Radiomic Cancer Hallmarks to Identify High-Risk Patients in Non-Metastatic Colon Cancer

The study was aimed to develop a radiomic model able to identify high-risk colon cancer by analyzing pre-operative CT scans. The study population comprised 148 patients: 108 with non-metastatic colon cancer were retrospectively enrolled from January 2015 to June 2020, and 40 patients were used as the external validation cohort. The population was divided into two groups—High-risk and No-risk—following the presence of at least one high-risk clinical factor. All patients had baseline CT scans, and 3D cancer segmentation was performed on the portal phase by two expert radiologists using open-source software (3DSlicer v4.10.2). Among the 107 radiomic features extracted, stable features were selected to evaluate the inter-class correlation (ICC) (cut-off ICC > 0.8). Stable features were compared between the two groups (T-test or Mann−Whitney), and the significant features were selected for univariate and multivariate logistic regression to build a predictive radiomic model. The radiomic model was then validated with an external cohort. In total, 58/108 were classified as High-risk and 50/108 as No-risk. A total of 35 radiomic features were stable (0.81 ≤ ICC <  0.92). Among these, 28 features were significantly different between the two groups (p < 0.05), and only 9 features were selected to build the radiomic model. The radiomic model yielded an AUC of 0.73 in the internal cohort and 0.75 in the external cohort. In conclusion, the radiomic model could be seen as a performant, non-invasive imaging tool to properly stratify colon cancers with high-risk disease.

Palliative Surgery or Metallic Stent Positioning for Advanced Gastric Cancer: Differences in QOL

Background and Objectives: Twenty percent of the patients affected with stage IV antropyloric stomach cancer are hospitalized with a gastric outlet obstruction syndrome (GOOS) requiring its resolution to improve the quality of life (QoL). We present our preliminary short- and mid-term results regarding the influence of endoscopic placement of self-expandable metal stent (SEMS) or open stomach-partitioning gastrojejunostomy in QoL. Materials and Methods: In this prospective randomized longitudinal cohort trial, we randomly assigned 27 patients affected with stage IV antropyloric stomach cancer into two groups: Group 1 (13 patients) who underwent SEMS positioning and Group 2 (14 patients) in whom open stomach-partitioning gastrojejunostomy was performed. The Karnofsky performance scale and QoL assessment using the EQ-5D-5L™ questionnaire was administered before treatment and thereafter at 1, 3, and 6 months. Results: At 1-month, index values showed a statistically significant deterioration of the QoL in patients of Group 2 when compared to those of Group 1 (p = 0.004; CI: 0.04 to 0.21). No differences among the groups were recorded at 3-month; whereas, at 6-month, the index values showed a statistically significant deterioration of the QoL in patients of Group 1 (p = 0.009; CI: −0.25 to −0.043). Conclusions: Early QoL of patients affected with stage IV antropyloric cancer and symptoms of GOOS is significantly better in patients treated with SEMS positioning but at 6-month the QoL significantly decrease in this group of patients. We explained the reasons of this fluctuation with the higher risk of re-hospital admission in the SEMS group.

Self-Expandable Metal Stents for Left Sided Colon Obstruction from Diverticulitis. A Single Center Retrospective Series

Background and Objectives: The incidence of diverticulitis is increasing in western countries. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Colonic symptomatic strictures are often treated with segmental colectomy. The aim of our study is to report our experience with Self Expandable Metal Stents (SEMS) placement to relieve sigmoid obstruction secondary to diverticulitis, either as a permanent solution or as a bridge to elective colectomy. Material and Methods: From January 2016 to December 2018, 21 patients underwent SEMS placement for sigmoid obstruction secondary to diverticulitis at our institution. In four patients with poor general conditions, SEMS was considered the definitive form of treatment. In 17 patients, the stent was placed as bridge to elective colectomy. Data were prospectively collected and retrospectively analyzed. Primary outcomes were postoperative mortality and morbidity after SEMS and subsequent elective colectomy. Results: There was no mortality or major morbidity after SEMS placement or subsequent elective colectomy. No stoma was performed. Conclusions: Placement of Colorectal Self Expandable Stent represents a useful tool to relieve obstruction in patients with left-sided colonic diverticulitis. SEMS placement makes it possible to transform an emergency clinical condition into an elective condition, giving time to resolve the inflammation and the infection inevitably associated with complicated diverticulitis.

