Risk factors for brain metastases in patients with metastatic colorectal cancer

BACKGROUND

Brain metastases (BM) from colorectal cancer (CRC) are rare, but the incidence is suspected to rise as treatment of metastatic (m) CRC improves. The aim of this study was to identify possible biological and clinical characteristics at initial presentation of mCRC that could predict later risk of developing BM. Furthermore, we wished to estimate the incidence of BM in long-term surviving patients.

MATERIAL AND METHODS

We conducted a retrospective study on a Danish multicenter cohort of patients with mCRC who received cetuximab and irinotecan (CetIri) as third-line treatment. All patients had previously progression on 5-FU, irinotecan and oxaliplatin containing regimens and received CetIri treatment independent of RAS mutations status. We subsequently performed KRAS, NRAS, BRAF, PIK3CA, PTEN, ERBB2 and EGFR sequencing of DNA extracted from primary tumor tissue.

RESULTS

Totally, 480 patients were included in our study. BM were diagnosed in 42 [8.8%; 95% confidence interval (CI) 6.4-11.6%] patients. Patients with BM had a significantly longer survival from mCRC diagnosis than non-BM patients (median = 32 versus 28 months, p = 0.001). On univariate cox regression analysis, the risk of developing BM was significantly increased in patients with rectal cancer (HR = 3.9; 95% CI = 1.2-13.3), metachronous metastatic disease (HR = 2.3; 95% CI = 1.2-4.4) and lung metastases (HR = 4.2; 95% CI = 2.2-7.9). On multivariate cox regression analysis only lung metastases were significantly associated BM (HR = 3.5; 95% CI = 1.8-6.8). None of the investigated mutations were associated with BM.

CONCLUSION

The incidence of BM was 8.8% in patients with mCRC who received third-line therapy. The most important risk factor for developing BM was lung metastases. Furthermore, rectal cancer, metachronous metastatic disease and long survival were linked to BM development.

Value of diffusion-weighted magnetic resonance imaging in predicting World Health Organization grade in G1/G2 pancreatic neuroendocrine tumors

The present study aimed to investigate the value of diffusion-weighted magnetic resonance imaging (DWI) in the grading of well-differentiated pancreatic neuroendocrine tumors (PanNETs). A total of 44 patients with histologically proven well-differentiated PanNET [grade 1 (G1) and grade 2 (G2) according to the World Health Organization (WHO) criteria] underwent pretreatment magnetic resonance imaging (MRI), which was retrospectively analyzed. The location, size, cystic or solid appearance, boundary, presence or absence of tumor contrast enhancement, and MRI signal of the tumor were assessed. Apparent diffusion coefficients (ADCs) within the primary tumor were measured on ADC maps. Receiver operating characteristic curves were used to determine ADC cut-off values and the sensitivity and specificity of the grade prediction. Spearman's rank correlation was utilized to probe the association between ADC value and PanNET grade or pathological parameters. G1 tumors exhibited a well-circumscribed border more often than G2 tumors. No marked differences were observed between PanNET G1 and PanNET G2 for cystic or solid appearance, enhancement, and T1- and T2-weighted imaging signals. Marked hyperintensities were more common in PanNET G2 tumors than in PanNET G1 tumors (P<0.01). The mean ADC values were statistically different between the normal pancreas and G1 and G2 tumors (P<0.01), and between PanNET G1 and PanNET G2 (P<0.05). Correlation analysis showed that ADC value was negatively correlated with PanNET grade, mitotic count and Ki-67 proliferation index (P<0.05). The cut-off ADC value was 0.930×10^-3 mm²/sec, which identified G2 tumors with 82.4% sensitivity and 79.5% selectivity. ADC value therefore represents a non-invasive and valuable imaging parameter in predicting the WHO grade of tumors in well-differentiated PanNET.

Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid-low rectal cancer following neoadjuvant chemoradiation therapy

PROPOSE

The use of robotic surgery and neoadjuvant chemoradiation therapy (CRT) for rectal cancer is increasing steadily worldwide. However, there are insufficient data on long-term outcomes of robotic surgery in this clinical setting. The aim of this study was to compare the 5-year oncological outcomes of laparoscopic vs. robotic total mesorectal excision for mid-low rectal cancer after neoadjuvant CRT.

MATERIALS AND METHODS

One hundred thirty-eight patients who underwent robotic (n = 74) or laparoscopic (n = 64) resections between January 2006 and December 2010 for mid and low rectal cancer after neoadjuvant CRT were identified from a prospective database. The long-term oncological outcomes of these patients were analyzed using prospective follow-up data.

RESULTS

The median follow-up period was 56.1 ± 16.6 months (range 11-101). The 5-year overall survival (OS) rate of the laparoscopic and robotic groups was 93.3 and 90.0 %, respectively, (p = 0424). The 5-year disease-free survival (DFS) rate was 76.0 % (laparoscopic) vs. 76.8 % (robotic) (p = 0.834). In a subgroup analysis according to the yp-stage (complete pathologic response, yp-stage I, yp-stage II, or yp-stage III), the between-group oncological outcomes were not significantly different. The local recurrence rate was 6.3 % (laparoscopic, n = 4) vs. 2.7 % (robotic, n = 2) (p = 0.308). The systemic recurrence rate was 15.6 % (laparoscopic, n = 10) vs. 18.9 % (robotic, n = 14) (p = 0.644). All recurrences occurred within less than 36 months in both groups. The median period of recurrence was 14.2 months.

CONCLUSION

Robotic surgery for rectal cancer after neoadjuvant CRT can be performed safely, with long-term oncological outcomes comparable to those obtained with laparoscopic surgery. More large-scale studies and long-term follow-up data are needed.

THE IMPACT OF CIRCADIAN RHYTHMS ON MEDICAL IMAGING AND RADIOTHERAPY REGIMES FOR THE PAEDIATRIC PATIENT

Daily rhythmic changes are found in cellular events in cell cycle, DNA repair, apoptosis and angiogenesis in both normal and tumour tissue, as well as in enzymatic activity and drug metabolism. In this paper, we hypothesize that circadian rhythms need to be considered in radiation protection and optimization in personalized medicine, especially for paediatric care. The sensitivity of the eye lens to ionizing radiation makes the case for limiting damage to the lens epithelium by planning medical radio-imaging procedures for the afternoon, rather than the morning. Equally, the tumour and normal tissue response to radiotherapy is also subject to diurnal variation enabling optimization of time of treatment.

Open Versus Laparoscopic Surgery for Rectal Cancer: Single-Center Results of 587 Cases

PURPOSE

We aimed to compare the short-term and long-term results of laparoscopic and open rectal resections.

METHODS

A total of 587 rectal cancer patients were included. The main measures were demographic data, duration of surgery, early postoperative results, pathologic data, and long-term follow-up.

RESULTS

There were no significant differences in demographic data, morbidity rate, tumor location, and sphincter-preservation rates between the 2 groups. The duration of surgery (155 vs. 173 min, P<0.001), time to gas passage, defecation, and solid food intake and length of hospital stay were significantly shorter in the laparoscopic group than the open group (P<0.05). According to the univariate and multivariate analysis, laparoscopic surgery did not have an effect on local recurrence but had a favorable effect on survival rates.

