is to assess that subcuticular sutures is superior to staples in liver surgery. This single-centre, single-blinded, randomised controlled trial was conducted at a university hospital between January 2015 and October 2018. Patients were randomly assigned (1:1) to receive either subcuticular sutures or staples for skin closure. Three risk factors (repeat resection, diabetes mellitus and liver function) were matched preoperatively for equal allocation. The primary endpoint was the wound complication rate, while secondary endpoints were surgical site infection (SSI), duration of postoperative hospitalisation and total medical cost. Subset analyses were performed only for the 3 factors allocated as secondary endpoints. Of the 581 enrolled patients, 281 patients with subcuticular sutures and 283 patients with staples were analysed. As the primary outcome, the wound complication rate with subcuticular sutures (12.5%) did not differ from that with staples [15.9%; odds ratio (OR), 1.33; 95% confidence interval (CI), 0.83-2.15; p = 0.241]. As secondary outcomes, no significant differences were identified between the two procedures in the overall cohort while overall wound complications [7 patients (8.5%) vs. 17 patients (20.0%); OR, 2.68; 95% CI, 1.08-7.29; p = 0.035] with repeat incision were significantly less frequent with subcuticular sutures. Subcuticular sutures were not shown to reduce wound complications compared to staples in open liver resection, but appear beneficial for repeat incisions.

A case of repeat resection for recurrent pulmonary metastasis from sebaceous gland carcinoma

BackgroundSebaceous gland carcinoma (SGC) of the eyelid is an aggressive malignant eyelid tumor, and it can metastasize to the regional lymph nodes and distant organs. There have been only a few reported cases of patients who underwent pulmonary metastasectomy for metastatic SGC. We herein report a patient who underwent repeat pulmonary metastasectomies for recurrent pulmonary metastases from SGC.Case presentationBilateral small pulmonary nodules were detected in a 59-year-old woman with a history of eyelid SGC. She underwent wide wedge resection of the left lower lobe, and the disease was diagnosed as pulmonary metastases from SGC. Six months after the first pulmonary resection, CT showed that the nodules of right S2 and S10 had increased in size, and three small nodules had newly appeared in the right lung. The patient therefore underwent six wide wedge resections of the right lung through thoracotomy. After that, she underwent pulmonary metastasectomy 2 times. Ninety months after the first pulmonary resection, the patient is doing well without disease.ConclusionsGiven that a long-term survival was ultimately achieved in the present case, repeat pulmonary metastasectomy may be beneficial for recurrent pulmonary metastasis from SGC.

Revision surgery after resection arthroplasty of the thumb saddle joint

Resection arthroplasty still is the gold standard for the treatment of basal thumb arthritis. In most patients, satisfactory results can be expected. However, the few patients with persisting problems are achallenge for the hand surgeon. They may complain of neuromas, tendinitis of the flexor carpi radialis (FCR) tendon, impingement and/or proximalization of the first metacarpal, arthritis of the scaphotrapezoidal joint or carpal collapse in the case of pre-existing scapholunate instability. This includes subtle clinical examination. Radiography may be completed by a CT scan. Probational infiltration is ahelpful tool to confirm diagnosis and may be the first step of aconservative treatment, when supplemented by orthoses. Revision surgery is guided by the nature of the present problem. Neurolysis should be indicated cautiously and performed according to existing principles. FCR tendinitis is treated by release or resection of the tendon. Impingement of the first metacarpal is treated by repeat resection and tendon interposition, proximalization by additional suspension arthroplasty or by arthrodesis between the bases of the first and second metacarpals. In the case of scaphotrapezoidal arthritis, the proximal third of the trapezoid is resected, whereas destabilization of the scaphoid with consecutive carpal collapse may necessitate midcarpal fusion.

