Tumor Unresectability Research Articles

Современные возможности лечения распространенной гепатоцеллюлярной карциномы у детей: клиническое наблюдение и обзор литературы

Hepatocellular carcinoma (HCC) is a rare primary malignant tumor of the liver in childhood accounting for 20% to 33% of cases. Important prognostic factors are the presence of distant metastases and tumor unresectability. Currently there are no proven curative treatment options for pediatric patients with the abovementioned unfavorable prognostic factors. Authors represent a clinical case report of the HCC development with intra-abdominal metastases in an 8 years old pediatric patient. The Lenvatinib therapy with previous cytostatic therapy combined with sorafenib allowed the 6 months control over the tumor process whilst maintaining reasonably good quality of life of a patient.

Patient Experiences After Aborted Cancer Surgery: A Qualitative Study.

Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used-both inductive and deductive methods-and iteratively identifying themes until saturation was reached. Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic (n = 9), cholangiocarcinoma (n = 3), hepatocellular carcinoma (n = 1), gallbladder (n = 1), and neuroendocrine (n = 1). The most common reasons for aborting surgery included local tumor unresectability (n = 8) and occult metastatic disease (n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Aborted cancer surgery at a single tertiary cancer center: Rates, reasons, and outcomes

BackgroundSurgical resection is typically necessary for curative-intent treatment of most solid organ cancers. However, even with meticulous preoperative evaluation, operative procedures are occasionally aborted. The incidence, outcomes, and long-term prognoses of aborted cancer surgery have not been thoroughly investigated. MethodsAll oncologic operations performed at a single tertiary cancer center between 2011–2021 were retrospectively queried; natural language processing of operative reports was used to identify aborted cancer surgeries. Surgical indications, clinicopathologic characteristics, short- and long-term outcomes, and palliative care involvement were retrospectively reviewed from the electronic medical record. ResultsOverall, 345 patients underwent aborted cancer surgery for a rate of 36 patients per year. The most common cancers were pancreatic (28%), biliary (14%), and colorectal (9%). The most commonly aborted operations were pancreatoduodenectomy (34%) and hepatectomy (22%). Most operations were aborted due to unanticipated tumor unresectability (47%) and occult metastatic disease (43%). Sixty percent of patients returned to cancer-directed therapy; 9% underwent successful reattempt at resection. The median overall survival of all patients after aborted surgery was 13.6 months (95% confidence interval, 11.2–16.0 months). Those who returned to oncologic therapy had longer survival (18.6 months vs 5.4 months, P < .001). Palliative care consultation was received by 34% and 13% of patients overall and within 30 days of surgery, respectively. ConclusionAborted cancer surgery was associated with poor outcomes, particularly in patients with aggressive cancer types and those who did not receive further cancer-directed therapy. Future studies should identify interventions such as palliative care consultation that may improve patient-centered outcomes.

The impact of multimodality therapies in marginally inoperable soft tissue sarcomas (STS): The Toronto Sarcoma Program (TSP) experience.