Current Status of the Self-Expandable Metal Stent as a Bridge to Surgery Versus Emergency Surgery in Colorectal Cancer: Results from an Updated Systematic Review and Meta-Analysis of the Literature

Background: The current use of endoscopic stenting as a bridge to surgery is not always accepted in standard clinical practice to treat neoplastic colonic obstructions. Objectives: The role of colonic self-expandable metal stent (SEMS) positioning as a bridge to resective surgery versus emergency surgery (ES) for malignant obstruction, using all new data and available variables, was studied and we focused on short- and long-term results. Materials and Methods: A systematic review with meta-analysis was performed. PubMed, SCOPUS and Web of Science databases were included. The search comprised only randomized controlled trials (RCTs) investigating the interventions that included SEMS positioning versus ES. The primary outcomes were the rates of overall postoperative mortality, clinical and technical success. The secondary outcomes were the short- and long-term results. Results: A total of 12 studies were eligible for further analyses. A laparoscopic colectomy was the most common operation performed in the SEMS group, whereas the traditional open approach was commonly used in the ES group. Intraoperative colonic lavage was seldomly performed during ES. There were no differences in mortality rates between the two groups (RR 1.06, 95% CI 0.55 to 2.04; I² = 0%). In the SEMS group, the rate of successful primary anastomosis was significantly higher in of SEMS (69.75%) than in the ES (55.07%) (RR 1.26, 95% 245 CI 1.01 to 1.57; I² = 86%). Conversely, the upfront Hartmann procedure was performed more frequently in the ES (39.1%) as compared to the SEMS group (23.4%) (RR 0.61, 95% CI 0.45 to 0.85; I² = 23%). The overall postoperative complications rate was significantly lower in the SEMS group (32.74%) than in the ES group (48.25%) (RR 0.61, 95% CI 0.41 to 0.91; I² = 65%). Conclusions: In the presence of malignant colorectal obstruction, SEMS is safe and associated with the same mortality and significantly lower morbidity than the ES group. The rate of successful primary anastomosis was significantly higher than the ES group. Nevertheless, recurrence and survival outcomes are not significantly different between the two groups. The analysis of short- and long-term results can suggest the use of SEMS as a bridge to resective surgery when it is performed by an endoscopist with adequate expertise in both colonoscopy and fluoroscopic techniques and who performed commonly colonic stenting.

Association of liver steatosis with colorectal cancer and adenoma in patients with metabolic syndrome

AIM

Metabolic syndrome has been identified as a risk factor for colorectal cancer and adenoma. The aim of our study was to assess the risk of colorectal cancer and adenoma in an adult Italian population with metabolic syndrome.

PATIENTS AND METHODS

Ninety patients with metabolic syndrome were prospectively compared against a matched population without the syndrome to assess the prevalence of colorectal adenoma. Another 1,500 patients undergoing screening colonoscopy were prospectively analyzed: 134 patients with metabolic syndrome and colorectal adenoma were compared against a group of 108 patients with colorectal adenoma without metabolic syndrome to assess the prevalence of cancer. The study was performed from January 2008 until December 2010. Data were analyzed from March to June 2011.

RESULTS

The prevalence of colorectal adenoma was twice as high in patients with metabolic syndrome. The incidence of cancer was higher in patients with colorectal adenoma and metabolic syndrome. Associated obesity and liver steatosis were the only factors with independent statistical value.

CONCLUSION

Metabolic syndrome is a risk factor for adenoma and cancer degeneration when obesity is present. Associated liver steatosis is a significant risk factor for colorectal cancer.

Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group

BACKGROUND

The authors report the final results of a prospective single-center randomized study whose aim was to compare the endoscopic placement of self-expandable stents with open surgical gastroenterostomy to relieve gastric outlet obstruction (GOO) in patients with advanced antropyloric adenocarcinoma. A systematic review of the medical literature from December 1999 to December 2011 was carried out to determine the results of endoscopic stenting in patients with GOO from unresectable primary cancer of the antropyloric region.

METHODS

In the prospective study, 18 patients with advanced adenocarcinoma of the antropyloric region and symptoms of GOO were enrolled. In 9 patients, self-expandable stents were placed, and in 9 patients, open surgical gastroenterostomy was performed. Patients were followed until death. Six hundred seventy-two patients with primary unresectable cancer of the antropyloric region and GOO syndrome who underwent endoscopic stenting were identified from the literature.