Impact of repeated operations for progressive low-grade gliomas

BackgroundMaximal, aggressive resection of diffuse low-grade gliomas (DLGG) is well established as the standard of care in neuro-oncology. The role of repeat resection for tumor progression is unclear. ObjectiveTo assess the role of repeated operation for DLGG, and the effect on malignant transformation and survival. MethodsWe conducted a historical cohort study in which all patients undergoing multiple resections of DLGG between the years 1995–2019 were evaluated for overall survival (OS) and time to transformation (TTT). We then compared the outcome of this group with that of a matched control group comprised of patients who underwent only one operation despite being eligible for repeat surgery at tumor progression, but had received non-surgical oncological therapy or declined additional treatment. ResultsOf 607 patients in our departmental DLGG database, 93 patients underwent 2 or more surgeries and had sufficient follow-up and imaging data to be included in the study group. Thirty-eight patients were included in the matched control group. Early (less than 1 year) progression was associated with decreased survival and shorter TTT in the study group. Patients undergoing multiple resections had significantly longer TTT and OS compared to patients who underwent a single surgery. This effect was especially noted in patients who had radiological evidence of tumor transformation. ConclusionsRepeated resections of LGG are safe and offer survival benefit in select patients. Early progression following resection is associated with worse prognosis. Patients with evidence of radiological transformation may benefit the most from re-resection.

Multidisciplinary treatment for colorectal liver metastases in elderly patients

BackgroundLimited data describe the therapeutic practice and outcomes of colorectal liver metastases (CRLMs) in elderly patients. We aimed to evaluate the impact of age on multidisciplinary treatment for CRLMs.MethodsWe reviewed treatment and outcomes for patients in different age groups who underwent initial hepatectomy for CRLMs from 2004 through 2012.ResultsWe studied 462 patients who were divided into three groups by age: ≤ 64 years (n = 265), 65–74 years (n = 151), and ≥ 75 years (n = 46). The rate of major hepatectomy and incidence of postoperative complications did not differ between groups. Adjuvant chemotherapy was used less in the ≥ 75-year group (19.6%) than that in the ≤ 64 (54.3%) or 65–74 age group (43.5%). Repeat hepatectomy for liver recurrence was performed less in the ≥ 75-year group (35%) than in the ≤ 64 (57%) or 65–74 (66%) age group. The 5-year disease-specific survival (DSS) rate of 44.2% in the ≥ 75-year group was lower than in the ≤ 64 (59.0%) or 65–74 (64.7%) age group. Multivariate analysis revealed age ≥ 75 years was an independent predictor of poor DSS.ConclusionsLiver resection for CRLMs can be performed safely in elderly patients. However, repeat resection for recurrence are performed less frequently in the elderly, which may lead to the poorer disease-specific prognosis.

Surgical management of thymic epithelial tumors.

Resection is the mainstay of treatment for thymic epithelial tumors (TETs), with complete removal of the tumor and involved organs being the ultimate aim. The choice of surgical approach plays a major role in defining treatment success, and the optimal choice of method should thus provide an adequate surgical view to achieve complete tumor resection. While median sternotomy is considered the gold standard for access to the mediastinum, several minimally invasive approaches to thymectomy have been described, including video-assisted robotic-assisted thymectomy, although the oncological outcomes of that procedure remain unclear. A multimodal approach incorporating chemotherapy or chemoradiotherapy followed by extended surgery may improve resectability and outcomes for patients with advanced TETs. Surgical debulking is also reportedly acceptable for invasive thymoma because of its potential for achieving favorable outcomes. Re-resection is an acceptable option for patients with recurrent thymoma after initial resection, and repeat resection for recurrent pleural dissemination seems effective. Here, the literature on current clinical practices in the surgical management and treatment of TETs is reviewed.