CONCLUSIONS

Laparoscopic rectal surgery has advantages over open surgery with respect to short-term and long-term clinical results and when performed in high-volume centers.

Pancreatic hardness: Correlation of surgeon’s palpation, durometer measurement and preoperative magnetic resonance imaging features

AIM

To evaluate the correlation between subjective assessments of pancreatic hardness based on the palpation, objective measurements using a durometer, and magnetic resonance imaging (MRI) findings for assessing pancreatic hardness.

METHODS

Eighty-three patients undergoing pancreatectomies were enrolled. An experienced surgeon subjectively evaluated the pancreatic hardness in the surgical field by palpation. The pancreatic hardness was also objectively evaluated using a durometer. Preoperative MRI findings were evaluated by a radiologist in terms of the apparent diffusion coefficient (ADC) values, the relative signal intensity decrease (RSID) of the pancreatic parenchyma, and the diameter of the pancreatic parenchyma and duct. Durometer measurement results, ADC values, RSID, pancreatic duct and parenchyma diameters, and the ratio of the diameters of the duct and parenchyma were compared between pancreases judged to be soft or hard pancreas on the palpation. A correlation analysis was also performed between the durometer and MRI measurements.

RESULTS

The palpation assessment classified 44 patients as having a soft pancreas and 39 patients as having a hard pancreas. ADC values were significantly lower in the hard pancreas group. The ductal diameter and duct-to-pancreas ratio were significantly higher in the hard pancreas group. For durometer measurements, a correlation analysis showed a positive correlation with the ductal diameter and the duct-to-pancreas ratio and a negative correlation with ADC values.

CONCLUSION

Hard pancreases showed lower ADC values, a wider pancreatic duct diameter and a higher duct-to-pancreas ratio than soft pancreases. Additionally, the ADC values, diameter of the pancreatic duct and duct-to-pancreas ratio were closely correlated with the durometer results.

Functional MRI for quantitative treatment response prediction in locally advanced rectal cancer

Despite advances in multimodality treatment strategies for locally advanced rectal cancer and improvements in locoregional control, there is still a considerable variation in response to neoadjuvant chemoradiotherapy (CRT). Accurate prediction of response to neoadjuvant CRT would enable early stratification of management according to good responders and poor responders, in order to adapt treatment to improve therapeutic outcomes in rectal cancer. Clinical studies in diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI have shown promising results for the prediction of therapeutic response in rectal cancer. DWI allows for assessment of tumour cellularity. DCE-MRI enables evaluation of factors of the tumour microvascular environment and changes in perfusion in response to treatment. Studies have demonstrated that predictors of good response to CRT include lower tumour pre-CRT apparent diffusion coefficient (ADC), greater percentage increase in ADC during and post CRT, and higher pre-CRT K^trans. However, the mean ADC and K^trans values do not adequately reflect tumour heterogeneity. Multiparametric MRI using quantitative DWI and DCE-MRI in combination, and a histogram analysis technique can assess tumour heterogeneity and its response to treatment. This strategy has the potential to improve the accuracy of therapeutic response prediction in rectal cancer and warrants further investigation.

Milk kefir: nutritional, microbiological and health benefits

Kefir is fermented milk produced from grains that comprise a specific and complex mixture of bacteria and yeasts that live in a symbiotic association. The nutritional composition of kefir varies according to the milk composition, the microbiological composition of the grains used, the time/temperature of fermentation and storage conditions. Kefir originates from the Caucasus and Tibet. Recently, kefir has raised interest in the scientific community due to its numerous beneficial effects on health. Currently, several scientific studies have supported the health benefits of kefir, as reported historically as a probiotic drink with great potential in health promotion, as well as being a safe and inexpensive food, easily produced at home. Regular consumption of kefir has been associated with improved digestion and tolerance to lactose, antibacterial effect, hypocholesterolaemic effect, control of plasma glucose, anti-hypertensive effect, anti-inflammatory effect, antioxidant activity, anti-carcinogenic activity, anti-allergenic activity and healing effects. A large proportion of the studies that support these findings were conducted in vitro or in animal models. However, there is a need for systematic clinical trials to better understand the effects of regular use of kefir as part of a diet, and for their effect on preventing diseases. Thus, the present review focuses on the nutritional and microbiological composition of kefir and presents relevant findings associated with the beneficial effects of kefir on human and animal health.

Modified docetaxel, cisplatin and capecitabine for stage IV gastric cancer in Japanese patients: A feasibility study

AIM

To evaluate the feasibility of chemotherapy including fluoropyrimidine, platinum and taxane with modified dosages for unresectable gastric cancer in Japanese patients.

METHODS

We performed a feasibility study of a modified docetaxel, cisplatin and capecitabine (DCX) regimen for stage IV gastric cancer. In particular, 30 or 40 mg/m² of docetaxel on day 1, 60 mg/m² of cisplatin on day 1, and 2000 mg/m² of capecitabine for 2 wk were administered every three weeks.

RESULTS

Three patients were treated with modified DCX (mDCX) with 30 mg/m² docetaxel, and five patients were treated with this regimen with 40 mg/m² docetaxel. Grade 3 or 4 neutropenia was observed in six of the eight patients; no patients exhibited febrile neutropenia. Partial response was achieved in four of the eight patients. Three patients underwent gastrectomy, which achieved R0 resection without residual tumors in dissected lymph nodes. In one of these three patients, resected specimens revealed pathological complete response in the primary lesion and in lymph nodes.

CONCLUSION

mDCX was well tolerated by Japanese patients with stage IV gastric cancer. This regimen might be useful for allowing gastric cancer patients with distant lymph node metastasis to undergo conversion surgery.

Pathologic complete response and disease-free survival are not surrogate endpoints for 5-year survival in rectal cancer: an analysis of 22 randomized trials

BACKGROUND

We performed a literature-based analysis of randomized clinical trials to assess the pathologic complete response (pCR) (ypT0N0 after neoadjuvant therapy) and 3-year disease-free survival (DFS) as potential surrogate endpoints for 5-year overall survival (OS) in rectal cancer treated with neoadjuvant (chemo)radiotherapy (CT)RT.

METHODS

A systematic literature search of PubMed, EMBASE, the Web of Science, SCOPUS, CINAHL, and the Cochrane Library was performed. Treatment effects on 3-year DFS and 5-year OS were expressed as rates of patients alive (%), and those on pCR as differences in pCR rates (∆^pCR%). A weighted regression analysis was performed at individual- and trial-level to test the association between treatment effects on surrogate (∆^pCR% and ∆^3yDFS) and the main clinical outcome (∆^5yOS).

RESULTS

Twenty-two trials involving 10,050 patients, were included in the analysis. The individual level surrogacy showed that the pCR% and 3-year DFS were poorly correlated with 5-year OS (R=0.52; 95% CI, 0.31-0.91; P=0.002; and R=0.60; 95% CI, 0.36-1; P=0.002). The trial-level surrogacy analysis confirmed that the two treatment effects on surrogates (∆^pCR% and ∆^3yDFS) are not strong surrogates for treatment effects on 5-year OS % (R=0.2; 95% CI, -0.29-0.78; P=0.5 and R=0.64; 95% CI, 0.29-1; P=0.06). These findings were confirmed in neoadjuvant CTRT studies but not in phase III trials were 3-year DFS could still represent a valid surrogate.

