Secondary Resection Research Articles

Peak Risk of Recurrence Occurs during the First Two Years after a Pancreatectomy in Patients Receiving Neoadjuvant FOLFIRINOX

No codified/systematic surveillance program exists for borderline/locally advanced pancreatic ductal carcinoma treated with neoadjuvant FOLFIRINOX and a secondary resection. This study aimed to determine the trend of recurrence in patients who were managed using such a treatment strategy. From 2010, 101 patients received FOLFIRINOX and underwent a pancreatectomy, in a minimum follow-up of 5 years. Seventy-one patients (70%, R group) were diagnosed with recurrence after a median follow-up of 11 months postsurgery. In the multivariable analysis, patients in the R-group had a higher rate of weight loss (p = 0.018), higher carbohydrate antigen (CA 19-9) serum levels at diagnosis (p = 0.012), T3/T4 stage (p = 0.017), and positive lymph nodes (p < 0.01) compared to patients who did not experience recurrence. The risk of recurrence in patients with T1/T2 N0 R0 was the lowest (19%), and all recurrences occurred during the first two postoperative years. The peak risk of recurrence for the entire population was observed during the first two postoperative years. The probability of survival decreased until the second year and rebounded to 100% permanently, after the ninth postoperative year. Close monitoring is needed at reduced intervals during the first 2 years following a pancreatectomy and should be extended to later than 5 years for those with unfavorable pathological results.

The influence of secondary resection using NeuroSAFE-technique on sexual function in unilateral nerve-sparing robot-assisted laparoscopic prostatectomies.

To demonstrate the surgical influence of secondary resection on sexual function in finally unilateral nerve-sparing robot- assisted laparoscopic prostatectomies (RALPs) performed with the 'neurovascular structure-adjacent frozen-section examination' (NeuroSAFE) technique by prospectively collecting EPIC-26-questionnaires. Sexual function status measured by the sexual-symptom-score (SexSS) in the EPIC-26-questionnaires was collected preoperatively and 12 months after RALP from 378 patients between 09/2019 and 04/2021. Cohorts of interest were defined as those patients undergoing unilateral nerve-sparing by secondary resection of the other neurovascular bundle (NVB), and as those patients undergoing primarily planned and successful unilateral nerve-sparing (unilateral nerve-sparing without secondary resection) in ≤cT2 prostate cancer. NeuroSAFE frozen section technique was performed in all nerve-sparing RALPs, and in case of cancer-positive surgical margins, the complete NVB was resected. In 109 RALPs with unilateral nerve-sparing (48 primarily vs. 61 by secondary resection), analyses showed a significant difference in postoperative SexSS for 'unilateral nerve-sparing by secondary resection' compared with 'unilateral nerve-sparing without secondary resection' (43 [interquartile range (IQR): 14;50] vs. 26 [IQR: 22;62], P = 0.04). In multivariable analyses, the preoperative SexSS was predictive for postoperative erectile dysfunction (OR = 0.96, 95% confidence interval: 0.93-0.98, P < 0.001). Oncological safety was not compromised by secondary resection (prostate-specific antigen after 12 months 0.01 ng/mL vs. 0.01 ng/mL [P = 0.3] for unilateral nerve-sparing by secondary resection vs. unilateral nerve-sparing without secondary resection). The results of this study suggest that nerve-sparing attempts applying the NeuroSAFEtechnique should be generously performed since a unilateral complete secondary resection leading to a unilateral nerve-sparing RALP did not seem to have a negative influence on sexual function and did not seem to compromise oncological safety compared with primarily performed and successful unilateral nerve-sparing RALP.

Neoadjuvant chemotherapy alone or combined with trans-arterial therapies for downstaging unresectable intrahepatic cholangiocarcinoma to surgical resection: a narrative review

Intrahepatic cholangiocarcinoma (ICCA) incidence has been rising in the last few decades. Currently, hepatic resection is the only curative treatment for ICCA, and there is a lack of evidence supporting the use of preoperative treatment. A narrative review was conducted to analyze the available literature published on the role of neoadjuvant chemotherapy (CHT), either alone or combined with intra-arterial therapies (IAT), for downstaging unresectable ICCA to surgical resection. Most of the studies included in this review showed that secondary resection was associated with improvement in overall survival. In particular, studies analyzing CHT alone reported the highest conversion rate ranging from 20% to 57.1%, confirming that systemic treatment may yield the best results, and therefore, it should always be included as part of the neoadjuvant protocol. Among all the IATs, the longest overall survival reported was after CHT plus hepatic artery infusion, 25 months. Downsizing neoadjuvant multimodal approach, including combined systemic therapy with IAT, might improve the long-term outcomes of unresectable patients and expand surgical indications. However, randomized controlled trials are necessary to confirm their effectiveness.

