Computerized tomography texture analysis of pheochromocytoma: relationship with hormonal and histopathological data

OBJECTIVES

Pheochromocytomas are rare tumors which can present with heterogeneous secretion profiles, clinical manifestations, and radiologic appearance. Under a histopathological point of view, they can be characterized as more or less aggressive with the Pheochromocytoma of the Adrenal gland Scaled Score (PASS) and the Grading system for Adrenal Pheochromocytoma and Paraganglioma (GAPP) score. The aim of this study is to analyze the texture analysis characteristics of pheochromocytoma and identify whether the texture analysis can yield information aiding in the diagnosis and the characterization of those tumors.

METHODS

Radiological, biochemical, and histopathological data regarding 30 consecutive patients with histologically confirmed pheochromocytoma were analyzed. Images obtained in the unenhanced, late arterial, venous, and delayed phases were used for the texture analysis.

RESULTS

Urinary epinephrine and metanephrine levels showed a significant correlation (R² = 0.946; R² = 699) in the multivariate linear model with texture features, as well as Ki-67 (R² = 0.397), PASS score (R² = 0.182), GAPP score (R² = 0.705), and cellularity showed a significant correlation (R² = 0.389). The cluster analysis based on radiomic features resulted in 2 clusters, with significative differences in terms of systolic and diastolic blood pressure values at the time of diagnosis (p = 0.025), GAPP score (4 vs 6, p = 0.05), histological pattern (1-2, p = 0.039), and comedonecrosis (0% vs 50%, p = 0.013).

CONCLUSION

In conclusion, our study provides the proof of concept for the use of texture analysis on contrast-enhanced CT images as a noninvasive, quantitative tool for helping in the characterization of the clinical, biochemical, and histopathological features of pheochromocytoma.

Minimally invasive adrenalectomy: a comprehensive systematic review and network meta-analysis of phase II/III randomized clinical controlled trials

PURPOSE

The best approach for minimally invasive adrenalectomy is still under debate.

METHODS

A systematic search of randomized clinical trials was carried out. A frequentist random-effects network meta-analysis was made reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded both in-hospital mortality and morbidity. The secondary endpoints were operative time (OP), blood loss (BL), length of stay (LOS), conversion, incisional hernia, and disease recurrence rate.

RESULTS

Eight studies were included, involving 359 patients clustered as follows: 175 (48.7%) in the TPLA arm; 55 (15.3%) in the RPLA arm; 10 (2.8%) in the Ro-TPLA arm; 25 (7%) in the TPAA arm; 20 (5.6%) in the SILS-LA arm; and 74 (20.6%) in the RPA arm. The RPLA had the highest probability of being the safest approach (SUCRA 69.6%), followed by RPA (SUCRA 63.0%). TPAA, Ro-TPLA, SILS-LA, and TPLA have similar probability of being safe (SUCRA values 45.2%, 43.4%, 43.0%, and 38.5%, respectively). Analysis of the secondary endpoints confirmed the superiority of RPA regarding OP, BL, LOS, and incisional hernia rate.

CONCLUSIONS

The best choice for patients with adrenal masses candidate for minimally invasive surgery seems to be RPA. An alternative could be RPLA. The remaining approaches could have some specific advantages but do not represent the first minimally invasive choice.

Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials

BACKGROUND & AIMS

The preoperative use of carbohydrate loading (CHO) is recommended in patients undergoing abdominal surgery, even if the advantages remain debatable. The aim was to evaluate the CHO benefits in patients undergoing abdominal surgery.

METHODS

A systematic search of randomized clinical trials was made. A frequentist random-effects network meta-analysis was carried out, reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded the morbidity rate. The secondary endpoints were aspiration/regurgitation rates, the length of stay (LOS), the rate of postoperative nausea and vomiting (PONV), the changes (Δ) in insulin sensitivity or resistance, and the postoperative C- reactive protein (CRP) values.