CONCLUSIONS

This analysis does not support the use of pCR and 3-year DFS% as appropriate surrogate endpoints for 5-year OS% in patients with rectal cancer treated with neoadjuvant therapy.

Clinical characteristics and treatment outcomes of patients with colorectal cancer who develop brain metastasis: a single institution experience

BACKGROUND

The development of brain metastasis (BM) in patients with colorectal cancer (CRC) is a rare and late event. We sought to investigate the clinical characteristics, disease course and safety using biologic agents in our patients with CRC who develop brain metastases.

METHODS

A retrospective review of patients with CRC with brain metastases treated at our institution from 01/2005-01/2015 was performed. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

Forty patients were included in the analysis. Median age was 55.5 years, 67.5% were males, and 28% had a KRAS mutation. Twenty-four percent were treatment-naive at the time of BM diagnosis. Patients had a median of two brain lesions. Sixty-five percent of the patients were treated with radiotherapy alone, 22.5% had both surgical resection and brain radiotherapy. Median overall survival was 3.2 months after development of BM. Overall survival was longer in patients who received combined modality local therapy compared to patients treated with surgical resection or radiotherapy alone. Patients who received systemic treatment incorporating biologics following development of BM had a median overall survival of 18.6 months. Overall, the administration of biologic agents was safe and well tolerated.

CONCLUSIONS

In summary, BM is an uncommon and late event in the natural history of metastatic CRC. The ability to deliver combined-modality local brain therapy as well as availability of more systemic therapy options appear to lead to improved outcomes.

The mitosis-specific marker phosphohistone-H3 (PHH3) is an independent prognosticator in uterine smooth muscle tumours: an outcome-based study

AIMS

Accurate mitosis counting, which is important in the diagnosis of uterine smooth muscle tumours (USMTs), is often difficult and subjective. The mitosis-specific immunohistochemical marker phosphohistone-H3 (PHH3) has been shown to be diagnostically useful, but its expression, in relation to outcome, has not been thoroughly investigated. The aim of this study is to evaluate PHH3 as a diagnostic and prognostic marker in USMTs.

METHODS AND RESULTS

PHH3 expression was evaluated in 55 leiomyosarcomas (LMSs), 26 smooth muscle tumours of uncertain malignant potential (STUMPs), 18 leiomyomas with bizarre nuclei (LBN), and 12 leiomyomas (LMs). Scores were expressed as counts per 10 high-power fields (HPFs). Median follow-up durations of patients with LMS, STUMP, LBN and LM were, respectively, 39, 78, 65.5 and 49.5 months. Twenty-eight patients with LMSs (50.9%) died, and two (7.7%) patients with STUMPs experienced recurrence. The median PHH3 scores for LMSs were significantly higher than those for other categories of tumour. A score of ≥29/10 HPFs was also independently associated with a poor outcome. To test whether the PHH3 score could distinguish between benign USMTs with atypical histology and those that were clinically malignant, two biological groups were further delineated. Patients in group 1 (18 LBNs and 24 STUMPs) all had an uneventful outcome, whereas patients in group 2 (two recurrent STUMPs and 32 LMSs) all had a recurrence or tumour-related death. Median PHH3 scores for the two groups were, respectively, 2/10 HPFs and 27/10 HPFs. A PHH3 score of ≥7/10 HPFs was highly associated with malignancy.

CONCLUSION

PHH3 is useful in evaluation of the biological behaviour of USMTs, and may serve as a prognostic indicator for LMSs.

Oxaliplatin-induced Peripheral Neuropathy in South Indian Cancer Patients: A Prospective Study in Digestive Tract Cancer Patients

Purpose:

The aim of the current study is to report our prospective experience on the prevalence of oxaliplatin-induced peripheral neuropathy (OXAIPN) in patients with digestive tract cancers treated with oxaliplatin-based combination therapy.

Materials and Methods:

A total of 219 patients scheduled to be treated with oxaliplatin-based combination therapy were prospectively examined at baseline and follow-up during the therapy between November 2014 and December 2016. The incidence of acute OXAIPN was measured using a descriptive questionnaire (yes/no question) based on sum of number of symptoms present and NCI-CTCAE version 4.03 was applied to clinically grade the severity of chronic OXAIPN.

Results:

Acute and chronic OXAIPN was found in 108 of 219 (49.3%) and 127 of 219 (58%) patients, respectively. Out of 11 acute OXAIPN symptoms, the vast majority of patients manifested cold-induced pharyngolaryngeal (63.8%) dysesthesias or perioral (61.1%) paresthesias. Development of acute OXAIPN was predictive of subsequent development of chronic OXAIPN (P = 0.0001). All the patients received a median cumulative dose of 780 mg/m² (range: 130–1040 mg/m²). There was a significant correlation between the patients who received the median cumulative dose and the development of chronic OXAIPN. The incidences of OXAIPN in patients with median cumulative dose of ≤780 mg/m² was 51/120 (42.5%) and >780 mg/m² was OXAIPN 76/99 (76.7%) (P = 0.0001).

Conclusion:

The current study results demonstrate that the vast majority of patients who receive oxaliplatin-based combination chemotherapy will manifest acute OXAIPN that may contribute to the development of chronic peripheral neuropathy on repeated courses of drug administration.

Comparison of intra-arterial chemoembolization with and without radiotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis: a meta-analysis

Purpose

Numerous studies have tried to combine transarterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC) with radiotherapy (RT) for the treatment of hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). However, the efficacy of TACE or HAIC combined with RT versus TACE or HAIC alone remains controversial. Thus, we performed a meta-analysis to compare the efficacy and safety of intra-arterial chemoembolization combined with RT versus intra-arterial chemoembolization alone for the treatment of HCC patients with PVTT.

Methods

PubMed, Embase, and Cochrane Library databases were systematically searched for eligible studies. Two authors independently reviewed the abstracts, extracted relevant data and rated the quality of studies. The major end points were objective response rate (ORR), overall survival (OS), and adverse events.

Results

Eight studies with a total of 1,760 patients were included in this meta-analysis. The pooled results showed that intra-arterial chemoembolization combined with RT significantly improved ORR of PVTT (OR, 4.22; 95% CI, 3.07–5.80; P<0.001) and OS (HR, 0.69; 95% CI, 0.57–0.83; P=0.001), but did not affect ORR of primary liver tumor (OR, 1.37; 95% CI, 0.67–2.79; P=0.390). The incidence of grade 3 or 4 leukopenia (OR, 5.80; 95% CI, 2.478–13.56; P<0.001) and thrombocytopenia (OR, 3.77; 95% CI, 1.06–13.43; P=0.041) was higher in the intra-arterial chemoembolization plus RT group than in the intra-arterial chemoembolization group.

