Validations of new cut-offs for surgical drains management and use of computerized tomography scan after pancreatoduodenectomy: The DALCUT trial

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most fearful complication after pancreatic surgery and can lead to severe postoperative complications such as surgical site infections, sepsis and bleeding. A previous study which identified cut-offs of drains amylase levels (DALs) determined on postoperative day (POD) 1 and POD3, was able to significantly predict POPF, abdominal collections and biliary fistulas, when related to specific findings detected at the abdominal computerized tomography (CT) scan routinely performed on POD3.

AIM

To validate the cut-offs of DALs in POD1 and POD3, established during the previous study, to assess the risk of clinically relevant POPF and confirm the usefulness of abdominal CT scan on POD3 in patients at increased risk of abdominal collection.

METHODS

The DALCUT trial is an interventional prospective study. All patients who will undergo pancreatoduodenectomy (PD) for periampullary neoplasms will be considered eligible. All patients will receive clinical staging and, if eligible for surgery, will undergo routine preoperative evaluation. After the PD, daily DALs will be evaluated from POD1. Drains removal and possible requirement of abdominal CT scans in POD3 will be managed on the basis of the outcome of DALs in the first three postoperative days.

RESULTS

This prospective study could validate the role of DALs in the management of surgical drains and in assessing the risk or relevant complications after PD. Drains could be removed in POD3 in case of POD1 DALs < 666 U/L and POD3 DALs < 207 U/L. In case of POD3 DALs ≥ 252, abdominal CT scan will be performed in POD3 to identify abdominal collections ≥ 5 cm. In this latter category of patients, drains could be maintained beyond POD3.

CONCLUSION

The results of this trial will contribute to a better knowledge of POPF and management of surgical drains.

Utility of preoperative systemic inflammatory biomarkers in predicting postoperative complications after pancreaticoduodenectomy: Literature review and single center experience

BACKGROUND

The role of preoperative inflammatory biomarkers (PIBs) in predicting postoperative morbidity has been assessed in colorectal and otorhinolaryngeal surgery. However, data regarding the role that preoperative inflammatory biomarkers have on morbidity after pancreaticoduodenectomiy (PD) are less consistent.

AIM

To assess the utility of PIBs in predicting postoperative complications after pancreaticoduodenectomy.

METHODS

A database of 317 consecutive pancreaticoduodenectomies performed from April 2003 to November 2018 has been retrospectively analyzed. Data regarding preoperative neutrophil-to-lymphocyte ratio (NLR), derived NLR and C-reactive protein (CRP), and postoperative complications of 238 cases have been evaluated. Exclusion criteria were: age < 18-years-old, previous neoadjuvant treatment, absence of data about PIBs, concomitant hematological disorders, and presence of active infections at the moment of the surgery. PIBs were compared using Mann-Whitney’s test and receiver operating characteristic (ROC) analysis was performed to define the cutoffs. The positive predictive value (PPV) was computed to evaluate the probability to develop complication. P-values < 0.05 were considered statistically significant.

RESULTS

According to the literature findings, only four papers have been published reporting the relation between the inflammatory biomarkers and PD postoperative morbidity. A combination of preoperative and postoperative inflammatory biomarkers in predicting complications after PD and the utility of preoperative NLR in the development of postoperative pancreatic fistula (POPF) have been reported. The combination of PIBs and postoperative day-1 drains amylase has been reported to predict the incidence of POPF. According to our results, CRP values were significantly different between patients who had/did not have postoperative complications and abdominal collections (P < 0.05). Notably, patients with preoperative CRP > 8.81 mg/dL were at higher risk of both overall complications and abdominal collections (respectively P = 0.0037, PPV = 0.95, negative predictive value [NPV] = 0.27 and P = 0.016, PPV = 0.59, NPV = 0.68). Preoperative derived neutrophil-to-lymphocyte ratio (dNLR) (cut off > 1.47) was also a predictor of abdominal collection (P = 0.021, PPV = 0.48, NPV = 0.71). Combining CRP and dNLR, PPV increased to 0.67. NLR (cut off > 1.65) was significantly associated with postoperative hemorrhage (P = 0.016, PPV = 0.17, NPV = 0.98).

CONCLUSION

PIBs may predict complications after PD. During postoperative care, PIB levels could influence decisions regarding the timing of drains removal and the selection of patients who might benefit from second level diagnostic exams.