RESULTS

CHO loading and water administration had a similar probability of being the approach with a lower morbidity rate (SUCRA = 62.4% and 64.7%). CHO and clear water also had a similar chance of avoiding the PONV (SUCRA of 80.8% and 77%). The aspiration regurgitation rate was not relevant in non-fasting patients (0.06%). CHO administration was associated with the shorter hospitalization (SUCRA 86.9%), with the best metabolic profile (SUCRA values for insulin resistance and sensitivity were 81.1% and 76%). CHO enriched was the best approach for postoperative CRP values. Preoperative fasting was the worst approach for morbidity, PONV, insulin resistance and sensitivity, and CRP (SUCRA values of 32.1%, 21.7%, 10.2%, 3.2%, and 2.0%).

CONCLUSION

Both preoperative CHO loading and clear water use were superior to the fasting about morbidity. CHO drinks use could provide specific advantages, reduce the PONV rate, and improve carbohydrate homeostasis, inflammatory pathway, and hospitalization.

The 3-Dimensional-Computed Tomography Texture Is Useful to Predict Pancreatic Neuroendocrine Tumor Grading

OBJECTIVES

The aim of this study is to evaluate the computed tomography texture parameters in predicting grading.

METHODS

This study analyzed 68 nonfunctioning pancreatic neuroendocrine neoplasms (Pan-NENs). Clinical and radiological parameters were studied. Four model models were built, including clinical and standard radiologic parameters (model 1), first- and second-order computed tomography features (models 2 and 3), all parameters (model 4). The diagnostic accuracy was reported as area under the curve. A score was computed using the best model and validated to predict progression-free survival.

RESULTS

The size of tumors and heterogeneous enhancement were related to the risk of "non-G1" Pan-NENs (coefficients 0.471, P = 0.012, and 1.508, P = 0.027). Four second-order parameters were significantly related to the presence of "non-G1" Pan-NENs: the gray level co-occurrence matrix correlation (6.771; P = 0.011), gray level co-occurrence matrix contrast variance (0.349; P = 0.009), the neighborhood gray-level different matrix contrast (-63.129; P = 0.001), and the gray-level zone length matrix with the low gray-level zone emphasis (-0.151; P = 0.049). Model 4 was the best, with a higher area under the curve (0.912; P = 0.005). The score obtained predicted the progression-free survival.

CONCLUSIONS

Computed tomography radiomics signature can be useful in preoperative workup.

Neoadjuvant Therapy for Resectable Pancreatic Cancer: A New Standard of Care. Pooled Data From 3 Randomized Controlled Trials

OBJECTIVE

The aim of this study was to pool data from randomized controlled trials (RCT) limited to resectable pancreatic ductal adenocarcinoma (PDAC) to determine whether a neoadjuvant therapy impacts on disease-free survival (DFS) and surgical outcome.

SUMMARY BACKGROUND DATA

Few underpowered studies have suggested benefits from neoadjuvant chemo (± radiation) for strictly resectable PDAC without offering conclusive recommendations.

METHODS

Three RCTs were identified comparing neoadjuvant chemo (± radio) therapy vs. upfront surgery followed by adjuvant therapy in all cases. Data were pooled targeting DFS as primary endpoint, whereas overall survival (OS), postoperative morbidity, and mortality were investigated as secondary endpoints. Survival endpoints DFS and OS were compared using Cox proportional hazards regression with study-specific baseline hazards.

RESULTS

A total of 130 patients were randomized (56 in the neoadjuvant and 74 in the control group). DFS was significantly longer in the neoadjuvant treatment group compared to surgery only [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.4-0.9] (P = 0.01). Furthermore, DFS for the subgroup of R0 resections was similarly longer in the neoadjuvant treated group (HR 0.6, 95% CI 0.35-0.9, P = 0.045). Although postoperative complications (Comprehensive Complication Index, CCI®) occurred less frequently (P = 0.008), patients after neoadjuvant therapy experienced a higher toxicity, but without negative impact on oncological or surgical outcome parameters.

CONCLUSION

Neoadjuvant therapy can be offered as an acceptable standard of care for patients with purely resectable PDAC. Future research with the advances of precision oncology should now focus on the definition of the optimal regimen.