Conclusion

Combination therapy of intra-arterial chemoembolization and RT for HCC patients with PVTT could bring higher ORR of PVTT and better survival benefits. This combination therapy was also associated with a significantly increased risk of adverse events. However, they were mostly mild to moderate and successfully treated with conservative treatment.

Polyvinyl alcohol terminal chemoembolization for hepatocellular carcinoma with hepatic arteriovenous shunts: Safety, efficacy, and prognostic factors

PURPOSE

To evaluate the safety and efficacy of polyvinyl alcohol (PVA) terminal chemoembolization and to identify the prognostic factors associated with survival in hepatocellular carcinoma (HCC) patients with hepatic arteriovenous shunts (HAVS).

MATERIALS AND METHODS

Of 133 patients' managements were retrospectively analyzed. HAVS was classified into three types: slow-flow, intermediate-flow and high-flow. The size of the PVA used was determined following the scheme: slow-flow HAVS: 300-500μm PVA; intermediate-flow HAVS: 500-710μm PVA; high-flow HAVS: 710-1000μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by PVA plus chemotherapeutic agents lipiodol emulsion, while the high-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by log-rank test. The influence of possible prognostic factors on survival were analyzed by multivariate Cox proportional-hazards method.

RESULTS

The median overall survival (OS) of 133 patients was 9.1 months. The median OS of the slow-flow type, intermediate-flow type and high-flow type patients were 10.8, 9.1 and 7.3 months, respectively. There was no statistically significant difference among different HAVS types (P=0.239). The 30-day mortality was 3.8%. Cox multivariate survival analysis revealed that initial preoperative AFP value≥400ng/ml (HR=2.105, P=0.006) was an independent risk factor. While multiple embolization (HR=0.482, P=0.011), tumor remission (HR=0.431, P=0.041) and multimodality therapy (HR=0.416, P=0.004) were independent protection factors.

CONCLUSION

It is safe and effective for HCCs with HAVS treated by terminal chemoembolization therapy with PVA plus chemotherapeutic agents lipiodol emulsion (or PVA plus chemotherapeutic agents). The HCCs with HAVS achieves good prognosis with multiple embolization, tumor remission and multimodality therapy, while achieves poor prognosis with inital preoperative high AFP value (≥400ng/ml).

Determinants and prognostic implications of malignant ascites in metastatic papillary renal cancer

OBJECTIVE

To describe the incidence of ascites in metastatic papillary renal cell cancer (pRCC), identify the factors associated with its development and evaluate its prognostic effect on the survival of these patients.

METHODS

A retrospective evaluation of the medical records of patients with metastatic pRCC seen at National Cancer Institute (2000-2014) was undertaken. Logistic regression to identify predictors of the development of malignant ascites and Kaplan-Meier analysis to estimate survival was done.

RESULTS

Overall, 106 consecutive patients with metastatic pRCC were identified; sufficient data were available in 100 patients to enable assessment of ascites. Further, 20% had evidence of malignant ascites. Median age at diagnosis of ascites was 48.0 years (26.1-76.6 years) and median time to development of ascites from initial diagnosis of metastatic disease was 16.0 (0-73.3) months. There was no significant difference in the incidence of ascites between patients with hereditary and sporadic pRCC (P = 0.803) or among patients with different subtypes of pRCC (P = 0.456). Elevated platelet-lymphocyte ratio predicted development of malignant ascites in our cohort (P = 0.009). Median overall survival was shorter for patients who developed ascites [25.0 (10.2-39.8) months] compared with patients who did not develop this complication [42.5 (30.5-54.4) months, P = 0.041].

CONCLUSION

To our knowledge, this is the first systematic evaluation of the incidence, predictors, and prognostic effect of ascites in metastatic pRCC. Malignant ascites is a common manifestation of metastatic pRCC and is associated with a shorter overall survival. An elevated platelet-lymphocyte ratio predicts a higher risk of developing malignant ascites.

A Retrospective Analysis on Two-week Short-course Pre-operative Radiotherapy in Elderly Patients with Resectable Locally Advanced Rectal Cancer

To validate that a two-week short-course pre-operative radiotherapy regimen is feasible, safe, and effective for the management of elderly patients with locally advanced rectal cancer (LARC), we retrospectively analyzed 99 radiotherapy-naive patients ≥70 years of age with LARC. Patients received pelvic radiation therapy (3D-CRT 30Gy/10f/2w) followed by TME surgery; some patients received adjuvant chemotherapy. The primary endpoint was OS, while the secondary endpoints were DFS, safety and response rate. The median follow-up time was 5.1 years. The 5-year OS and DFS rates were 58.3% and 51.2%, respectively. The completion rate of radiotherapy (RT) was 99.0% (98 of 99). Grade 3 acute adverse events, which resulted from RT, occurred in only 1 patient (1.0%). In addition, no grade 4 acute adverse events induced by RT were observed. All 99 patients (100%) were able to undergo R0 surgical resection, and 68.6% of the patients received sphincter-sparing surgery. The rate of occurrence of clinically relevant post-operative complications was 12.1%. Three patients (3.0%) achieved pathologic complete responses, and forty-three patients (43.4%) achieved pathologic partial responses. The rates of T-downsizing and N-downstaging were 30.3% and 55.7%, respectively. Therefore, we believe that a two-week short-course pre-operative radiotherapy is feasible in elderly patients with resectable LARC.

Analysis of patients with colorectal cancer and brain metastases

Brain metastases from colorectal cancer (CRC) are relatively rare. However, the incidences of brain metastasis have increased. We investigated 516 CRC patients who developed recurrence or metastatic disease. We investigated the primary site, distant metastasis, histological type, clinical features of processes of death and neurological symptoms. Brain metastases were detected in 5.8%. Odds ratios were 6.89 for the lung metastasis (p < 0.001), 0.43 for the liver (p = 0.04). The survival after brain metastasis was significantly poor in multiple brain metastases (hazard ratio: 4.12; p = 0.03) and poor performance status (hazard ratio: 5.38; p = 0.003). Lung metastasis is a higher factor and liver metastasis is a lower factor of brain metastasis. Survival after brain metastasis was poor in multiple brain metastasis and poor performance status.

Trans-arterial radioembolization in intermediate-advanced hepatocellular carcinoma: systematic review and meta-analyses

Trans-arterial radioembolization (TARE) is a recognized, although not explicitly recommended, experimental therapy for unresectable hepatocellular carcinoma (HCC).A systematic literature review was performed to identify published studies on the use of TARE in intermediate and advanced stages HCC exploring the efficacy and safety of this innovative treatment.Twenty-one studies reporting data on overall survival (OS) and time to progression (TTP), were included in a meta-analysis. The pooled post-TARE OS was 63% (95% CI: 56-70%) and 27% (95% CI: 21-33%) at 1- and 3-years respectively in intermediate stage HCC, whereas OS was 37% (95% CI: 26-50%) and 13% (95% CI: 9-18%) at the same time intervals in patients with sufficient liver function (Child-Pugh A-B7) but with an advanced HCC because of the presence of portal vein thrombosis. When an intermediate and advanced case-mix was considered, OS was 58% (95% CI: 48-67%) and 17% (95% CI: 12-23%) at 1- and 3-years respectively. As for TTP, only four studies reported data: the observed progression probability was 56% (95% CI: 41-70%) and 73% (95% CI: 56-87%) at 1 and 2 years respectively. The safety analysis, focused on the risk of liver decompensation after TARE, revealed a great variability, from 0-1% to more than 36% events, influenced by the number of procedures, patient Child-Pugh stage and treatment duration.Evidence supporting the use of radioembolization in HCC is mainly based on retrospective and prospective cohort studies. Based on this evidence, until the results of the ongoing randomized trials become available, radioembolization appears to be a viable treatment option for intermediate-advanced stage HCC.