Optimal number of lymph node stations associated with improved survival among patients with non-small cell lung cancer (NSCLC).

8571 Background: Good quality pathologic nodal evaluation is associated with improved long-term survival in NSCLC after surgical resection. However, there is no universal definition of quality. We examined the association between number of lymph node stations (NLNS) sampled and overall survival. Methods: We examined the population-based Mid-South Quality of Surgical Resection (MS-QSR) cohort, excluding patients with neoadjuvant therapy, positive margins, and secondary resections. We summarized demographic and clinical characteristics with appropriate statistics. We employed four Cox regression models: 1) including NLNS as the only predictor; 2) model 1, adjusting for age, sex, histology, clinical stage, extent of resection, and surgical technique; 3) examined the impact of pathologic staging (pStage in 3 groups: IA/IB[&lt;4cm tumor size]; IB[&gt;4cm]/II/IIIA[pN2-]; pN2]) by modeling interaction with pStage and NLNS; 4) model 3 plus adjustments (no clinical stage). In a cut point analysis to identify the optimal NLNS for improved survival, we dichotomized the NLNS for cut points 0 to 12. Hazard ratios (HR) were calculated (as above) and plotted for each dichotomization. Results: The 3916 eligible patients were 21% Black, 54% male, 15% on Medicaid and 49% Medicare; 84% and 85% had clinical and pathologic stage I/II, respectively; 84% had no invasive staging; 84% had a PET-CT scan. For every additional lymph node station sampled, the HR decreased by 0.94 (95% confidence interval: 0.92, 0.96). After adjustments, the HR remained significant (Table). Our pStage cohorts comprised of 2474 (64%) IA/IB[&lt;4cm]; 1080 (28%) IB[&gt;4cm]/II/IIIA[pN2-]; and 290 (8%) pN2+. Once stratified, HRs remained significant among those with early stage but not for pN2+ (Table). When further adjusted, only pStage IA/IB[&lt;4cm] patients had a significant HR, 0.94 (0.91, 0.97). The cut point analysis indicated sequential survival improvement up to ≥ 7 total stations sampled, consistently across all models/adjustments. Conclusions: The number of lymph node stations examined is directly associated with survival after lung cancer resection. Examination of a total of 7 intrapulmonary, hilar and mediastinal stations seems optimal. Hazard ratios (95% confidence intervals) for modeling hazards as a function of lymph node stations sampled (model 1), further adjusted for age, sex, histology, clinical stage, extent of resection, and surgical technique (model 2), including interaction with pathologic stage with no adjustments (model 3), and interaction with pathological stage with adjustments (no clinical stage) (model 4). [Table: see text]

Impact of induction therapy in locally advanced intrahepatic cholangiocarcinoma

IntroductionAfter local or systemic treatment, a small number of patients with primarily unresectable intrahepatic cholangiocarcinoma (ICC) may benefit from secondary resection. This study aimed to analyze the oncological outcome of patients who underwent radical surgery after preoperative treatment. MethodsFrom 2000 to 2021, all patients who underwent curative-intent liver resection for ICC in three tertiary centers were selected. Patients were divided into two groups: upfront surgery (US) and preoperative treatment (POT). Oncologic data (preoperative treatment, histologic data, adjuvant chemotherapy, overall survival, and recurrence-free survival) were compared between the two groups. ResultsAmong 198 included patients, 31 (15.7%) received POT including chemotherapy (74.2%), radioembolization (12.9%), chemoembolization (9.7%), or combined radiotherapy and chemotherapy (3.2%). Major resection was performed in 156 (78.8%) patients, and 53 (26.8%) had vascular and/or biliary reconstruction. Histological findings were similar between US and POT group and were not affected by the type of POT. After a median follow-up of 23 months, recurrence rate (58.1% POT vs. 55.1% US, p = 0.760) and type were similar between groups. Recurrence-free survival at 1 and 3 years (41.9% and 22.6% vs. 46.7 and 21.6% in the POT and US, respectively, p = 0.989) and overall survival at 1 and 3 years (77.4% and 32.3% vs. 69.5% and 34.7% in the POT and US respectively, p = 0.323) were similar and independent of the POT type. ConclusionAfter POT, downstaged patients who underwent curative-intent resection for initially unresectable ICC have similar long-term outcomes as those undergoing upfront surgery.