Detection of Pancreatic Ductal Adenocarcinoma by Ex Vivo Magnetic Levitation of Plasma Protein-Coated Nanoparticles

Pancreatic Ductal Adeno Carcinoma (PDAC) is one of the most lethal malignancies worldwide, and the development of sensitive and specific technologies for its early diagnosis is vital to reduce morbidity and mortality rates. In this proof-of-concept study, we demonstrate the diagnostic ability of magnetic levitation (MagLev) to detect PDAC by using levitation of graphene oxide (GO) nanoparticles (NPs) decorated by a biomolecular corona of human plasma proteins collected from PDAC and non-oncological patients (NOP). Levitation profiles of corona-coated GO NPs injected in a MagLev device filled with a paramagnetic solution of dysprosium(III) nitrate hydrate in water enables to distinguish PDAC patients from NOP with 80% specificity, 100% sensitivity, and global classification accuracy of 90%. Our findings indicate that Maglev could be a robust and instrumental tool for the early detection of PDAC and other cancers.

Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

The Role of Pathological Method and Clearance Definition for the Evaluation of Margin Status after Pancreatoduodenectomy for Periampullary Cancer. Results of a Multicenter Prospective Randomized Trial

BACKGROUND

There is extreme heterogeneity in the available literature on the determination of R1 resection rate after pancreatoduodenectomy (PD); consequently, its prognostic role is still debated. The aims of this multicenter randomized study were to evaluate the effect of sampling and clearance definition in determining R1 rate after PD for periampullary cancer and to assess the prognostic role of R1 resection.

METHODS

PD specimens were randomized to Leeds Pathology Protocol (LEEPP) (group A) or the conventional method adopted before the study (group B). R1 rate was determined by adopting 0- and 1-mm clearance; the association between R1, local recurrence (LR) and overall survival (OS) was also evaluated.

RESULTS

One-hundred-sixty-eight PD specimens were included. With 0 mm clearance, R1 rate was 26.2% and 20.2% for groups A and B, respectively; with 1 mm, R1 rate was 60.7% and 57.1%, respectively (p > 0.05). Only in group A was R1 found to be a significant prognostic factor: at 0 mm, median OS was 36 and 20 months for R0 and R1, respectively, while at 1 mm, median OS was not reached and 30 months. At multivariate analysis, R1 resection was found to be a significant prognostic factor independent of clearance definition only in the case of the adoption of LEEPP.

CONCLUSIONS

The 1 mm clearance is the most effective factor in determining the R1 rate after PD. However, the pathological method is crucial to accurately evaluate its prognostic role: only R1 resections obtained with the adoption of LEEPP seem to significantly affect prognosis.

Nanotechnology and pancreatic cancer management: State of the art and further perspectives

Pancreatic ductal adenocarcinoma (PDAC) represents a leading cause of cancer death and is often diagnosticated too late to allow adequate treatments. Lots of biomarkers have been discovered in lasts years but, to date, there is a lack of low-cost and non-invasive tools for PDAC early detection. Nonetheless, drugs commonly used in PDAC treatment do not allow achieving long-term satisfying results. Nanotechnology is gaining importance in both PDAC early detection and treatment. The main implications of nanotechnology in cancer diagnosis lay in the ability that nanoparticles have on concentrate the alteration in human proteome caused by cancer. Nanoparticle-enabled blood tests have been demonstrated to reach high rate of sensitivity (up to 85%) and specificity (up to 100%). In the field of cancer therapy nanoparticles can be used as nanocarriers able to reach specific tumour's cells and selectively release the drug they contain into them. A literature review was carried out with the aim to assess the state of the art and highlight the future perspectives of nanotechnology in PDAC early detection and therapy.

A Bio-Imaging Signature as a Predictor of Clinical Outcomes in Locally Advanced Pancreatic Cancer