11548 Background: The mainstay therapy of operable STS remains surgery, which may include (neo)adjuvant therapies. Within the TSP, marginally inoperable STS are often treated with sequential chemo (CTX) and radiation (RT) therapy, followed by surgery (SX). Herein we present our experience of multi-modality therapies for marginally inoperable STS patients (pts). Methods: This was a dual-center, single program, retrospective review. Pts were included if deemed to have marginally inoperable primary or recurrent STS, as determined at the TSP tumor board. Pts included must have had CTX with the intent of having RT and SX after. Pts demographics, treatment details and clinical outcomes data were collected. Relapse free survival (RFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Multivariate analysis of the influence of disease characteristics and treatment on outcomes was assessed using Cox regression. Results: From June 2005 to May 2019, 75 pts were identified. Median age was 52 years (range 16-72). Pts were predominantly male (55%). Histological subtypes included dedifferentiated liposarcoma (29%), leiomyosarcoma (27%), synovial sarcoma (19%) and others (25%). Primary tumor was located in the retroperitoneum (48%), extremity (23%), pelvis (12%), thorax (9%), and other sites (8%). All pts had doxorubicin and ifosfamide CTX (median 4 cycles; range 1-6), while RT dose delivered was 50.4Gy/28 fractions in 58 (77%) of cases. Twenty three pts (31%) achieved partial response, 40 pts (53%) had stable disease and 12 pts (16%) had progression of disease (PD) on CTX, of which half (8%) did not undergo further treatment. Nine pts (12%) underwent CTX followed by SX due to significant response, 9 pts (12%) underwent CTX and RT without SX due to persistent tumor unresectability or PD. The final 50 pts (67%) completed multi-modality treatment (CTX, RT &amp; SX). Overall, 59 pts (79%) had SX; negative margins were achieved in 53 (71%). 19 pts (25%) had postoperative complications, causing death in 2 pts (2.7%). With a median follow-up of 72 months, median RFS and OS were 26.9 months (95% CI: 0-86.0), and 65 months (95% CI: 13.5-116.4). Extremity location was associated with superior RFS (median not reached [NR], HR 0.28 95% CI 0.09-0.83, p = 0.022), and OS (median NR, HR 0.29 95% CI 0.09-0.90, p = 0.032). Receipt of RT was associated with superior RFS (median NR, HR 0.23 95% CI 0.10-0.52, p &lt; 0.001); and OS (median NR, HR 0.21 95% CI 0.09-0.50, p &lt; 0.001). Pts who had PD after CTX were associated with poor outcomes - RFS (median 4.7 months, HR 2.03 95% CI 0.61-6.76, p = 0.24); and OS (median 21.9 months, HR 2.48 95% CI 0.73-8.47, P = 0.144). Conclusions: Multi-modality approach resulted in successful resection for most pts with marginally inoperable STS. Extremity location and RT administration were associated with better RFS and OS, while progression on CTX confers worse survival outcomes.

Preoperative CA 19-9 and the Yield of Staging Laparoscopy in Patients with Radiographically Resectable Pancreatic Adenocarcinoma

Staging laparoscopy for patients with radiographically resectable pancreatic adenocarcinoma has been reported to yield an 8-15% finding of unresectable disease. Factors associated with the likelihood of subradiographic unresectable disease have not been clearly defined. A prospectively maintained pancreatic database was reviewed and patients were identified who underwent staging laparoscopy for radiographically resectable pancreatic adenocarcinoma between January 2000 and December 2006. Preoperative carbohydrate antigen 19-9 (CA 19-9) values were assessed for their association with the presence of subradiographic unresectable disease. Four hundred ninety-one patients underwent staging laparoscopy. Resection was performed in 80% (n = 395). Of the 96 patients with unresectable disease, 75 (78%) had metastases either in the liver (n = 60) or peritoneum (n = 15). Preoperative CA 19-9 values were available for 262 of the 491 patients. Fifty-one of these patients had unresectable disease, of which 78% were due to distant disease. The median preoperative CA 19-9 value for patients who underwent resection was 131 U/ml versus 379 U/ml for those patients with unresectable disease (P = 0.003). A receiver operating characteristics (ROC) curve was developed for preoperative CA 19-9 value and tumor resectability. The statistically optimal cutoff value was determined to be 130 U/ml. Unresectable disease was identified in 38 of the 144 patients (26.4%) with a preoperative CA 19-9 >or= 130 U/ml, and in 13 of the 118 patients (11%) with a CA 19-9 < 130 U/ml (P = 0.003). CA 19-9 values greater than 130 U/ml remained a predictor of tumor unresectability on multivariate regression analysis [hazard ratio (HR) 2.70, 95% confidence interval (CI) 1.34-5.44; P = 0.005]. In this study, preoperative CA 19-9 values were strongly associated with the identification of subradiographic unresectable disease. Preoperative CA 19-9 values may allow surgeons to better select patients for staging laparoscopy.

Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas: In Situ versus Invasive Carcinoma—Surgical Resectability

To retrospectively evaluate computed tomographic (CT) findings in patients with in situ and invasive malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and to evaluate the accuracy for surgical resectability, with surgery and pathologic analysis as the reference standards. Institutional review board approval was obtained, and the informed consent requirement was waived. Forty-six patients with malignant IPMN proved at pathologic examination of the surgically resected specimen (n = 44) or laparotomy (n = 2) underwent surgery after multidetector CT was performed. CT findings were retrospectively evaluated to determine if a pancreatic malignant IPMN tumor was present; to make this determination, CT criteria were used to differentiate in situ from invasive tumors and signs of unresectability (liver metastasis, vascular CT pattern of encasement, or regional lymph node metastasis). The extent of the vascular CT pattern of encasement was recorded for each patient (no obliteration of the fat plane, obliteration of the fat plane of <50%, or obliteration of the fat plane of > or =50%). Statistical analysis was performed with the chi(2) and Student t tests. CT revealed a mural nodule in the pancreatic duct wall in 14 patients with in situ carcinoma and one patient with invasive carcinoma (P < .003). CT revealed an infiltrative pancreatic mass in 17 patients with invasive carcinoma and two patients with in situ carcinoma (P < .02). Of the mural nodules, 93% were seen in patients with in situ carcinoma, whereas 90% of infiltrative pancreatic masses were observed in patients with invasive carcinomas. The positive predictive value of CT for determining resectability was 100%, and the overall accuracy of CT for determining resectability and unresectability was 74%. The positive predictive value of CT for determining unresectability was 17%, mainly owing to overestimation of arterial invasion. CT is helpful in the differentiation of in situ and invasive IPMN. Classic vascular invasion criteria lead to the overestimation of surgical tumor unresectability in patients with malignant IPMN.

Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival. Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes. Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023). For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy.

Preoperative stage and tumor resectability assessment of pancreatic cancer with multi-slice helical CT

仅有约20%的胰腺癌患者在就诊时尚有手术切除的机会.多层螺旋CT对于胰腺癌术前不可切除的阳性预测值较高,而可以切除的阴性预测值相对较低,主要是因为未发现小的肝脏或腹膜转移以及未发现主要血管受侵.注射对比剂后增强扫描的胰腺期及肝脏期对于术前分期及可切除性评价至关重要。

Evaluation of MRI in Diagnosing Hilar Cholangiocarcinoma

Objective: To investigate the clinical application of MRI in the diagnosis and preoperative evaluation of hilar cholangiocarcinoma (HC). Methods: Thirty-four cases of HC were examined with 1.5T super-conduct MR unit. The plain MRI and MRCP were followed by dynamic Gd-DTPA (0.1 mmol/kg) contrast-enhanced scanning, which was repeated at 30 s intervals in the first 3 min with the patient being remained in the same position. Delayed scanning was done at 5, 8, 10, 12 and 15 min respectively. 3DDCE- MRA was performed in arterial and portal venous phase with an additional bolus injection of 15-20 mL Gd-DTPA (0.15-0.20 mmol/kg). The contrast time-signal curve of both the liver and the tumor was drawn from DCE imaging, and both arterial and portal venous phase imaging were reconstructed with MIP. MRI findings were compared with surgical findings and pathology. Results: Hilar lesion, intrahepatic ducts dilatation and disconnect of main hepatic duct were shown in all cases. Thirty-one cases had tumor-delayed enhancement. In 3D-DCE-MRA, spiral artery deformed was displayed in 6 cases, infiltration, encasement or occlusion of portal vein was displayed in 18 cases. The accuracy of assessing tumor unresectability and resectability by preoperative MRI was 95.0% (19/20) and 78.6% (11/14) respectively. The total accuracy rate of MRI assessing was 88.2% (30/34). Conclusion: All-in-one MR, including plain MR, MRCP, MR DCE and 3D-DCE-MRA, can accurately show the lesions and involvement of neighbouring tissues. It was of great value in diagnosis and preoperative evaluation of HC.

Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration of cystic lesions of the pancreas

BACKGROUND: Endoscopic ultrasound and fine-needle aspiration (EUS-FNA) has gained wide acceptance as a modality for the diagnosis and staging of pancreatic cancer. EUS-FNA has also recemly been reported to differentiate benign from malignant cystic lesions of the pancreas. The aim of this study is to establish the accuracy of EUS-FNA in diagnosing cystic lesions when compared to surgical pathology. METHOD: We retrospecnvely analyzed all patients who underwent EUS-FNA of a cystic pancreatic lesion from 10/99 9/02. A positive FNA result was defined by the presence of adenocarcinoma mucin; cytology reported as highly suspicious for adenocarcinoma was also considered positive. Cyst fluid CEA levels were defined as consistent with malignancy if greater than 500 units/ml. Cyst fluid amylase levels were defined as consistent with a benign inflammatory pseudocyst if greater than 5000 IU/L. RESULTS: EUS-FNA was performed on 84 patients with a mean age of 58.9 years. 63% were female patients. Fluid and mucnions material was successfully aspirated from the pancreatic cyst in 73 patients. 24 of the 73 patients underwent surgical resection of the pancreas. 15 of the 24 surgical patients were found to have adenocarcinoma a mucinous neoplasm on final histopathology of the surgical specimen. 14 (93%) of the 15 patients were correctly diagnosed preoperatively by EUS-FNA. 9 of the 24 patients were found to have a nonmalignant diagnosis on final histopathology of the surgical specimen. 3 (30%) were correctly diagnosed either as serous cystadenomas (1) inflammatory pseudocysts (2). 49 of 73 patients did not undergo surgery. EUS-FNA was positive in 21 of these patients; surgery was not performed because of medical co-mothidities, metastatic disease or local tumor unresectability. Clinical follow-up supported advanced cancer in all 2t patients. EUS-FNA suggested benign disease in 28 of the 49 patients; clinical and radiographic follow-up has failed to demonstrate invasive cancer in any of these 28 patients. CONCLUSION: EUS-FNA of pancreatic cystic lesions is an accurate technique for the differentiation of benign and malignant disease. It is the diagnostic procedure of choice in those patients who require a cytological diagnosis of malignancy to allow the delivery of chemotherapy in patients with presumed benign disease (serous cystadenoma pseudocyst) in whom observation is most appropriate.

Vascular Invasion of Klatskin Tumor: Computed Tomography vs Digital Subtraction Angiography in Determining Resectability

Purpose : To compare the accuracy of computed tomography (CT) with that of digital subtraction angiography (DSA) in predicting the resectability of Klatskin tumor on the basis of vascular invasion. Materials and Methods : Twenty-five patients with Klatskin tumor who had undergone laparotomy were in-cluded in this study. In order to assess the surgical resectability of their tumors, the preoperative CT scans and DSA of these patients were retrospectively assessed in terms of vascular invasion. The criteria of unresectability were tumoral invasion of the proper hepatic artery or main portal vein, or simultaneous invasion of the hepatic artery on one side and the other side portal vein. Results : Tumors were unresectable in 13 cases, and resectable in 12. CT and DSA predicted nine and three tumors as unresectable ones, respectively. The sensitivity, specificity, positive predictive value, negative predic-tive value and accuracy of CT in determining whether a tumor was unresectable were 61.5%, 91.7%, 88.9%, 68.8% and 76.0%, respectively. For DSA, the respective figures were 23.1%, 100%, 100%, 54.5% and 60.0%. For the detection of vascular invasion without diameter change, CT was superior to DSA; for the evaluation of vascular anatomy, it was, however, less effective. CT failed to detect small hepatic metastasis (n=2), lymph node metastasis (n=1), variation of the bile duct (n=1), and the distal extent of tumor in the bile duct (n=1), factors which precluded surgical resection. Conclusion : CT is a reliable method for the detection of vascular invasion and tumor unresectability. For the detection of vascular anatomic variation, the combined use of CT and DSA would be helpful.