D2-resected stage IIIc gastric cancer patients benefit from adjuvant chemoradiotherapy

Although adjuvant chemoradiotherapy has been an important part in the treatment of gastric cancer, whether or not adjuvant radiation can benefit patients undergoing resection with D2 lymph node dissection remains controversial. This retrospective study aimed to evaluate the role of adjuvant chemoradiotherapy on patients with D2‐resected gastric cancer. A total of 337 patients with resected gastric cancer treated at Zhongnan Hospital of Wuhan University from 2004 to 2012 were retrospectively analyzed. Eligible patients were divided into the adjuvant chemoradiotherapy group (CRT; n = 124) and the adjuvant chemotherapy group (CT; n = 213). The primary endpoints were disease‐free survival (DFS) and overall survival (OS), with toxicity as the secondary endpoint. A subgroup analysis was performed based on clinical staging. The two groups were comparable in baseline characteristic, except for the number of lymph nodes dissected. The median OSs in the CRT and CT groups were 51.0 months and 48.6 months, respectively (P = 0.251), and the median DFSs were 40.7 months and 31.2 months, respectively (P = 0.112). Subgroup analysis revealed that the median OSs in patients at stage IIIc in the CRT group and CT group were 29.0 and 23.0 months, respectively (P = 0.049), and those of the median DFSs were 21.2 and 15.1 months, respectively (P = 0.015). There was no significant difference in main adverse events between two groups. Collectively, adjuvant chemoradiotherapy in gastric cancer patients with D2 resection was well tolerated. For Stage IIIc patients, the addition of adjuvant chemoradiotherapy was associated with a significant benefit in both OS and DFS.

Long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision of mid-low rectal cancer following neoadjuvant chemoradiation therapy

PROPOSE

The use of robotic surgery and neoadjuvant chemoradiation therapy (CRT) for rectal cancer is increasing steadily worldwide. However, there are insufficient data on long-term outcomes of robotic surgery in this clinical setting. The aim of this study was to compare the 5-year oncological outcomes of laparoscopic vs. robotic total mesorectal excision for mid-low rectal cancer after neoadjuvant CRT.

MATERIALS AND METHODS

One hundred thirty-eight patients who underwent robotic (n = 74) or laparoscopic (n = 64) resections between January 2006 and December 2010 for mid and low rectal cancer after neoadjuvant CRT were identified from a prospective database. The long-term oncological outcomes of these patients were analyzed using prospective follow-up data.

RESULTS

The median follow-up period was 56.1 ± 16.6 months (range 11-101). The 5-year overall survival (OS) rate of the laparoscopic and robotic groups was 93.3 and 90.0 %, respectively, (p = 0424). The 5-year disease-free survival (DFS) rate was 76.0 % (laparoscopic) vs. 76.8 % (robotic) (p = 0.834). In a subgroup analysis according to the yp-stage (complete pathologic response, yp-stage I, yp-stage II, or yp-stage III), the between-group oncological outcomes were not significantly different. The local recurrence rate was 6.3 % (laparoscopic, n = 4) vs. 2.7 % (robotic, n = 2) (p = 0.308). The systemic recurrence rate was 15.6 % (laparoscopic, n = 10) vs. 18.9 % (robotic, n = 14) (p = 0.644). All recurrences occurred within less than 36 months in both groups. The median period of recurrence was 14.2 months.

CONCLUSION

Robotic surgery for rectal cancer after neoadjuvant CRT can be performed safely, with long-term oncological outcomes comparable to those obtained with laparoscopic surgery. More large-scale studies and long-term follow-up data are needed.

Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer

AIM

To investigate the prognostic effect of a delayed interval between neoadjuvant chemoradiotherapy (CRT) and surgery in locally advanced rectal cancer.

METHODS

We evaluated 87 patients with locally advanced mid- or distal rectal cancer undergoing total mesorectal excision following an interval period after neoadjuvant CRT at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul between January 2009 and January 2014. Patients were divided into two groups according to the interval before surgery: < 8 wk (group I) and ≥ 8 wk (group II). Data related to patients, cancer characteristics and pathological examination were collected and analyzed.

RESULTS

When the distribution of timing between group I (n = 45) and group II (n = 42) was viewed, comparison of interval periods (median ± SD) of groups showed a significant difference of as 5 ± 1.28 wk in group I and 10.1 ± 2.2 wk in group II (P < 0.001). The median follow-up period for all patients was 34.5 (9.9-81) mo. group II had significantly higher rates of pathological complete response (pCR) than group I had (19% vs 8.9%, P = 0.002). Rate of tumor regression grade (TRG) poor response was 44.4% in group I and 9.5% in group II (P < 0.002). A poor pathological response was associated with worse disease-free survival (P = 0.009). The interval time did not show any association with local recurrence (P = 0.79).

CONCLUSION

Delaying the neoadjuvant CRT-surgery interval may provide nodal down-staging, improve pCR rate, and decrease the rate of TRG poor response.

Management of hepatocellular carcinoma with portal vein tumor thrombosis: Review and update at 2016

Portal vein tumor thrombosis (PVTT) is a common phenomenon in hepatocellular carcinoma (HCC). Compared to HCC without PVTT, HCC with PVTT is characterized by an aggressive disease course, worse hepatic function, a higher chance of complications related to portal hypertension and poorer tolerance to treatment. Conventionally, HCC with PVTT is grouped together with metastatic HCC during the planning of its management, and most patients are offered palliative treatment with sorafenib or other systemic agents. As a result, most data on the management of HCC with PVTT comes from subgroup analyses or retrospective series. In the past few years, there have been several updates on management of HCC with PVTT. First, it is evident that HCC with PVTT consists of heterogeneous subgroups with different prognoses. Different classifications have been proposed to stage the degree of portal vein invasion/thrombosis, suggesting that different treatment modalities may be individualized to patients with different risks. Second, more studies indicate that more aggressive treatment, including surgical resection or locoregional treatment, may benefit select HCC patients with PVTT. In this review, we aim to discuss the recent conceptual changes and summarize the data on the management of HCC with PVTT.

Effect of intraperitoneal cetuximab administration on colonic anastomosis and early postoperative adhesion formation in a rat model

OBJECTIVE

We aimed to evaluate the effect of intraperitoneal cetuximab administration on the healing of anastomosis and development of early adhesion formation in a rat model.