Purpose: To evaluate the predictive value of ¹⁸F-FDG PET/CT semiquantitative parameters of the primary tumour and CA 19-9 levels assessed before treatment in patients with locally advanced pancreatic cancer (LAPC). Methods: Among one-hundred twenty patients with LAPC treated at our institution with initial chemotherapy followed by curative chemoradiotherapy (CRT) from July 2013 to January 2019, a secondary analysis with baseline ¹⁸F-FDG PET/CT was conducted in fifty-eight patients. Pre-treatment CA 19-9 level and the maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) of primary tumour were measured. The receiving operating characteristics (ROC) analysis was performed to define the cut-off point of SUVmax, MTV, TLG and CA 19-9 values to use in prediction of early progression (EP), local progression (LP) and overall survival (OS). Areas under the curve (AUCs) were assessed for all variables. Post-test probability was calculated to evaluate the advantage for parameters combination. Results: For EP, CA 19-9 level > 698 U/mL resulted the best marker to identify patient at higher risk with OR of 5.96 (95% CI, 1.66-19.47; p = 0.005) and a Positive Predictive Value (PPV) of 61%. For LP, the most significant parameter was TLG (OR 9.75, 95% CI, 1.64-57.87, p = 0.012), with PPV of 83%. For OS, the most significant parameter was MTV (OR 3.12, 95% CI, 0.9-10.83, p = 0.07) with PPV of 88%. Adding consecutively each of the other parameters, PPV to identify patients at risk resulted further increased (>90%). Conclusions: Pre-treatment CA 19-9 level, as well as MTV and TLG values of primary tumour at baseline ¹⁸F-FDG PET/CT and their combination, may represent significant predictors of EP, LP and OS in LAPC patients.

Improving the accuracy of pancreatic cancer clinical staging by exploitation of nanoparticle-blood interactions: A pilot study

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) early diagnosis is  crucial  and new, cheap and user-friendly techniques for biomarker identification  are  needed. "Protein corona" (PC) is emerging a new bio-interface potentially useful in tumor early diagnosis. In a previous investigation, we showed that relevant differences between the  protein patterns of  PCs formed on lipid NPs after exposure to PDAC and non-cancer plasma  samples exist. To extend that research, We performed this pilot study to investigate the effect of PDAC tumor size and distant metastases on PC composition.

METHODS

Twenty PDACs were clinically staged according to the UICC TNM staging system 8 t h Edition. Collected plasma samples were let to interact with lipid NPs; resulting PCs were characterized by SDS-PAGE. To properly evaluate changes in the PC, the protein intensity profiles were reduced to four regions of molecular weight: < 25 kDa, 25-50 kDa, 50-120 kDa, > 120 kDa.  RESULTS: Data analysis allowed to distinguish T1-T2 cases from T3 and above all from metastatic ones (p < 0.05). Discrimination power was particularly due to a subset of plasma proteins with molecular  weight comprised between 25-50 kDa  and 50-120 kDa.

CONCLUSIONS

PC composition is critically influenced by tumor size and presence of distant metastases in PDAC. If our findings will be further confirmed, we envision that future developments of cheap and user-friendly PC-based tools will allow to improve the accuracy of PDAC clinical staging, identifying among resectable  PDACs with potentially better prognosis (i.e. T1 and T2) those at higher risk of occult distant metastases.

Neutrophil to lymphocyte ratio predicts risk of nodal involvement in T1 colorectal cancer patients

BACKGROUND

Risk of nodal involvement in T1 colorectal cancer is assessed by tumor histological features. In several tumors, the ratio between neutrophils and lymphocytes (NLR) or platelets and lymphocytes (PLR) have been applied to lymph-node metastases prediction. The aim of this study was to evaluate the role of NLR, derived NLR (dNLR) and PLR in predicting nodal involvement in T1 colorectal cancers.

METHODS

NLR, dNLR and PLR in surgical resected T1 colorectal cancers were retrospectively calculated and analysed in nodal positive and negative cases.

RESULTS

Data regarding 102 patients were considered. Nodal involvement rate was 10.8%. NLR values were higher in node positive patients (P=0.04). A trend toward significance (P=0.05) was found for higher dNLR values and positive nodal status. For NLR, ROC curve analysis allowed to choose a predictive cut-off value of 3.7 (AUC of 0.69; 95% CI: 0.48-0.89). Nodal positivity was reported in 71.5% of high NLR patients; only two N0 cases (28.5%) were registered in high NLR group (P<0.001). The logistic regression analysis aimed to evidence the predictive role of high NLR in node positivity resulted in a significant OR of 37.1 (P<0.0001; 95% CI: 0.48-0.89). NLR allowed to distinguish N0 from N1 patients in 99.4% of cases.

CONCLUSIONS

NLR<3.7 was associated with lower risk of lymph-node metastases in T1 colorectal cancer patients. NLR could be used with histopathological data to identify patients at lower risk of nodal metastases.

Ipilimumab and immune-mediated adverse events: a case report of anti-CTLA4 induced ileitis

Background

Ipilimumab is a fully human monoclonal antibody directed against cytotoxic T-lymphocyte antigen-4 , a key negative regulator of T-cell activation approved by the Food and Drug Administration as of March 2011 for the treatment of metastatic melanoma. As a result of the up-regulation of the immune system, several immune-mediated adverse effects have been reported including colitis, dermatitis, hepatitis and rarely hypophysitis. The most frequent immune-mediated adverse effects described in literature include gastrointestinal toxicity such as diarrhea, colitis and case of colitis and ileitis.