Effectiveness and safety of capecitabine, irinotecan and panitumumab in advanced colorectal cancer.

Capecitabine, irinotecan, and panitumumab (CAPIRI-P) is a controversial regimen for metastatic colorectal cancer, with concerns regarding the efficacy and toxicity. However, its toxicity profile has been improved with dose reduction, and concerns regarding efficacy have been extrapolated from other trials. This retrospective study reports the real-world effectiveness and safety of modified CAPIRI-P (mCAPIRI-P). Advanced colorectal cancer patients receiving mCAPIPI-P in the first-line setting between July 2019 and December 2021 were analyzed. The progression-free survival on treatment (PFSOT) and overall survival (OS) were estimated using the Kaplan-Meier method, and the association with clinical and disease factors was analyzed using the Cox regression model. Serial changes in carcinoembryonic antigen (CEA) level and treatment toxicity were also evaluated. A total of 106 patients were included, of whom 97 (92%) and 31 (29%) had left-sided primary and unresectable liver-only disease, respectively. The median PFSOT and OS were 15.4 (95% CI 12.5-18.3) and 25.5 (95% CI 17.6-33.4) months, respectively. Sixteen (51.6%) and 10 (32.3%) liver-only disease patients underwent secondary liver treatment and R0 resection, respectively. In multivariable Cox regression, CEA responders (PFSOT: HR 0.53) and CEA normalization (PFSOT: HR 0.27; OS: HR 0.28) were independent favorable prognostic factors for PFSOT and OS. Grade ≥3 toxicity rate was 43%, mainly related to uncomplicated hematological toxicities. The real-world data show that mCAPIRI-P is safe and effective as the first-line treatment regimen for RAS wild-type advanced colorectal cancer and warrants further study.

PD27-04 AURORA A 3D MODEL GUIDED NERVE SPARING TECHNIQUE IN ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 Apr 2023PD27-04 AURORA A 3D MODEL GUIDED NERVE SPARING TECHNIQUE IN ROBOTIC RADICAL PROSTATECTOMY Christian Engesser, Brantner Philip, Julian Gehweiler, Matthias Walter, Christian Wetterauer, Helge Seifert, Svetozar Subotic, Cyrill Rentsch, Lukas Bubendorf, Tatjana Vlajnic, Abolfazl Hosseini, and Jan Ebbing Christian EngesserChristian Engesser More articles by this author , Brantner PhilipBrantner Philip More articles by this author , Julian GehweilerJulian Gehweiler More articles by this author , Matthias WalterMatthias Walter More articles by this author , Christian WetterauerChristian Wetterauer More articles by this author , Helge SeifertHelge Seifert More articles by this author , Svetozar SuboticSvetozar Subotic More articles by this author , Cyrill RentschCyrill Rentsch More articles by this author , Lukas BubendorfLukas Bubendorf More articles by this author , Tatjana VlajnicTatjana Vlajnic More articles by this author , Abolfazl HosseiniAbolfazl Hosseini More articles by this author , and Jan EbbingJan Ebbing More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003305.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nerve-sparing (NS) procedures in radical prostatectomy have gained importance as they show better functional outcomes in terms of erectile function. It is recommended that the neurovascular bundle (NVB) should be removed if residual tumor is suspected. Alternatively, intraoperative fresh frozen section (FFS) may help in this decision. However, standard FFS techniques do not provide a direct visual impression of the positive surgical margin (PSM) for guidance regarding secondary resection (SR) at the GNB. We therefore intend to optimize precision for SR using a personalized 3D printed prostate model in robotic-assisted radical prostatectomy (RARP). METHODS: We prospectively included 100 patients in which NS-RARP was performed between September 2018 and August 2021 at the University Hospital Basel and Cantonal Hospital Basel-Land. Image data of the preoperative pelvic MRI scan were used to render and print a personalized 3D prostate model. PIRADS lesions (>grade 3) and potential capsular involvement were color-characterized in the model. The model was used during surgery to allow the pathologist to mark a positive surgical margin (PSM) on the model and to help guide the surgeon for selective SR (SSR). Functional outcome was assessed using IIEF-5 prior and one year after surgery. RESULTS: 17.0% (17/100) of all patients had PSM in final histology with a rate of 15.4% in pT2 and 25% in pT3 tumors, respectively. PSM was identified during FFS in 23.0% (23/100) of patients, and SSR achieved a tumor-free surgical margin on final histology in 19 of these 23 patients (82.6%), with SSR containing tumor tissue in 9 of 23 patients (39.1%). Intraoperative PSM was associated with a PIRADS lesion in 11 patients (48%). PSA was undetectable 6 weeks postoperatively in 18/19 (94.7%) patients with successful SSR but only in 76.5 % of patients with PSM in final pathology. False negative rate of FFS was 16.9% (13/77). Despite 6/8 (75%) patients with biochemical recurrence (BCR) having a PSM successfully converted, only 1 had imageproven local recurrence in PSMA PET CT. CONCLUSIONS: 3D printed prostate models are a promising approach to precision SSR and improve communication between surgeons and pathologists. Successful conversion rates (82.6%) were similar to procedures using NEUROSafe (86%). The sensitivity of MRI, the false-negative rate of conventional FFS and cost effectiveness remain critical limitations. Source of Funding: Intuitive Surgical © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e742 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Engesser More articles by this author Brantner Philip More articles by this author Julian Gehweiler More articles by this author Matthias Walter More articles by this author Christian Wetterauer More articles by this author Helge Seifert More articles by this author Svetozar Subotic More articles by this author Cyrill Rentsch More articles by this author Lukas Bubendorf More articles by this author Tatjana Vlajnic More articles by this author Abolfazl Hosseini More articles by this author Jan Ebbing More articles by this author Expand All Advertisement PDF downloadLoading ...