Laparoscopic versus open distal pancreatectomy: a single centre propensity score matching analysis

The laparoscopic approach is considered as standard practice in patients with body-tail pancreatic neoplasms. However, only a few randomized controlled trials (RCTs) and propensity score matching (PSM) studies have been performed. Thus, additional studies are needed to obtain more robust evidence. This is a single-centre propensity score-matched study including patients who underwent laparoscopic (LDP) and open distal pancreatectomy (ODP) with splenectomy for pancreatic neoplasms. Demographic, intra, postoperative and oncological data were collected. The primary endpoint was the length of hospital stay. The secondary endpoints included the assessment of the operative findings, postoperative outcomes, oncological outcomes (only in the subset of patients with pancreatic ductal adenocarcinoma-PDAC) and total costs. In total, 205 patients were analysed: 105 (51.2%) undergoing an open approach and 100 (48.8%) a laparoscopic approach. After PSM, two well-balanced groups of 75 patients were analysed and showed a shorter length of hospital stay (P = 0.001), a lower blood loss (P = 0.032), a reduced rate of postoperative morbidity (P < 0.001) and decreased total costs (P = 0.050) after LDP with respect to ODP. Regarding the subset of patients with PDAC, 22 patients were analysed: they showed a significant shorter length of hospital stay (P = 0.050) and a reduction in postoperative morbidity (P < 0.001) after LDP with respect to ODP. Oncological outcomes were similar. LDP showed lower hospital stay and postoperative morbidity rate than ODP both in the entire population and in patients affected by PDAC. Total costs were reduced only in the entire population. Oncological outcomes were comparable in PDAC patients.

Development and validation of a preoperative "difficulty score" for laparoscopic transabdominal adrenalectomy: a multicenter retrospective study

Background

A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative “difficulty score” for LA.

Methods

A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon’s characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with p-value, was used.

Results

In model A, gender (OR 2.04, p = 0.001), BMI (OR 1.07, p = 0.002), previous surgery (OR 1.29, p = 0.048), site (OR 21.8, p < 0.001) and size of the lesion (OR 1.16, p = 0.002), cumulative sum of procedures (OR 0.99, p < 0.001), extended (OR 26.72, p < 0.001) or associated procedures (OR 4.32, p = 0.015) increased the pOT. In model B, ASA (OR 2.86, p = 0.001), lesion size (OR 1.20, p = 0.005), and extended resection (OR 8.85, p = 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99, p < 0.001; OR 1.37, p = 0.007; OR 1.70, p < 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively.

Conclusion

A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08678-6.

Contemporary indications for upfront total pancreatectomy

Currently, advances in surgical techniques, improvements in perioperative care, new formulations of intermediate and long-acting insulin and of modern pancreatic enzyme preparations have allowed obtaining good short and long-term results and quality of life, especially in high-volume centres in performing total pancreatectomy (TP).Thus, the surgeon's fear in performing TP is not justified and total pancreatectomy can be considered a viable option in selected patients in high-volume centres. The aim of this review was to define the current indications for this procedure, in particular for upfront TP, considering not only the pancreatic disease, but also the surgical approach (open, mini-invasive) and the relationship with vascular resection.

The use of comprehensive complication Index® in pancreatic surgery: a comparison with the Clavien-Dindo system in a high volume center

BACKGROUND

The Clavien-Dindo classification (CDC) system and Comprehensive Complication Index (CCI®) are both widely used methods for reporting the burden of postoperative complications. This study aimed to compare the accuracy of the CDC and CCI® in predicting outcomes associated with pancreatic surgery.

METHODS

The CCI® and CDC were applied to 668 patients who underwent pancreatic resection. Length of postoperative stay (LOS) was chosen as the primary outcome variable. The comparison between CCI® and CDC was made with the Spearman test, reporting þs with standard error (SE) and logistic regression, reporting the Odds Ratio (OR) and Area Under the Curve with SE.

RESULTS

The median value with the interquartile range (IQR) of CCI® was 20.9 (0-29.6). Both CCI® (þs = 0.609) and CDC (0.590) were significantly (P < 0.001) correlated to LOS. CCI (OR 1.056 and OR 1.052) and CDC (OR 1.978, and OR 1.994) predicted (P < 0.001) LOS over the median and 75th percentile. The accuracy of CCI® was superior to CDC for LOS over 50th (0.785 vs. 0.740; P = 0.004) and over 75th (0.835 vs. 0.761; P < 0.001) percentile.