RESULTS

In the prospective study of 18 patients, there was no case of postprocedural mortality. Efficient gastric emptying resumed more quickly in patients who received stents, although 3 months after the procedures, there was no difference between the 2 groups. Mean crude survival was 258 days in patients who received stents and 283 days in those who underwent surgical gastroenterostomy (P = NS). In patients who underwent stent placement, there were 2 cases of stent migration and 2 cases of food impaction, which were resolved with endoscopy at a mean follow-up of 70 days. In the 672 patients from the literature, operative mortality and morbidity were very low. In prospective studies, complications related to stents were more common than previously thought.

CONCLUSIONS

Endoscopic placement of metallic stents offers an effective therapy in patients with advanced primary adenocarcinoma of the antropyloric region and poor general condition. In patients with longer life expectancies, the form of therapy should be chosen individually, considering that surgical gastroenterostomy has fewer complications in the medium term and that in patients with endoscopic stenting, very careful follow-up is required, with the possibility of new operative endoscopy in half of the patients.

Malignant intestinal obstruction: useful technical advice in self-expanding metallic stent placement

BACKGROUND

The use of endoluminal self-expanding metallic stents is an effective alternative to surgery in neoplastic gastrointestinal tract obstructions. It is often difficult to mark the proximal segment of the stricture under fluoroscopic guidance (due to patient movements or change of markers' position).

PATIENTS AND METHODS

We placed Ultraflex precision colonic stent (Microvasive, Boston Scientific) in ten patients with neoplastic stricture of the rectosigmoid colon. Before placement of the delivery catheter, a radiopaque proximal marker was identified on the delivery catheter under fluoroscopic guidance. The external side of the delivery catheter was coloured (in correspondence with the radiopaque marker) with non toxic colour. After the introduction of the delivery catheter, we placed the proximal coloured marker just above the distal tumour margin under endoscopic guidance.

RESULTS

The procedure was successful in relieving the obstruction in all patients, without mortality or complications. In all patients the coloured marker was identified and the stent correctly placed.

CONCLUSION

The location of a coloured marker in the external side of the delivery catheter permits an accurate and correct placement of the stent, without unnecessary exposure to X-rays.

Significance of T stadium and grading as prognostic factors in transitional cell carcinoma of the ureter

BACKGROUND

Surgery is nowadays the standard treatment for carcinoma of the ureter, even if adjuvant therapies can modify the prognosis in selected patients. Because of the small number of patients in the literature series, the significance of prognostic factors that can be used in clinical practice is still controversial, as is the choice of the most suitable surgical and adjuvant treatment.

PATIENTS AND METHODS

We considered 27 consecutive patients (Ta-T2 N0 M0) who underwent radical surgery (nephroureterectomy with bladder cuff excision and lymphoadenectomy) for transitional cell carcinoma of the ureter, from 1982 through 1992. Seven patients (25.9%) had Ta tumors, 7 patients (25.9%) had T1 tumors and 13 patients (48.2%) had T2 tumors. In 4 cases (14.8%) the tumor was well-differentiated (G1), in 14 cases (51.8%) it was mildly-differentiated (G2), and in 9 cases (33.4%) it was poorly-differentiated.

RESULTS

Thirteen of the 14 patients affected by Ta-T1 tumors were alive 10 years after surgery (one patient lost at follow-up); in the T2 tumor group the 5-year survival rate was 84.6% and 10-year survival rate was 69.2%. According to grading, the 10-year survival rate was 100% for G1 tumors, the 3, 5 and 10-year survival rates were, respectively, 100%, 92.8% G3 tumors.

CONCLUSION

Data from our study show the significance of the T stage and grading as prognostic factors.

Palliative management of malignant antro-pyloric strictures. Gastroenterostomy vs. endoscopic stenting. A randomized prospective trial

BACKGROUND

Gastroenterostomy was the palliative treatment of choice in patients with malignant unresectable gastric outlet obstruction. Palliative endoscopic treatment of malignant gastric outlet obstruction with endoluminal self-expanding metallic stents is nowadays a well-established procedure.

PATIENTS AND METHODS

Eighteen patients referred for treatment with diagnosis of malignant strictures of the antro-pyloric tract presenting at an advanced unresectable stage. The patients were randomly assigned into two treatment groups (endoscopic vs. surgery) according to random-number tables. The length of procedure, morbidity and mortality rate, restoration of oral intake and gastric emptying at 8, 15 days and 3 months from treatment and hospital stay were assessed.