MATERIALS AND METHODS

Twenty-four female rats were used. A colon segment was resected and end-to-end anastomosis was performed. The rats were randomized into three groups after the performance of colonic anastomosis and received 10 mL of intraperitoneal solution including study drugs after closure of abdominal cavity: normal saline was administered to the normal saline group (n=8), cetuximab (400 mg/m(2)) was administered to the postoperative 1 group (n=8) 1 day after surgery, and cetuximab (400 mg/m(2)) was administered to the peroperative group (n=8) during surgery.

RESULTS

The mean adhesion grade was 2.63±0.92, and 0.50±0.76 and 0.63±0.74 for control and test groups, respectively. Cetuximab reduced adhesion formation in test groups (p<0.05). When all groups were compared, it was found that vascular endothelial growth factor levels decreased significantly only in the abdomen (p<0.05). Hydroxyproline levels and anastomosis bursting pressure were examined, and a statistical difference was found between groups (hydroxyproline p<0.05, bursting pressure p<0.05). However, when postoperative 1 day group was compared with the control group, it was found that there was no difference between groups according to these parameters (p>0.05), but when peroperative group was compared with the control group a significant decrease was observed in both parameters. Histopathological healing score was also evaluated. No statistical difference between groups was found.

CONCLUSION

Twenty-four hours later from the operation, intraperitoneal cetuximab therapy may be a safe and feasible treatment for metastatic colorectal patients.

Kefir: a multifaceted fermented dairy product

Kefir is a fermented dairy beverage produced by the actions of the microflora encased in the "kefir grain" on the carbohydrates in the milk. Containing many bacterial species already known for their probiotic properties, it has long been popular in Eastern Europe for its purported health benefits, where it is routinely administered to patients in hospitals and recommended for infants and the infirm. It is beginning to gain a foothold in the USA as a healthy probiotic beverage, mostly as an artisanal beverage, home fermented from shared grains, but also recently as a commercial product commanding shelf space in retail establishments. This is similar to the status of yogurts in the 1970s when yogurt was the new healthy product. Scientific studies into these reported benefits are being conducted into these health benefits, many with promising results, though not all of the studies have been conclusive. Our review provides an overview of kefir's structure, microbial profile, production, and probiotic properties. Our review also discusses alternative uses of kefir, kefir grains, and kefiran (the soluble polysaccharide produced by the organisms in kefir grains). Their utility in wound therapy, food additives, leavening agents, and other non-beverage uses is being studied with promising results.

Pancreatic cancer

Pancreatic cancer is a highly lethal disease, for which mortality closely parallels incidence. Most patients with pancreatic cancer remain asymptomatic until the disease reaches an advanced stage. There is no standard programme for screening patients at high risk of pancreatic cancer (eg, those with a family history of pancreatic cancer and chronic pancreatitis). Most pancreatic cancers arise from microscopic non-invasive epithelial proliferations within the pancreatic ducts, referred to as pancreatic intraepithelial neoplasias. There are four major driver genes for pancreatic cancer: KRAS, CDKN2A, TP53, and SMAD4. KRAS mutation and alterations in CDKN2A are early events in pancreatic tumorigenesis. Endoscopic ultrasonography and endoscopic ultrasonography-guided fine-needle aspiration offer high diagnostic ability for pancreatic cancer. Surgical resection is regarded as the only potentially curative treatment, and adjuvant chemotherapy with gemcitabine or S-1, an oral fluoropyrimidine derivative, is given after surgery. FOLFIRINOX (fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nanoparticle albumin-bound paclitaxel (nab-paclitaxel) are the treatments of choice for patients who are not surgical candidates but have good performance status.

Chronomodulated oxaliplatin plus Capecitabine (XELOX) as a first line chemotherapy in metastatic colorectal cancer: A Phase II Brunch regimen study

PURPOSE

The aim of this study was to evaluate safety and toxicity of chronomodulated capecitabine administered in the morning and at noon according to a specific time schedule (Brunch Regimen: Breakfast and Lunch) as a part of first-line XELOX chemotherapy in patients with metastatic colorectal cancer.

METHODS

A total of 30 treatment-naïve colorectal cancer patients with metastatic disease were included. Oxaliplatin 130 mg/m(2) on day 1 plus chronomodulated oral capecitabine 2000 mg/m(2) per day were administered (50 % dose at 8:00 a.m. and 50 % dose at 12:00 noon on days 1-14, every 21 days). All adverse events, treatment responses and survival were evaluated. In addition, pharmacokinetic profile of capecitabine was examined in a subset of 5 patients.

RESULTS

Median age was 57.1 years (range 32-77 years). Median follow-up was 19 months (range 3-36 months). Three patients (10 %) had complete response, 13 patients (43.3 %) had partial response and 4 patients (13.3 %) had stabile disease. Ten patients had progressive disease at their first evaluation (33.3 %). The median progression-free survival (PFS) was 10 months (range 2-36 months). There were no grade 4 toxicities. One patient (3.3 %) had grade 3 neutropenia. Hand-foot syndrome developed in three patients (10 %): 6.6 %, grade 1 and 3.3 %, grade 2.

CONCLUSIONS

Chronomodulated XELOX seems to represent a promising therapeutic option in the first-line treatment of metastatic colorectal carcinoma due to good tumor control and favorable toxicity profile. Phase III randomized trials are required to assess the actual clinical efficacy and side effect profile of this regimen.

Treatment Interval between Neoadjuvant Chemoradiotherapy and Surgery in Rectal Cancer Patients: A Population-Based Study

Background

Neoadjuvant chemoradiation therapy (CRT) has been widely implemented in the treatment of rectal cancer patients, but optimal timing of surgery after neoadjuvant therapy is unclear. The purpose of this study was to evaluate the effects of prolonged intervals between long-course CRT and surgery in rectal cancer patients.

Methods

Data on all rectal cancer patients diagnosed between 2006 and 2011 were retrieved from the population-based Netherlands Cancer Registry; the main outcome parameters were pathologic complete response (pCR) and overall survival (OS). Outcomes were reported separately for patients with early tumors (ETs; N = 217) and locally advanced rectal cancer (LARC; N = 1073). Patients were divided into 2-week interval groups according to treatment interval, ranging from 5–6 to 13–14 weeks. Kaplan–Meier curves, and logistic regression and Cox regression models were used for data analysis.

Results

No significant difference in pCR rate was observed for ET patients according to treatment interval. Compared with a treatment interval of 7–8 weeks, pCR rates in LARC patients were higher after 9–10 weeks (18.4 %; odds ratio [OR] 1.56, 95 % CI 1.03–2.37) and 11–12 weeks of treatment interval (20.8 %; OR 1.94, 95 % CI 1.15–3.26). Treatment interval did not influence OS in ET or LARC patients.

Conclusions

Treatment intervals of 9–12 weeks between surgery and CRT seem to improve the chances of pCR in LARC patients, without an effect on OS. The length of treatment interval did not affect outcomes in patients with ET. The ongoing search for minimally invasive surgery drives the need for exploration of factors that improve pathologic response.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-016-5294-0) contains supplementary material, which is available to authorized users.