CONCLUSION

The accuracy of CCI® in measuring the complicated postoperative course was superior to CDC, correctly classifying eight patients every ten tested.

External validation of nomogram for predicting malignant intraductal papillary mucinous neoplasm (IPMN): from the theory to the clinical practice using the decision curve analysis model

The management of IPMNs is a challenging and controversial issue because the risk of malignancy is difficult to predict. The present study aimed to assess the clinical usefulness of two preoperative nomograms for predicting malignancy of IPMNs allowing their proper management. Retrospective study of patients affected by IPMNs. Two nomograms, regarding main (MD) and branch duct (BD) IPMN, respectively, were evaluated. Only patients who underwent pancreatic resection were collected to test the nomograms because a pathological diagnosis was available. The analysis included: 1-logistic regression analysis to calibrate the nomograms; 2-decision curve analysis (DCA) to test the nomograms concerning their clinical usefulness. 98 patients underwent pancreatic resection. The logistic regression showed that, increasing the score of both the MD-IPMN and BD-IPMN nomograms, significantly increases the probability of IPMN high grade or invasive carcinoma (P = 0.029 and P = 0.033, respectively). DCA of MD-IPMN nomogram showed that there were no net benefits with respect to surgical resection in all cases. DCA of BD-IPMN nomogram, showed a net benefit only for threshold probability between 40 and 60%. For these values, useless pancreatic resection should be avoided in 14.8%. The two nomograms allowed a reliable assessment of the malignancy rate. Their clinical usefulness is limited to BD-IPMN with threshold probability of malignancy of 40–60%, in which the patients can be selected better than the “treat all” strategy.

Pancreatic mucinous cystadenocarcinoma in a patient harbouring BRCA1 germline mutation effectively treated with olaparib: A case report

BACKGROUND

Pancreatic mucinous cystadenocarcinoma (MCAC) is a rare malignancy with a poor prognosis when it presents metastases at diagnosis. Due to its very low incidence, there are no clear recommendations for the treatment of advanced disease. Olaparib (an oral PARP inhibitor) has been approved for the maintenance treatment of patients with metastatic pancreatic adenocarcinoma harbouring germline BRCA1/2 mutations. Herein, we report the first case of a germline BRCA1 mutated unresectable MCAC which was effectively treated with olaparib.

CASE SUMMARY

A 41-year-old woman, without personal or family history of cancer, was diagnosed with ovarian and peritoneal metastases of MCAC. She underwent 12 cycles of gemcitabine plus oxaliplatin (GEMOX) obtaining a partial response and allowing radical surgery. One year later, local recurrence was documented, and other 12 cycles of GEMOX were administered obtaining a complete response. Seven years later, another local recurrence, not amenable to surgical resection, was diagnosed. She started FOLFIRINOX (oxaliplatin, irinotecan, leucovorin and fluorouracil), obtaining a partial response after 8 cycles. Given the excellent response to platinum-based chemotherapy, BRCA testing was performed, and a BRCA1 germline mutation was detected. She was switched to maintenance olaparib due to chemotherapy-related toxicities and achieved an almost complete metabolic response, with a reduction in the diameter of the lesion, after three months of therapy.

CONCLUSION

The current case suggests the beneficial effect of olaparib in BRCA mutated MCAC. However, further studies are required.

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases: Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate. Staged approach, with initial colorectal resection followed by liver resection (LR), or even the reverse, liver-first approach in specific situations, is traditionally preferred. Simultaneous resections, however, represent an appealing strategy, because may have perioperative risks comparable to staged resections in appropriately selected patients, while avoiding a second surgical procedure. In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases, simultaneous major hepatectomies may determine worse perioperative outcomes, so that parenchymal-sparing LR should represent the most appropriate option whenever feasible. Mini-invasive colorectal surgery has experienced rapid spread in the last decades, while laparoscopic LR has progressed much slower, and is usually reserved for limited tumours in favourable locations. Moreover, mini-invasive parenchymal-sparing LR is more complex, especially for larger or multiple tumours in difficult locations. It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise, at least for more complex procedures. This review aims to critically analyze the current status and future perspectives of simultaneous resections, and the present role of the available mini-invasive techniques.