Carcinoma of the head of the pancreas: evaluation of the pancreaticoduodenal veins with dynamic CT--potential for improved accuracy in staging.

To determine if detection of abnormal dilatation of pancreaticoduodenal veins can improve the accuracy of computed tomographic (CT) staging of pancreatic adenocarcinoma. CT scans obtained during bolus administration of contrast material in 86 patients (aged 34-85 years) with pancreatic head carcinoma were reviewed. The diameter of the small veins that surround the head of the pancreas was measured (normal diameter of gastrocolic trunk, < or = 7 mm; of anterior superior pancreaticoduodenal vein, < or = 4 mm; of posterior superior pancreaticoduodenal vein, < or = 4 mm). Twenty-nine abnormally dilated peripancreatic veins were identified in 22 patients. Twenty-two of these dilated veins were in 16 patients with other CT criteria of tumor unresectability; seven dilated veins were in six patients with tumors deemed resectable at CT. All tumors in these latter six patients were unresectable at surgery. Although dilatation of these small peripancreatic veins without other CT criteria of tumor unresectability is an unusual finding, it may be a reliable sign of unresectable pancreatic carcinoma.

RADIOLOGIC STAGING OF PANCREATIC ADENOCARCINOMA

Dynamic CT currently is the imaging modality of choice for staging of pancreatic carcinoma. It has an accuracy of 72% in predicting tumor resectability and an accuracy of virtually 100% in predicting tumor unresectability. However, it is important that the CT criteria of unresectability be defined for each individual institution. In some hospitals, extended pancreatectomy, including resection of involved major extrapancreatic vessels, contiguous solid or hollow organs, and regional lymph nodes, is performed for pancreatic carcinoma. Thus, these CT findings would not be considered to obviate surgical resection, whereas in other hospitals, surgeons consider tumor spread beyond the gland, particularly vascular involvement, as a contraindication for resection. It is also important to note that enlarged regional lymph nodes that would be included in the resection are not considered to be a CT criteria of unresectability when they occur as an isolated finding. MR imaging, EUS, and angiography have less significant roles compared with CT in the staging of pancreatic carcinoma; however, MR imaging and EUS can be valuable staging techniques in patients in whom an optimal dynamic contrast-enhanced CT cannot be obtained, although angiography now is indicated primarily to provide the surgeon with a vascular roadmap prior to resection or to evaluate patients in whom CT is equivocal.

Adenocarcinoma of the gastroesophageal junction: barium and CT examination.

Seventy-seven patients with adenocarcinoma of the gastroesophageal junction were evaluated with upper gastrointestinal barium studies (single-contrast, 40: double-contrast, 37) and 21 of these had preoperative computed tomography for staging. Single- and double-contrast studies were equally sensitive in detecting exophytic tumors, but double-contrast studies were slightly more sensitive (25 of 26) than single-contrast examinations (21 of 25) in detecting infiltrating tumors. Computed tomography accurately staged 18 (86%) of 21 cases (16 unresectable, two resectable). The most reliable computed tomographic findings of tumor unresectability were metastases (liver, adrenal) and local tumor extension, both found in 10 (48%) of 21 cases, and regional adenopathy, present in eight (38%) of 21 cases. The presence or absence of the periesophageal soft-tissue planes was an unreliable finding and led to both false-positive (two cases) and false-negative (four cases) diagnoses. CT-guided percutaneous fine-needle aspiration biopsy was used successfully in four cases to obtain a cytologic diagnosis of metastatic adenocarcinoma.