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing.

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown. To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing. Case series; Level of evidence, 4. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared. Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR. Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status (Expanded Prostate Cancer Index Composite, EPIC-26).

The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy (RALP) on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26. This is a prospective evaluation of 232 patients undergoing RALP between September, 2019 and September, 2020. Urinary continence status and postoperative incontinence (pad usage) were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires. Patients were categorized according to their surgical approach and outcome into the following groups: successful nerve sparing (NS), primarily without nerve sparing (prim. NNS), and no nerve sparing by secondary resection (NNS by SR). The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction. Urinary continence status 12 months after RALP differed significantly between the NS and prim. NNS (p = 0.0071) and the NS and NNS by SR (p = 0.0076) groups. There was no significant difference between the prim. NNS and NNS by SR (p = 0.53) groups. Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle (p = 0.14). Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence, regardless of whether a non-nerve-sparing result was planned or reached through SR. Instead, preservation of neurovascular bundle seems to lead to better long-term continence rates.

Abstract No. 546 Pre-Operative Portal Vein Embolization to Promote Primary and Secondary Liver Tumor Resection

Abstract No. 546 Pre-Operative Portal Vein Embolization to Promote Primary and Secondary Liver Tumor Resection

Effect of dynamic circulating tumor DNA minimal residual disease detection on recurrence surveillance and second resection rate after curative intent resection of colorectal liver metastasis: A prospective cohort study.