The Usefulness of a Preoperative Nomogram for Predicting the Probability of Conversion from Laparoscopic to Open Distal Pancreatectomy: A Single-Center Experience

Background

Laparoscopic distal pancreatectomy (LDP) represents a challenging procedure with a high conversion rate. A nomogram is a simple statistical predictive tool which is superior to risk groups. The aim of this study was to develop and validate a preoperative nomogram for predicting the probability of conversion from laparoscopic to open distal pancreatectomy.

Methods

This is a retrospective study of 100 consecutive patients who underwent LDP. For each patient demographic, pre-intra- and postoperative data were collected. Univariate and multivariate analyses were carried out to identify the factors significantly influencing the conversion rate. The effect of each factor was weighted using the beta coefficient (β), and a nomogram was built. Finally, a logistic regression between the score and the conversion rate was carried out to calibrate the nomogram.

Results

The conversion rate was 19.0%. At multivariate analysis, female (β =  − 1.8 ± 0.9; P = 0.047) and tail location of the tumor (β =  − 2.1 ± 1.1; P = 0.050) were significantly related to a low probability of conversion. Body mass index (BMI) (β = 0.2 ± 0.1; P = 0.011) and subtotal pancreatectomy (β = 2.4 ± 0.9; P = 0.006) were factors independently related to a high probability of conversion. The nomogram constructed had a minimum value of 4 and a maximum value of 18 points. The probability of conversion increased significantly starting from a minimum score of 6 points (P = 0.029; conversion probability 14.4%; 95%CI, 1.5–27.3%) up to 16 (P = 0.048; 27.8%; 95%CI, 0.2–48.7%).

Conclusion

The nomogram proposed could serve as an effective preoperative tool capable of assessing the probability of conversion, allowing to take reliable decisions regarding indications and adequate stepwise training program of LDP.

Twenty-year survival after iterative surgery for metastatic renal cell carcinoma: A case report and review of literature

BACKGROUND

The therapeutic approach of metastatic renal cell carcinoma (RCC) represents a real challenge for clinicians, because of the variable clinical course; the recent availability of numerous targeted therapies that have significantly improved overall oncological results, but still with a low percentage of complete responses; and the increasing role of metastasectomy (MSX) as an effective strategy to achieve a durable cure, or at least defer initiation of systemic therapies, in selected patients and in the context of multimodality treatment strategies.

CASE SUMMARY

We report here the case of a 40-year-old man who was referred to our unit in November 2004 with lung and mediastinal lymph nodes metastases identified during periodic surveillance 6 years after a radical nephrectomy for RCC; he underwent MSX of multiple lung nodules and mediastinal lymphadenectomy, with subsequent systemic therapy with Fluorouracil, Interferon-alpha and Interleukin 2. The subsequent clinical course was characterized by multiple sequential abdominal and thoracic recurrences, successfully treated with multiple systemic treatments, repeated local treatments, including two pancreatic resections, conservative resection and ablation of multiple bilobar liver metastases, resection and stereotactic body radiotherapy of multiple lung metastases. He is alive without evidence of recurrence 20 years after initial nephrectomy and sequential treatment of recurrences in multiple sites, including resection of more than 38 metastases, and 5 years after his last MSX.

CONCLUSION

This case highlights that effective multimodality therapeutic strategies, including multiple systemic treatments and iterative aggressive surgical resection, can be safely performed with long-term survival in selected patients with multiple metachronous sequential metastases from RCC.

Radiologically defined lipid-poor adrenal adenomas: histopathological characteristics

BACKGROUND

Adrenal lipid-poor adenomas (LPA) are defined by high unenhanced density (≥ 10 HU), and absolute and relative contrast medium washout > 60% and > 40%, respectively, at computerized tomography (CT). To date, no thorough histopathological characterization has been performed in those frequent lesions (one-third of adrenal adenomas). Our aim was to analyze the histopathological characteristics of adrenal LPA.