RESULTS

Endoscopic group: The median length of procedure was 40 minutes. No death and one minor complication (11.1%) was reported. Mean time for oral intake was 2.1 days. Gastric emptying was satisfactory in 88.9% after 8 days and in 100% of patients after 15 days and 3 months. The median hospital stay was 3.1 days. Surgery group: The median length of the operation was 93 minutes. No mortality was reported. One patient (11.1%) developed anastomotic bleeding which required relaparotomy. Mean time for oral intake was 6.3 days. Gastric emptying was satisfactory in 66.7% of patients after 8 days, in 88.9% after 15 days and in 100% after 3 months. The median hospital stay was 10 days.

CONCLUSION

There were no statistically significant differences between the 2 groups even with respect to morbidity, mortality, delayed gastric emptying and clinical outcomes at 3-month follow-up. Endoscopic stenting was significantly more effective with respect to operative time, restoration of oral intake and median hospitalization. Our results would suggest that endoscopically placed metal stents offer an effective alternative to surgical palliation in patients with unresectable malignant strictures.

Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting. A randomized prospective trial

BACKGROUND

Colostomy was the palliative treatment of choice in patients with malignant unresectable rectosigmoid obstruction. Palliative endoscopic treatment of malignant rectosigmoid obstruction by endoluminal self-expanding metallic stents is nowadays a well-established procedure.

PATIENTS AND METHODS

Twenty-two patients, referred for treatment with diagnosis of malignant obstruction of the rectosigmoid region presenting an advanced unresectable stage, were enrolled. Patients were randomly assigned into two treatment groups (endoscopic stenting vs colostomy) according to random-number tables. The length of procedure, morbidity and mortality rate, canalization of the gastrointestinal tract, restoration of oral intake and hospital stay were assessed.

RESULTS

Endoscopic group: The median length of procedure was 36 minutes. No death was observed. None of the patients reported complications. All patients resumed bowel function within 24 hours. The restoration of oral intake was achieved one day after stent placement. The median hospital stay was 2.6 days. Colostomy group: The median length of the operation was 75.4 minutes. No mortality was reported. In 1 patient (9.1%) stoma prolapse was observed 3 days after the operation. Canalization of the gastrointestinal tract was restored when colostomy was opened (on postoperative day 3). All patients were able to resume oral feedings on postoperative day 3. The median hospital stay was 8.1 days.

CONCLUSION

There were no statistically significant differences between the 2 groups concerning morbidity and mortality. Endoscopic stenting was significantly more effective concerning operative time, restoration of bowel function and oral intake and median hospitalization. Our results would suggest that endoscopically placed metal stents offer an effective alternative to surgical palliation in patients suffering from unresectable malignant rectosigmoid obstruction.

Hepatocyte ultrastructural aspects after preoperative biliary drainage in pancreatic cancer patients with cholestatic jaundice

BACKGROUND

The usefulness of preoperative biliary drainage in long-standing obstructive jaundice remains controversial. This study was designed to assess microscopic and ultrastructural changes in the morphology of hepatocytes from patients with obstructive jaundice treated with biliary drainage for 14 days.

PATIENTS AND METHODS

In 8 patients with jaundice due to pancreatic neoplasms we obtained two fine-needle liver biopsies: the first during a transhepatic cholangiographic examination before placing preoperative drainage and the second at surgery, on day 14 of drainage. Biopsy samples were examined by light and electron microscopy and correlated to serum liver functional tests recorded before and after biliary drainage.

RESULTS

Pre-drainage biopsy presented diffuse morphological signs of congestion and cholestasis, lipid and bilirubin cytoplasm inclusions, loss of bile canaliculi microvilli and diffuse bile canaliculi dilatation. After-drainage biopsies presented reduction of bile canaliculi dilatation, partial restoring of bile canaliculi microvilli and persistence of diffuse hepatocyte structural and ultrastructural changes. Patients' laboratory values (bilirubin, alkaline phosphatase, SGGT, SGOT and SGPT), that were significantly impaired before drainage, returned almost to normal within two weeks after drainage.

CONCLUSION

Preoperative biliary drainage in patients with long-standing obstructive jaundice has received wide yet controversial support due to a well established pathophysiological background. The present findings of scarce recovery of hepatocyte changes after 14 days' drainage seemingly question its appropriateness.

Subcutaneous metastasis of pancreatic cancer in the site of percutaneous biliary drainage

A subcutaneous metastatic lesion from a carcinoma of the pancreas or common bile-duct along the tract of a percutaneous transhepatic biliary drainage is a rare finding. Prompted by a case that came to our observation by chance, we reviewed the literature and analysed the 29 cases collected. Neoplastic cell seeding along a percutaneous drainage tract, albeit rare, must be kept in mind. The complication can be avoided if patients at risk, whenever possible, undergo endoscopic drainage.