242 Background: Recurrence rates after curative intent resection of colorectal cancer liver metastases (CRLM) are nearly 50%. Standard of care surveillance includes intensive computed tomographic (CT) imaging and CEA measurements. However, recurrence detection often happens too late to resume a second resection. Previous studies have shown that circulating tumor DNA (ctDNA) detection, as a biomarker of minimal residual disease (MRD), is a robust prognostic factor for patients with colorectal cancers. Here, we performed a prospective study to explore the potential use for improving postoperative CRLM surveillance by dynamic ctDNA detection and its impact on the second resection of recurrent patients. Methods: Enrolled patients received curative intent resection of CRLM and were confirmed at the status of no evidence of disease (NED) by CT about one month after surgery. All patients received stand-of-care postoperative surveillance and serial plasma samples were collected, including presurgical and postsurgical samples (4-6 weeks after surgery) and every 3rd month until relapse or up to 24 months after resection. A personalized tumor-informed assay (Signatera/HuaJianwei bespoke multiplex-PCR NGS) was used to quantify ctDNA in plasma samples. Results: A total of 318 plasma samples from 60 patients recruited from July 2020 to July 2021 were included in our analysis. Twenty-five (41.6%) patients received neoadjuvant chemotherapy, and 46 patients (76.7%) received adjuvant chemotherapy after surgery. The median follow-up time was 18.0 months (range, 7.5 to 25.3 months). ctDNA was detectable in 58/60 (96.7%) patients before surgery, in 35/60 (58.3%) patients after surgery, and in 23/58 (39.7%) patients at the end of treatment (EOT). Patients with ctDNA/MRD positive status post-surgery or EOT experienced a significant shorter recurrence-free survival (RFS) than patients with negative ctDNA/MRD [hazard ratio (HR) 4.2; P &lt; 0.001 and HR 9.8; P &lt; 0.001]. The recurrence rate in MRD-positive patients (aka. positive predictive value, PPV) was 91.4% (32/35) at post-surgery and 91.3% (21/23) at EOT, respectively. In 93.0% of postoperative MRD-positive patients, ctDNA detected early relapse with a lead time up to 9.0 months (median 3.4 months) compared with standard radiological imaging. Among 40 patients with recurrence, the total secondary resection rate was 52.5% (21/40) with 40% (21/40) cases reached secondary NED. While among 24 recurrent cases with only liver metastases, the secondary resection rate was 66.7% (16/24) with 58.3% (14/24) cases reached secondary NED. Conclusions: Postoperative ctDNA status is strongly associated with shorter RFS. Serial ctDNA monitoring assists early detection of relapse, and therefore, improves patient outcomes by secondary resection. Clinical trial information: ChiCTR2000035677 .

Liquid biopsy assay to triage patients with high-risk non-muscle-invasive bladder cancer for secondary transurethral resection of bladder tumors

Liquid biopsy assay to triage patients with high-risk non-muscle-invasive bladder cancer for secondary transurethral resection of bladder tumors

Modified (m)-FOLFOXIRI plus cetuximab versus m-FOLFOXIRI plus bevacizumab as initial treatment of patients with unresectable RAS and BRAF wild-type metastatic colorectal cancer: Survival analysis of the phase II randomized DEEPER trial by JACCRO.

120 Background: Triplet regimen, FOLFOXIRI, plus bevacizumab is considered as one of standard first-line treatments in metastatic colorectal cancer (mCRC). On the contrary, FOLFOXIRI plus anti-EGFR antibody has been shown to be a promising regimen with greater depth of response (DpR) in patients with RAS wild-type mCRC from the VOLFI and MACBETH trials (J Clin Oncol 2019, JAMA Oncol 2018). We therefore performed a randomized phase II study, DEEPER trial (JACCRO CC-13) [NCT02515734], to investigate the efficacy and safety of cetuximab (cet) vs. bevacizumab (bev) in combination with modified (m)-FOLFOXIRI in previously untreated mCRC patients with RAS wild-type tumors. We have reported a significantly better DpR of m-FOLFOXIRI plus cet compared to bev as the primary endpoint (Tsuji A, et al. ASCO 2021). Methods: This trial was a randomized phase II trial to evaluate modified (m)-FOLFOXIRI (irinotecan 150 mg/m2, oxaliplatin 85 mg/m2, 5-FU 2400 mg/m2) plus cet vs. bev as initial treatment in terms of DpR during the entire course as the primary endpoint in 360 patients with RAS wild-type mCRC. The aim of the trial was to show that median DpR of cet arm was more than 12.5% higher than bev arm, with a power of 85% at a significance level of 0.05, in per protocol set (PPS) consisted of patients evaluable for the DpR. Secondary endpoints included progression-free survival, overall survival, overall response rate, early tumor shrinkage rate, secondary resection rate, and toxicity. A total of 359 patients were enrolled between July 2015 and June 2019. For the PPS (median age 65y, 64% male, PS0/1: 91%/9%, left/right primary: 84%/16%), 159 and 162 patients were randomly assigned to the cet and bev arms, respectively. Clinical outcomes will be analyzed according to primary tumor sidedness which is included in the stratification factor. Additionally, we will collect data of BRAF status, and analyze the clinical outcomes in mCRC patients with RAS/ BRAF wild-type tumors and/or left-sided tumors. Pre-planned survival analysis will be performed to compare the two treatment arms at the time of 3 years after last patients’ enrollment using a log-rank test. All statistical tests are two-sided, and P values ≤ 0.05 are deemed significant. Statistical analyses will be performed using SAS version 9.4. Clinical trial information: NCT02515734 .