METHODS

Patients with LPA (n = 57) were selected among consecutive subjects referred for an adrenal incidentaloma or ACTH-independent Cushing syndrome. FluoroDeoxyGlucose-Positron Emission Tomography (FDG-PET) was performed in 37 patients. In patients treated by adrenalectomy (n = 17), Weiss score and Lin-Weiss-Bisceglia score (in tumors composed entirely or predominantly of oncocytes) were calculated.

RESULTS

Radiological parameters did not differ among patients with ACTH-independent Cushing syndrome (n = 6) and those with adrenal incidentalomas associated with primary aldosteronism (n = 2), autonomous cortisol secretion (n = 14), or non-functioning (n = 35). Patients treated by adrenalectomy had larger tumors (28.9 ± 11.2 vs 17.3 ± 8.4 mm, P < 0.001), higher CT unenhanced density (29.1 ± 11.0 vs 23.1 ± 9.0 HU, P = 0.043), and FDG-PET adrenal uptake (9.0 ± 6.4 vs 4.4 ± 2.3 SUV, P = 0.003) than non-operated ones. Oncocytic features > 75% of the tumor were detected in 12/17 cases (70.6%). Five of those showed borderline-malignant histopathological characteristics by Lin-Weiss-Bisceglia score. Among remaining non-oncocytic tumors, 1/5 had a Weiss score ≥ 3. Overall, 6/17 tumors (35.3%) had borderline-malignant potential. Radiological parameters were similar between patients with benign and borderline-malignant tumors.

CONCLUSIONS

Adrenal LPA are a heterogeneous group of tumors, mostly composed of oncocytomas. Up to 1/3 of those tumors may have a borderline-malignant potential at histopathology.

The Italian National Registry for minimally invasive pancreatic surgery: an initiative of the Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS)

The value of minimally invasive pancreatic surgery (MIPS) is still uncertain, despite the growing number of publications, including reviews and meta-analyses, and the quick diffusion of these procedures worldwide. The Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS) was created under the auspices of three Scientific Societies: Associazione Italiana Studio Pancreas (AISP), Associazione Italiana Chirurgia Epato-Bilio-Pancreatica (AICEP, former IT-IHPBA), and Società Italiana di Chirurgia Endoscopica (SICE). The main aim of IGoMIPS is to develop and implement a national registry for MIPS. IGoMIPS was founded on February 22, 2019 in Pisa. The IGoMIPS registry became operational in September 2019, following approval by the Ethic Committees of founding Institutions, inscription into the Registry of Patient Registries (RoPR), and a wrap-up meeting held in Bologna during the Annual Congress of the Italian Surgical Society. During this meeting IGoMIPS members approved that the Italian Registry will provide data to the European Registry, while retaining the right to analyze and publish Italian data. An audience survey was also conducted to obtain information on perceived value and current implementation of MIPS in founding Institutions. MIPS is performed in 94.7% of IGoMIPS centers, including pancreaticoduodenectomy in 42.1%. Robotic assistance was employed in 52.6% of Institutions. The annual volume of MIPS was 6-10 cases in 38.9% of the centers, 11-20 cases in 16.7%, 21-30 cases in 22.2%, and > 30 cases in 22.2%. The registry was felt to be extremely important for both safety improvement and educational purposes by 94.5% of the centers.

Intraoperative electrochemotherapy in locally advanced pancreatic cancer: Results and impact on quality of life. a single center experience