Recurrence After Liver Resection of Colorectal Liver Metastases: Repeat Resection or Ablation Followed by Hepatic Arterial Infusion Pump Chemotherapy

BackgroundThe aim of this study was to investigate the effectiveness of adjuvant hepatic arterial infusion pump (HAIP) chemotherapy after complete resection or ablation of recurrent colorectal liver metastases (CRLM).MethodsA retrospective cohort study was conducted of patients from two centers who were treated with resection and/or ablation of recurrent CRLM only between 1992 and 2018. Overall survival (OS) and hepatic disease-free survival (hDFS) were estimated using the Kaplan–Meier method. The Cox regression method was used to calculate hazard ratios (HRs) with corresponding 95% confidence intervals (CI).ResultsOf 374 eligible patients, 81 (22%) were treated with adjuvant HAIP chemotherapy. The median follow-up for survivors was 65 months (IQR 32–118 months). Patients receiving adjuvant HAIP were more likely to have multifocal disease and receive perioperative systemic chemotherapy at time of resection for recurrence. A median hDFS of 46 months (95% CI 29–81 months) was found in patients treated with adjuvant HAIP compared with 18 months (95% CI 15–26 months) in patients treated with resection and/or ablation alone (p = 0.001). The median OS and 5-year OS were 89 months (95% CI 52–126 months) and 66%, respectively, in patients treated with adjuvant HAIP compared with 57 months (95% CI 47–67 months) and 47%, respectively, in patients treated with resection and/or ablation only (p = 0.002). Adjuvant HAIP was associated with superior hDFS (adjusted HR 0.599, 95% CI 0.38–0.93, p = 0.02) and OS (adjusted HR 0.59, 95% CI 0.38–0.92, p = 0.02) in multivariable analysis.ConclusionAdjuvant HAIP chemotherapy after resection and/or ablation of recurrent CRLM is associated with superior hDFS and OS.

Favorable outcomes of surgical resection for extrahepatic recurrent hepatocellular carcinoma

Repeat resection for intrahepatic recurrent hepatocellular carcinoma (HCC) is effective for the long-term survival of patients; however, little is known about the surgical outcomes of extrahepatic nodules. The aim of this study is to investigate whether resection can contribute to the survival of patients with extrahepatic recurrent HCC. Under the conditions that intrahepatic recurrent HCC was absent or controlled by locoregional therapies, patients who had resectable extrahepatic recurrent HCC in the lymph nodes, adrenal gland, peritoneum, lung, or brain were included in this study. The survival of patients who did (Surgical group) and did not (Non-surgical group, underwent other therapies) undergo resection for extrahepatic recurrent HCC was compared. Thirty-eight and 26 patients were included in the Surgical and Non-surgical groups, respectively. No patient had severe postoperative complications. After a median follow-up of 1.2 (range, 0.2-8.8) years, the median cumulative incidence of extrahepatic recurrent HCC was 1.2years (95% confidence interval [CI], 0.4-3.5) in the Surgical group. The median overall survival was 5.3 (95% CI, 2.5-8.8) and 1.1 (0.8-2.3) years in the Surgical and Non-surgical groups, respectively (P< 0.001). The 5-year rates of survival were 60.5% and 9.1% in the Surgical and Non-surgical groups, respectively. Surgical resection, α-fetoprotein, disease-free interval, and metastasis at the adrenal gland were the independent factors for overall survival. Due to the favorable surgical outcomes, resection should be considered as one of the therapeutic choices for patients with extrahepatic recurrent HCC if intrahepatic recurrent HCC can be controlled by locoregional therapies.

Assessing the efficacy of repeat resections in recurrent glioblastoma: a systematic review.