Recurrent Hepatic Encephalopathy Complicated with Hepatic Myelopathy after Secondary Resection with Hepatocellular Carcinoma: A Case Report

Hepatocellular carcinoma (HCC) is celerity increasing throughout the world with a high mortality rate. The progression of HCC in patients is induced mainly by cirrhosis and hepatitis. Surgical treatment has played a crucial role for HCC therapy, especially at the very early/early HCC stage. It is widespread for patients to experience a postoperative complication after surgery, including Hepatic encephalopathy/myelopathy. This case report disclosed in details a patient diagnosed and treated in our hospital suffered from recurrent hepatic encephalopathy along with hepatic myelopathy due to the secondary surgical resection of HCC.

Stereotactic MR-Guided Adaptive Radiotherapy for Pancreatic Tumors: Updated Results of the Montpellier Prospective Registry Study.

Stereotactic MR-guided Adaptive RadioTherapy (SMART) is a novel process to treat pancreatic tumors. We present an update of the data from our prospective registry of SMART for pancreatic tumors. After the establishment of the SMART indication in a multidisciplinary board, we included all patients treated for pancreatic tumors. Primary endpoints were acute and late toxicities. Secondary endpoints were survival outcomes (local control, overall survival, distant metastasis free survival) and dosimetric advantages of adaptive process on targets volumes and OAR. We included seventy consecutive patients in our cohort between October 2019 and April 2022. The prescribed dose was 50 Gy in 5 consecutive fractions. No severe acute SMART related toxicity was noted. Acute and late Grade ≤ 2 gastro intestinal were low. Daily adaptation significantly improved PTV and GTV coverage as well as OAR sparing. With a median follow-up of 10.8 months since SMART completion, the median OS, 6-months OS, and 1-year OS were 20.9 months, 86.7% (95% CI: (75-93%), and 68.6% (95% CI: (53-80%), respectively, from SMART completion. Local control at 6 months, 1 year, and 2 years were, respectively, 96.8 % (95% CI: 88-99%), 86.5 (95% CI: 68-95%), and 80.7% (95% CI: 59-92%). There was no grade &gt; 2 late toxicities. Locally Advanced Pancreatic Cancers (LAPC) and Borderline Resectable Pancreatic Cancers (BRPC) patients (52 patients) had a median OS, 6-months OS, and 1-year OS from SMART completion of 15.2 months, 84.4% (95% CI: (70-92%)), and 60.5% (95% CI: (42-75%)), respectively. The median OS, 1-year OS, and 2-year OS from initiation of induction chemotherapy were 22.3 months, 91% (95% CI: (78-97%)), and 45.8% (95% CI: (27-63%)), respectively. Twenty patients underwent surgical resection (38.7 % of patients with initially LAPC) with negative margins (R0). To our knowledge, this is the largest series of SMART for pancreatic tumors. The treatment was well tolerated with only low-grade toxicities. Long-term OS and LC rates were achieved. SMART achieved high secondary resection rates in LAPC patients.

Confocal laser microscopy for assessment of surgical margins during radical prostatectomy.