Case presentation

In this paper we report an interesting case of immune-mediate ileitis without colitis in a 54 years old woman with metastatic melanoma treated with ipilimumab. We also discuss about case management and the possible pathological mechanisms considering also previous reports.

Conclusions

The aim of this article is to support further investigations concerning epigenetic and genetic analysis in order to personalize biological therapy and to reduce immune related adverse events observed after ipilimumab administration.

Serum lactate dehydrogenase alone is not a helpful prognostic factor in resected colorectal cancer patients

Several studies showed how serum levels of lactate dehydrogenase (LDH) are related with a worse prognosis and response to therapy. Its role in colorectal cancer is not still assessed. The aim of this study was to assess the prognostic role of serum level of LDH in non-metastatic, previously untreated, T2-T3-T4 colorectal tumours undergoing surgery. Data regarding preoperative serum levels of LDH have been retrospectively collected. A group with normal levels of serum LDH (group A) and a group with high levels of serum LDH (group B) have been identified and compared in relation with disease staging and outcome. A series of 96 cases have been analysed. Only age was significantly associated with increased LDH serum level (p 0.001). No significant differences between serum LDH levels, staging pT (p 0.721), pN (p 0.080) and grading (0.849) have been found. Test's sensitivity and specificity were 76 and 46.5%, respectively. Preoperative serum levels of LDH alone failed to demonstrate a prognostic role in a selected series of colorectal cancer patients. Low rates of sensitivity and specificity have been found.

Conversion in mini-invasive colorectal surgery: the effect of timing on short term outcome

INTRODUCTION

Different results have been reported about postoperative outcomes of conversion during laparoscopic colorectal surgery. We aimed to detect the effect of conversion on postoperative outcome and to identify features associated to better outcome after conversion.

METHODS

Two hundred-fourteen mini-invasive left colonic and rectal resections were retrospectively analysed. Two groups were identified: mini-invasive colorectal surgery (MI) that includes both laparoscopic and robotic resections, and conversion to open surgery.

RESULTS

Among 214 colorectal procedures, 189 were MI. Conversion rate was 11.7%. Operating time was shorter for MI at overall analysis (p 0.003) and sub-analysis of left colectomies (p 0.001). MI procedures had shorter hospital stay (p 0.000) both in left colectomy and rectal resection (p 0.008 and p 0.001 respectively). A shorter time to first flatus emission was detected in MI group in both overall analysis (p 0.003) and procedure's sub-analysis (left colectomy p 0.032; anterior rectal resection p 0.040). Oral feeding was resumed earlier after mini-invasive rectal resections (p 0.014). Converted procedures required more blood transfusions (p 0.000) and grade II complication rate was lower after MI procedures (p 0.013). Conversion presented higher anastomotic leakage and reoperation rates (p 0.035 and p 0.006 respectively). Conversion before 105 min (early conversion) had a significant lower number of blood transfusions (p 0.047).

CONCLUSIONS

Conversion is associated to higher rate of blood transfusions, grade II complication and slower recovery. Earlier conversion has better outcomes. Colorectal surgeons should identify any critical aspects that could avoid late conversion allowing reducing negative effects of conversion.

T1 colorectal cancer: poor histological grading is predictive of lymph-node metastases

INTRODUCTION

After complete local excision of pT1 colorectal cancers, prediction of the absence of lymph-node involvement represents an interesting perspective in order to avoid unnecessary additional radical surgery, reducing morbidity, mortality and costs of care. We aimed to identify independent risk factors predictive of nodal involvement in pT1 colorectal cancer patients.

METHODS

Data regarding depth of submucosal invasion, histological grading, tumour budding and lymphovascular invasion in a consecutive series of 48 pT1 surgically resected colorectal cancers have been retrospectively collected and related to the nodal status.

RESULTS

A 12.5% rate of nodal involvement has been found. The poor differentiation was found as the only independent predictor of nodal metastases in pT1 colorectal cancer (p = 0.01).

CONCLUSIONS

Poor differentiation was the only independent significant predictor of nodal involvement in pT1 colorectal tumours. Our and literature's data confirm that risk factors must be prospectively collected and reported; further genetic and epigenetic predictive factors have to be investigated in order to carefully evaluate the needing of major surgery for pT1 colorectal cancer.