The inevitable recurrence of glioblastoma (GBM) results in patients often undergoing multiple resections with questionable benefit to overall survival (OS). To systematically review and analyze prior studies examining the potential added benefit of repeat resection (RR) in recurrent GBM. We performed a PRISMA-compliant systematic review of literature published between 1969 to 2019 involving patients undergoing RR at GBM recurrence. The search yielded 3994 non-duplicate citations. Final abstraction included 43 articles, with 2 level II and 41 level III studies. The earliest paper we included was published in 1987 [1], and 35 identified papers (81.4%) were published within the last 10 years. The survival data of 9236 patients (55% male) were analyzed, with a median age of 56; 3726 patients underwent RR. In 31 studies with a comparable single-surgery-only cohort, 20 articles reported a statistically significant increase in OS with RR, 7 reported nonsignificant trends toward increased OS with RR, and 4 reported no significant increase in OS with RR. Twenty-two articles with multivariate analyses of Karnofsky performance scores and 17 articles with extent-of-resection reported these as significant prognostic factors of OS. In 26 studies, median OS among all patients was 17.85 months inclusive of median OS following RR totaling 9.6 months. Notably, in 10 studies with data on subsequent progressions (2+ recurrences), 6 studies reported significant increases in OS with subsequent repeat resection (sRR) compared to those not undergoing sRR. Recurrent GBM presents a treatment challenge. There appears to be an OS benefit for RR upon first recurrence as well as sRR. Such findings warrant further investigation of the potential benefits of continued surgical intervention after subsequent progressions of GBM.

Mo1727 HOT AVULSION OF RESIDUAL VISIBLE NEOPLASIA IN LARGE LATERALLY SPREADING TUMORS RESULTS IN LOW RECURRENCE RATES WITHOUT THE NEED OF ABLATION OF THE MARGINS

EMR of large laterally spreading tumors (LSTs) results in recurrent or residual adenomas (RRAs) ranging from 15 to 30%.Attempts to reduce this rate include careful optical attention to residual visible neoplasia with additional resection with cold biopsy forceps, wide margin snare excision, or ablation with argon plasma coagulation (APC).Invisible residual neoplasia has been addressed with snare tip soft coagulation of the margins,extended marginal excision,and APC which results in decreased recurrences.We introduced hot avulsion as a means to excise parts of the polyp not amenable to snare resection due to adherence to the submucosa, difficulty in snare orientation, and inability to entrap neoplastic tissue. Hot avulsion steps includes:1)Using a hot biopsy forceps to grasp visible residual neoplastic tissue;2)Application of continuous traction effectively tenting the tissue away from the resection base (in order to minimize possible thermal injury);3)Delivering short bursts of a cutting current resulting in tissue shearing.This method is efficient and employs readily available inexpensive accessories, and addresses recurrences related to central areas of the polyp as well as marginal residual neoplasia. A retrospective review of our endoscopy database was performed(5/16-9/19).Inclusion criteria included: EMR of polyps >2cm,use of hot avulsion, and at least one follow up colonoscopy.All index procedures for polypectomy were performed by single expert endoscopist (GBH). LSTs considered endoscopically unresectable (with features of invasive carcinoma) were excluded. 254 LSTs were resected using EMR and avulsion, of which 118 LSTs in108 patients met follow up criteria to be included in the study.The average age was 64 years with 65 females(60%).Average LST size was36mm. Most polyps were resected in the ascending colon(33%).Histopathologic examination revealed 29% tubular adenoma (TA),29% sessile serrated adenoma (SSA), and20% tubulovillous adenoma (TVA). High-grade dysplasia (HGD) was found in17.7% of polyps and intramucosal adenocarcinoma in 2%. 9 patients had more than one qualifying polyp for resection with EMR and avulsion .Average time to first follow up colonoscopy was eight months (3-36 months). Optically visible RRAs were found in 5 patients(4%)with repeat resection histology revealing TA(3), TVA(1)and SSA(1). Initial histopathology of patients with RRA included 2 TVA with HGD,1 TVA,1 TA, and 1 TA with HGD.Post-polypectomy biopsy of scar was performed in 100 out of the 118 cases. Hot avulsion as an adjunct to endoscopic mucosal resection results in very low recurrence rates equivalent to the lowest rates achieved with other more laborious adjunctive therapies. Moreover the strength of this study is the high rate of histologic interrogation of the scar(85%) not performed in most studies of recurrence.Adverse Events, Follow-up Colonoscopies and Recurrence Lesion CharacteristicsView Large Image Figure ViewerDownload Hi-res image Download (PPT)