To evaluate the feasibility of confocal laser microscopy (CLM) for intraoperative margin assessment as faster alternative to neurovascular structure-adjacent frozen-section examination (NeuroSAFE) during robot-assisted radical prostatectomy (RARP). Surgical margins were assessed during 50 RARP procedures in patients scheduled for NeuroSAFE. Posterolateral sections were cut and imaged with CLM and further processed to conform with the NeuroSAFE protocol. Secondary resection (SR) was performed in case a positive surgical margin (PSM) was observed with NeuroSAFE. Afterwards, the CLM images were non-blinded assessed for the presence of PSMs. The accuracy of both NeuroSAFE and CLM was compared with conventional histopathology. Agreement for detection of PSMs between NeuroSAFE and CLM was evaluated with Cohen's kappa coefficient. Procedure times were compared with a Wilcoxon signed-ranks test. In total, 96 posterolateral sections of RP specimens were evaluated for the presence of PSMs. CLM identified 15 (16%) PSMs and NeuroSAFE identified 14 (15%) PSMs. CLM had a calculated sensitivity, specificity, positive predictive value and negative predictive value of 86%, 96%, 80% and 98% respectively for the detection of PSMs compared to definite pathology. After SR, residual tumour was found in six of 13 cases (46%), which were all identified by both techniques. There was a substantial level of agreement between CLM and NeuroSAFE (κ = 0.80). The median procedure time for CLM was significantly shorter compared to NeuroSAFE (8 vs 50 min, P< 0.001). The main limitation of this study was the non-blinded assessment of the CLM images. Compared to NeuroSAFE, CLM is a promising technique for intraoperative margin assessment and is able to reduce the time of intraoperative margin assessment.

Soft tissue reconstruction strategy for sacral tumor resection

Objective: To investigate the clinical strategy and effect of soft tissue reconstruction after sacral tumor resection in different planes. Methods: The data of 27 consecutive patients who underwent primary or secondary sacral tumor resection and soft tissue reconstruction from June 2012 to June 2021 at Dongnan Hospital of Xiamen University (the 909th Hospital) were retrospectively analyzed. There were 11 males and 16 females, aged (M(IQR)) (46.2±23.6) years (range: 16 to 72 years). Sacrospinous muscle, gluteus maximus and vertical rectus abdominis muscle flap were selected for soft tissue reconstruction according to the tumor site and the size of tissue defect. the postoperative follow-up was performed. The operative methods, intraoperative conditions, complications and disease outcomes were summarized. Results: Among the 27 patients with sacral tumor, the tumor plane was located in S1 in 8 cases, S2 in 5 cases and S3 or below in 14 cases. There were 12 patients with tumor volume≤400 cm3 and 15 patients with tumor volume>400 cm3. Operation time was 100(90) minutes (range: 70 to 610 minutes), intraoperative blood loss was 800(1 600) ml (range: 400 to 6 500 ml). Soft tissue reconstruction was performed by transabdominal rectus abdominis transfer repair in 2 cases, extraperitoneal rectus abdominis transfer repair in 1 case, gluteus maximus transfer repair in 5 cases, gluteus maximus advancement repair in 13 cases, and sacrospinous muscle transfer repair in 6 cases. Postoperative complications occurred in 6 cases, including 1 case of incision infection, 4 cases of skin border necrosis, and 1 case of delayed infection due to fracture of internal fixator 3 years after operation, all of them were cured. The follow-up time was (35±21) months. Among the patients, 6 patients had recurrence, 2 patients with Ewing sarcoma died of lung metastasis 1 year after operation, 4 patients with metastatic cancer died of primary disease, and the remaining patients survived without disease. Conclusion: Choosing different soft tissue reconstruction strategies according to sacral tumor location and tissue defect size can effectively fill the dead space after sacral tumor resection, reduce postoperative complications and improve the prognosis of patients.

Application of liver venous deprivation in secondary hepatic resection of primary liver cancer