The Correlation of Plasma 25-Hydroxyvitamin D Deficiency With Risk of Breast Neoplasms: A Systematic Review

CONTEXT

Breast cancer has been considered as one of the most common types of cancer among the women worldwide, and patients with breast neoplasms have been reported with high prevalence of low serum 25-hydroxyvitamin D levels.

OBJECTIVES

Our aim was to evaluate the correlation of plasma 25-hydroxyvitamin D deficiency with breast neoplasms risk among women.

DATA SOURCES

PubMed database was searched with MeSH (medical subject headings) keywords "vitamin D AND breast neoplasms" which was restricted by original articles written only in English and published from January 1, 2014.

STUDY SELECTION

To find the articles that met eligibility criteria, titles and abstracts were examined.

DATA EXTRACTION

This systematic review was conducted according to PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement. Critical appraising of evidence was performed, using the study quality assessment tools of national institutes of health, national heart, lung and blood institute (NHLBI).

RESULTS

Overall, 76 potential articles were identified and after screening, 13 articles met eligible criteria for inclusion. Definition of low vitamin D levels varied greatly among studies, making comparisons difficult, but most of them have defined deficiency as 25(OH)D < 20 ng/mL. Evidence was mainly of fair quality.

CONCLUSIONS

This study has provided evidence that vitamin D deficiency has been very prevalent in patients with breast neoplasms, more than comparable matched control population, and risk of breast cancer has increased with low vitamin D levels, suggesting the need for high quality studies that assessed the health consequences attributable to vitamin D deficiency employing standard definitions.

Systematic review: brain metastases from colorectal cancer--Incidence and patient characteristics

Background

Brain metastases (BM) from colorectal cancer (CRC) are a rare event. However, the implications for affected patients are severe, and the incidence has been reported to be increasing. For clinicians, knowledge about the characteristics associated with BM is important and could lead to earlier diagnosis and improved survival.

Method

In this paper, we describe the incidence as well as characteristics associated with BM based on a systematic review of the current literature, following the PRISMA guidelines.

Results

We show that the incidence of BM in CRC patients ranges from 0.6 to 3.2 %. BM are a late stage phenomenon, and young age, rectal primary and lung metastases are associated with increased risk of developing BM. Molecular markers such as KRAS, BRAF, NRAS mutation as well as an increase in CEA and CA19.9 levels are suggested predictors of brain involvement. However, only KRAS mutations are reasonably well investigated and associated with an increased risk of BM.

Conclusion

The incidence of BM from CRC is 0.6 to 3.2 % and did not seem to increase over time. Development of BM is associated with young age, lung metastases, rectal primary and KRAS mutation. Increased awareness of brain involvement in patients with these characteristics is necessary.

How to reduce the laparoscopic colorectal learning curve

Background:

The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.

Methodology:

From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.

Results:

Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70.

Conclusions:

The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12.

What is new in this paper?

The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.

Evaluation of the Added Value of Diffusion-Weighted Imaging to Conventional Magnetic Resonance Imaging in Pancreatic Neuroendocrine Tumors and Comparison With 68Ga-DOTANOC Positron Emission Tomography/Computed Tomography

OBJECTIVES

The aims of this study were to investigate the added value of diffusion-weighted imaging (DWI) in pancreatic neuroendocrine tumor (pNET) evaluation and to compare magnetic resonance imaging (MRI) to Ga-DOTANOC positron emission tomography/computed tomography (PET/CT) results.

METHODS

Morphological MRI (T2-weighted [T2-w] + contrast-enhanced [CE] T1-w) and DWI (T2-w + DWI) and Ga-DOTANOC PET/CT in 25 patients/30 pNETs were retrospectively evaluated. Per-patient and per-lesion detection rates (pDR and lDR, respectively) were calculated. Apparent diffusion coefficient values were compared among pNET and surrounding and normal pancreas (control group, 18 patients). Apparent diffusion coefficient and standardized uptake value (SUV) values were compared among different grading and staging groups.

RESULTS

No statistically significant differences in PET/CT and MRI session detection rates were found (morphological MRI and DW-MRI, 88% pDR and 87% lDR; combined evaluation, 92% pDR and 90% lDR; Ga-DOTANOC PET/CT, 88% pDR and 80% lDR). Consensus reading (morphological/DW-MRI + PET/CT) improved pDR and lDR (100%). Apparent diffusion coefficient mean value was significantly lower compared with surrounding and normal parenchyma (P < 0.01). The apparent diffusion coefficient and SUV values of pNETs among different grading and staging groups were not statistically different.

CONCLUSIONS

Conventional MRI, DW-MRI + T2-w sequences, and Ga-DOTANOC PET/CT can be alternative tools in pNET detection. Diffusion-weighted MRI could be valuable in patients with clinical suspicion but negative conventional imaging findings. However, the consensus reading of the 3 techniques seems the best approach.

Predicted survival in patients with brain metastases from colorectal cancer: Is a current nomogram helpful?

OBJECTIVE

To examine the clinical applicability of a new nomogram by comparing survival of patients with brain metastases from colorectal cancer treated with surgery and/or radiotherapy in the authors' institutions with nomogram-predicted median survival.

METHODS

Retrospective analysis of 64 patients treated with comparable approaches and during the same time period as the patients in the nomogram study. Points were assigned for age, performance status, number and site of brain metastases, as required for nomogram use.

RESULTS

In 46 patients (72%), the observed survival was shorter than the predicted median. The median deviation was -1.4 months. The nomogram underestimated the survival of patients treated with radiosurgery/surgery by a median of 4.2 months, whereas it overestimated the survival of patients treated with whole-brain radiotherapy (WBRT) by a median of 2.1 months (p=0.0001). Nevertheless, all 5 patients with predicted median survival ≤3 months died within 3 months. Among 8 patients with predicted median survival >12 months, 6 (75%) survived for >12 months. Not all prognostic factors in the nomogram correlated with survival. In the multivariate Cox model, only performance status and number of brain metastases were significant, both with p=0.0001.

CONCLUSION

Despite differences in prognostic factors and survival of many individual patients, especially those with intermediate prognosis, the nomogram performed promising in poor- and good-prognosis patients. Evaluation of separate prediction tools for patients treated with WBRT and more aggressive local approaches appears warranted in order to minimize the influence of better local control of the brain metastases.

Robotic Surgery for Rectal Cancer: An Update in 2015

During the last decade, robotic surgery for rectal cancer has rapidly gained acceptance among colorectal surgeons worldwide, with well-established safety and feasibility. The lower conversion rate and better surgical specimen quality of robotic compared with laparoscopic surgery potentially improves survival. Earlier recovery of voiding and sexual function after robotic total mesorectal excision is another favorable outcome. Long-term survival data are sparse with no evidence that robotic surgery offers major benefits in oncological outcomes. Although initial reports are promising, more rigorous scientific evaluation in multicenter, randomized clinical trials should be performed to definitely determine the advantages of robotic rectal cancer surgery.