e16731

Background: Locally advanced pancreatic cancer (LAPC) is usually treated with chemoradiotherapy with poor results, thus additional therapies have been proposed. Of the latter, electrochemotherapy (ECT) represents a non-thermal ablation method, which combines the administration of chemotherapeutic drugs with permeabilizing electric pulses for cell membrane electroporation. The present study is the first to assess the short and long-term results, and the quality of life of the patients who underwent ECT for LAPC. Methods: Observational study of patients affected by LAPC who underwent intraoperative ECT after chemoradiotherapy. The inclusion criteria were: 1- patients with LAPC (defined according to the National Comprehensive Cancer Network 2019), 2- previous chemoradiotherapy and 3- absence of disease progression at restaging. Data at diagnosis and at restaging were collected for each patient. The Quality of life was evaluated using the Euro Quality of Life Group Association Questionnaire (EQ-5D-5L). The questionnaire was administered to all patients before and after ECT. Results: From May 25, 2018 to November 26, 2019 five patients underwent ECT: in 4 cases, the tumors were located in the head and, in one, in the body of the pancreas. Preoperative chemotherapy consisted mainly of 6 cycles of modified folfirinox, while the radiotherapy consisted of 54 Gy (27 fractions). At restaging, the serum value of CA 19-9 and tumor size were reduced; however, the vascular involvement did not change. No downstaging was recorded. Intravenous bleomycin 15,000IU/m2 was given as a bolus, the ECT procedure was performed using at least 4 needles with a mean duration time of 27 minutes, (range 15-40). No postoperative mortality or major complications were reported. The mean length of stay was 8 days (range 5-14). Four patients were alive and well at the end of the study while one patient died from disease progression. The mean follow-up was 20.8 months (range 9-34) from diagnosis and 9.4 months (range 2-19) from ECT. The quality of life was good (EQ-5D-5L scale > 50 in all cases) and there was improvement in pain/discomfort with respect to the pre-treatment period in 3 out of 5 patients. Conclusions: Electrochemotherapy can be considered a simple, feasible and safe palliative additional treatment in LAPC without progression after chemoradiotherapy, and it seems to allow a good quality of life and pain improvement.

Histopathological diagnosis of appendiceal neuroendocrine neoplasms: when to perform a right hemicolectomy? A systematic review and meta-analysis

PURPOSE

The European Neuroendocrine Tumor Society (ENETS) guidelines advocate a right hemicolectomy (RHC) only in patients with appendiceal neuroendocrine neoplasms (aNENs) at risk for N+(node positive). The risk is defined using site, size, and grading of tumor as well as mesoappendiceal or lymphovascular invasion.

METHODS

A systematic review and meta-analysis was carried out. The data were reported using risk difference (RD) to define the risk of N+. The number needed to treat/harm (NNT/NNH) and the likelihood of being helped or harmed (LHH) were calculated using RD. Two strategies were considered: "to treat all" versus "to treat only patients having aNENs with risk stigmata". The aim was to evaluate the harm/benefit ratio related to the use of the ENETS lymph-nodal metastases (N+) risk factors.

RESULTS

Six studies were included involving a total of 261 patients. The RD (-0.30; P < 0.001) of N+ was significantly lower in aNENs ≤ 20 mm as compared to those >20 mm. One unnecessary RHC every five patients (NNT = 5) could be avoided while 1 patient with N+ every six patients (NNH = 6) remained untreated. The risk was lower than the benefits (LHH = 1.2). The RD NNT, NNH, and LHH values suggested that only a 15 mm cutoff and the presence of lymphovascular invasion could be considered useful.

CONCLUSIONS

An RHC should be performed in patients with aNENs >20 mm. The use of a 15 mm cutoff criterion had a similar outcome to that of a 20 mm cutoff. Lymphovascular invasion should only be considered a minor criterion. Selection based on other parameters should be avoided.

Adjuvant chemoradiation in pancreatic cancer: impact of radiotherapy dose on survival

BACKGROUND

To evaluate the impact of radiation dose on overall survival (OS) in patients treated with adjuvant chemoradiation (CRT) for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A multicenter retrospective analysis on 514 patients with PDAC (T1-4; N0-1; M0) treated with surgical resection with macroscopically negative margins (R0-1) followed by adjuvant CRT was performed. Patients were stratified into 4 groups based on radiotherapy doses (group 1: < 45 Gy, group 2: ≥ 45 and < 50 Gy, group 3: ≥ 50 and < 55 Gy, group 4: ≥ 55 Gy). Adjuvant chemotherapy was prescribed to 141 patients. Survival functions were plotted using the Kaplan-Meier method and compared through the log-rank test.