Objective: To investigate the efficacy and safety of liver venous deprivation (LVD) before secondary resection of primary liver cancer. Methods: 56 patients with advanced primary liver cancer who were not suitable for primary resection in Liver Surgery Department of Xinxiang Central Hospital from January 2018 to January 2019 were analyzed retrospectively. They were divided into liver vein deprivation group (LVD group: LVD+ PVE, n=26) and portal vein embolization group (PVE group, n=30). The dynamic changes of liver reserve function and future liver remnant volume (FLR-V), R0 resection rate, surgical complications, postoperative recurrence rate and overall survival rate of two groups before and after LVD/PVE were compared. Results: The success rate of puncture and embolization in LVD group and PVE group was 100%. There were no grade Ⅳ complications, and there was no significant difference of grades Ⅰ, Ⅱ and Ⅲ complications between the groups (P=0.808). The FLR-V of LVD group before embolization, 7, 14 and 21 days after embolization was (493.1±25.8), (673.2±56.1), (779.5±81.6) and (853.3±85.2) cm(3), respectively. The FLR-V of PVE group before embolization, 7, 14 and 21 days after embolization were (502.4±20.1), (688.6±43.9), (656.8±73.7) and (563.5±69.1) cm(3), respectively. There was no significant difference in FLR-V between the two groups before and 7 days after embolization (P>0.05). The FLR-V of LVD group was higher than that of PVE group at 14 and 21 days after embolization (P<0.01). The preparation time of LVD group was (20.4±6.3) days, which was shorter than that of PVE group [(31.5±8.8) days, P=0.045]. The rate of secondary hepatectomy was 92.3% (24/26), which was higher than that of PVE group [70.0% (21/30), P=0.036]. The R0 resection rate was 87.5% (21/24), which was higher than that of the PVE group [57.1% (12/21), P=0.022]. However, there were no significant differences in surgical methods, operation time, intraoperative blood loss, Clavien-Dindo complication grade and length of hospital stay between the two groups (P>0.05). After hepatectomy, the median recurrence time and median survival time of LVD group were 12.6 months and 21.3 months, respectively, which were longer than those of PVE group (9.4 months and 13.5 months, respectively, P<0.01). Conclusions: For patients with advanced liver cancer who are not suitable for primary hepatectomy, preoperative LVD can significantly increase FLR-V, improve the resection rate of secondary surgery, shorten the preparation time of two operations, and do not increase surgical complications. Moreover, patients with LVD can improve the R0 resection rate of secondary surgery. The postoperative recurrence time and overall survival rate of patients with LVD are better than those of patients with PVE, and LVD has a good long-term effect.

Interest of arthroscopic distal clavicular resection in shoulder pain after rotator cuff repair and healing

To evaluate outcomes of secondary distal clavicle resection (DCR) in patients that had failed conservative treatment of symptomatic ACJ arthropathy following isolated rotator cuff repair (RCR) with complete tendon healing. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥ 6 m following index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included subjective shoulder value (SSV) and pain at rest. Clinical assessment at > 12 months after DCR included SSV, pain at rest, Constant-Murley score and range of motion. Study design: case series, level III. Of the initial cohort of 23 patients, 5 were lost to follow-up, leaving 18 patients aged 53.3 ± 7.6 years (range, 39–68) for outcome assessment. None of the patients had complications or ACJ instability following DCR. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV improved to 76.1 ± 20.2, the pain at rest decreased to 2.8 ± 1.9. At final follow-up, the Constant-Murley score was 64.7 ± 20.5. Secondary DCR for symptomatic ACJ arthropathy following isolated RCR reduced pain in only 67% of patients, though 94% were satisfied and would undergo secondary DCR again. It is worth noting that residual pain is common following RCR, which does not always restore normal shoulder function.

Residual and Recurrent Spinal Cord Cavernous Malformations: Outcomes and Techniques to Optimize Resection and a Systematic Review of the Literature.

Intramedullary spinal cord cavernous malformations (SCCMs) account for only 5% of overall cavernous malformations (CMs). The occurrence of recurrent or residual SCCMs has not been well discussed, nor have the technical nuances of resection. To assess the characteristics of residual SCCMs and surgical outcomes and describe the techniques to avoid leaving lesion remnants during primary resection. Demographic, radiologic, intraoperative findings and surgical outcomes data for a cohort of surgically managed intramedullary SCCMs were obtained from an institutional database and retrospectively analyzed. A systematic literature review was performed using PRISMA guidelines. Of 146 SCCM resections identified, 17 were for residual lesions (12%). Patients with residuals included 13 men and 4 women, with a mean age of 43 years (range 16-70). All patients with residual SCCMs had symptomatic presentations: sensory deficits, paraparesis, spasticity, and pain. Residuals occurred between 3 and 264 months after initial resection. Approaches for 136 cases included posterior midline myelotomy (28.7%, n = 39), pial surface entry (37.5%, n = 51), dorsal root entry zone (27.9%, n = 38), and lateral entry (5.9%, n = 8). Follow-up outcomes were similar for patients with primary and residual lesions, with the majority having no change in modified Rankin Scale score (63% [59/93] vs 75% [9/12], respectively, P = .98). SCCMs may cause significant symptoms. During primary resection, care should be taken to avoid leaving residual lesion remnants, which can lead to future hemorrhagic events and neurological morbidity. However, satisfactory results are achievable even with secondary or tertiary resections.