Clinicopathological features of primary angiosarcoma of the kidney: a review of 62 cases

Angiosarcoma (AS) is a malignant tumor occurring in less than 2% of soft tissue sarcomas. Primary involvement of the kidney is rare, its pathogenesis remains largely unknown and it has overlapping features with other tumors of the kidney. The objective of this paper is to review the case reports of primary AS of the kidney in the literature. The search terms were primary AS of the kidney, primary renal AS and primary renal hemangiosarcoma. The total cohort of the cases reviewed was 62. The mean age of presentation was 61 years old with a predilection for the male sex. Metastatic disease at the time of diagnosis accounted for 44.9% (22/49) of the cases reported and 44.4% (12/27) of patients with non-metastatic disease at diagnosis, subsequently developed metastasis. Primary AS of the kidney is a rare malignant tumor with a poor prognosis. Local recurrence and distant metastasis is common. Primary AS of the kidney shares similar clinical presentation with other renal tumors and imaging does not allow for tumor specific diagnosis. Histopathological examination and immunohistochemistry is very important for the confirmation of the diagnosis. Current treatment options include a variable combination of surgery, radiotherapy and chemotherapy.

Randomized multicenter phase III study of a modified docetaxel and cisplatin plus fluorouracil regimen compared with cisplatin and fluorouracil as first-line therapy for advanced or locally recurrent gastric cancer

BACKGROUND

The V325 study showed that docetaxel, cisplatin, and fluorouracil (DCF) prolonged overall survival (OS) of patients with advanced gastric cancer, but with a high incidence of dose-limiting toxicities. We investigated the efficacy and safety of a modified DCF (mDCF) regimen for Chinese patients with advanced gastric cancer.

METHODS

Untreated advanced gastric cancer patients randomly received docetaxel and cisplatin at 60 mg/m(2) (day 1) followed by fluorouracil at 600 mg/m(2)/day (days 1-5; mDCF regimen) or cisplatin at 75 mg/m(2) (day 1) followed by fluorouracil at 600 mg/m(2)/day (days 1-5; CF) every 3 weeks. The primary end point was progression-free survival (PFS). The secondary end points were OS, overall response rate (ORR), time-to-treatment failure (TTF), and safety.

RESULTS

In total, 243 patients were randomized to treatment (mDCF regimen 121; CF 122). Compared with CF, the mDCF regimen significantly improved PFS and OS: the median PFS was 7.2 and 4.9 months, respectively [hazard ratio (HR) 0.58, log-rank P = 0.0008], and the median OS was 10.2 and 8.5 months, respectively (HR = 0.71, P = 0.0319). Additionally, the mDCF regimen improved the parameters used as secondary objectives: the ORR was 48.7% with the mDCF regimen versus 33.9% with CF (P = 0.0244); the median TTF was 3.4 months with the mDCF regimen and 2.4 months with CF (HR = 0.67, P = 0.0027). Grade 3 and grade 4 treatment-related adverse events occurred in 77.3 % of patients who received the mDCF regimen versus 46.1% of patients who received CF (P < 0.001).

CONCLUSIONS

The mDCF regimen, compared with CF, significantly prolonged PFS and OS and enhanced ORR of Chinese patients with advanced gastric cancer. The mDCF regimen achieved efficacy comparable to that of DCF but with fewer toxicities, which is appropriate for the Chinese population.

The Correlation Between Diffusion-Weighted Imaging at 3.0-T Magnetic Resonance Imaging and Histopathology for Pancreatic Ductal Adenocarcinoma

PURPOSE

The aim of this study was to discuss the correlation between diffusion-weighted imaging (DWI) at 3.0-T magnetic resonance and histopathology for pancreatic ductal adenocarcinoma (PDA).

MATERIALS AND METHODS

Twenty-eight patients with histopathologically proven PDA were included in this study after 108 cases of suspected pancreatic tumors had been performed with DWI. The sequences of DWI included respiratory-triggered DWI and breath-hold DWI, which were performed with 2 b values (0 and 500 s/mm; 0 and 1000 s/mm), respectively. According to magnetic resonance images, wax blocks and slices were selected and stained with hematoxylin-eosin for anti-vascular endothelial growth factor (VEGF), anti-CD34, and anti-Ki-67 (Mib-1). The relationship between tumor apparent diffusion coefficient (ADC) and tumor fibrosis, as well as the expression of tumor VEGF, Ki-67, and multivessel density (MVD), were studied.

RESULTS

The ADC values of PDA of different grades of differentiation and fibrosis grade did not show statistically significant difference. The ADC values of PDA did not show the statistically significant correlation with the grades of differentiation, fibrosis grade, Ki-67 expression, and expression of VEGF and MVD.

CONCLUSIONS

The ADC of PDA cannot be used to reflect grades of differentiation, degree of tumor fibrosis, the expression of VEGF, the expression of Ki-67, and the tumor MVD.

Outcomes and Predictors of Toxicity after Selective Internal Radiation Therapy Using Yttrium-90 Resin Microspheres for Unresectable Hepatocellular Carcinoma

Purpose

We sought to report outcomes and toxicity in patients with hepatocellular carcinoma (HCC) who received resin yttrium-90 selective internal radiation therapy (⁹⁰Y-SIRT) and to identify factors associated with declining liver function.

Methods

Patients treated with ⁹⁰Y-SIRT were retrospectively evaluated. Radiographic response was assessed using RECIST 1.1. Median liver progression-free survival (LPFS) and overall survival (OS) were calculated using the Kaplan–Meier method. Bivariate analysis was used to examine associations between change in Child-Pugh (CP) score/class and patient characteristics and treatment parameters.

Results

Twenty-seven patients with unresectable HCC underwent SIRT, 52% were CP Class A, 48% were Class B, 11% were BCLC stage B, and 89% were stage C. Forty-four percent of patients had portal vein thrombus at baseline. One-third of patients received bilobar treatment. Median activity was 32.1 mCi (range 9.18–43.25) and median-­absorbed dose to the liver was 39.6 Gy (range 13.54–67.70). Median LPFS and OS were 2.5 and 11.7 months, respectively. Three-month disease control rate was 63 and 52% in the target lesions and whole liver, respectively. New onset or worsened from baseline clinical toxicities were confined to Grade 1–2 events. However, new or worsened Grade 3–4 laboratory toxicities occurred in 38% of patients at 3 months and 43% of patients at 6 months following SIRT (six had lymphocytopenia, three had hypoalbuminemia, and two had transaminasemia). After 3 months, six patients had worsened in CP score and five had worsened in class from baseline. After 6 months, four patients had worsened in CP score and one had worsened in class from baseline. Pretreatment bilirubinemia was associated with a 2+ increase in CP score within 3 months (P = 0.001) and 6 months (P = 0.039) of ⁹⁰Y-SIRT. Pretreatment transaminasemia and bilirubinemia were associated with increased CP class within 3 months of SIRT (P = 0.021 and 0.009, respectively).

Conclusion

⁹⁰Y-SIRT was well-tolerated in patients with unresectable HCC, with no Grade 3–4 clinical toxicities. However, Grade 3–4 laboratory toxicities and worsened CP scores were more frequent. HCC patients with pretreatment bilirubinemia or transaminasemia may be at higher risk of experiencing a decline in liver function following ⁹⁰Y-SIRT.