RESULTS

Median follow-up was 35 months (range: 3-120 months). At univariate analysis, a worse OS was recorded in patients with higher preoperative Ca 19.9 levels (≥ 90 U/ml; p < 0.001), higher tumor grade (G3-4, p = 0.004), R1 resection (p = 0.004), higher pT stage (pT3-4, p = 0.002) and positive nodes (p < 0.001). Furthermore, patients receiving increasing doses of CRT showed a significantly improved OS. In groups 1, 2, 3, and 4, median OS was 13.0 months, 21.0 months, 22.0 months, and 28.0 months, respectively (p = 0.004). The significant impact of higher dose was confirmed by multivariate analysis.

CONCLUSIONS

Increasing doses of CRT seems to favorably impact on OS in adjuvant setting. The conflicting results of randomized trials on adjuvant CRT in PDAC could be due to < 45 Gy dose generally used.

A cure model survival analysis of patients affected by small intestinal neuroendocrine neoplasms: the Bologna ENETS center experience

PURPOSE

The primary end-point was to evaluate the cure fraction. Secondary end-points were to investigate the time to cure, the excess of death risk, the probability of cure and the factors related to these parameters.

METHODS

Retrospective study of an ENETS database regarding patients affected by Si-NENs. For each patients, clinical, pathological and follow-up data were collected. The survival analysis was made using a novel approach: the cure model approach.

RESULTS

The cure fraction was 92.1%. The death risk, time to cure and the probability of cure were 6/1000 person-years, 3.6 years and 98.2%, respectively. The independent factors influencing these parameters were the grading and the R status (P = 0.041 and P = 0.017, respectively). Patients affected by Si-NENs G2 increased the death risk and time to cure respect to Si-NENs G1 (51 versus 6 per 1000 person-years and 5.1 versus 3.6 years, respectively) as well as patients not operated respect to those radically resected (R0/1) (66 versus 1 per 1000 person-years and 4.8 versus 0.4 years, respectively). The probability of cure decreased (88.1 versus 97.8% and 80.4 versus 99.7%, respectively). R2 resection shows better results than no resection.

CONCLUSIONS

A large portion of patients affected by Si-NENs can be cured. The highest probability of cure regards patients with Si-NENs G1 who underwent to R0/R1 resection; the lower, those with Si-NENs G2 and no resection. R2 resection seems to be preferred respect to no resection.

Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases

Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

Prognostic Impact of Presurgical CA19-9 Level in Pancreatic Adenocarcinoma: A Pooled Analysis

BACKGROUND: Presurgical carbohydrate antigen 19-9 (CA19-9) level predicts overall survival (OS) in resected pancreatic adenocarcinoma (PaC). The aim of this pooled analysis was to evaluate if presurgical CA19-9 level can also predict local control (LC) and distant metastasis-free survival (DMFS). METHODS: Seven hundred patients with PaC from eight institutions who underwent surgical resection ± adjuvant treatment between 2000 and 2014 were analyzed. Patients were divided based on four presurgical CA19-9 level cutoffs (5, 37, 100, 353 U/ml). Weibull regression model to identify independent predictors of OS on 404 patients with complete information was fitted. RESULTS: Median follow-up was 17 months (range: 2-225 months). Univariate analysis showed a better prognosis in pT1-2, pN0, diameter <30 mm, or grade 1 tumors and in patients undergoing R0 resection, distal pancreatectomy, or adjuvant chemotherapy and with lower CA19-9 levels. Five-year OS, LC, and DMFS were as follows: CA19-9 <5.0: 5.7%, 47.2%, 17.0%; CA19-9 5.1-37.0: 37.9%, 63.3%, 46.0%; CA19-9 37.1-100.0: 27.1%, 59.4%, 39.0%; CA19-9 100.1-353.0: 17.4%, 43.4%, 26.7%; CA19-9 >353.1: 10.9%, 50.2%, and 23.4%, respectively. At multivariate analysis, CA19-9 >100 and <353 level (P=.002), CA19-9 ≥353.1 (P<.001) level, G3 tumor (P=.002), and tumor diameter >30 mm (P<.001) correlated with worse OS. Patients treated with postoperative chemoradiation doses >50.0 Gy showed improved OS (P<.001). CONCLUSION: Presurgical CA19-9 predicts both OS and pattern of failure. Therefore, CA19-9 should be included in predictive models in order to customize treatments based on prognostic factors. Moreover, future studies should stratify patients according to presurgical CA19-9 level.