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De Bellis M, Mastrosimini MG, Capelli P, Alaimo L, Conci S, Campagnaro T, Pecori S, Scarpa A, Guglielmi A, Ruzzenente A. The Relevance of Radial Margin Status in Perihilar Cholangiocarcinoma: A State-of-the-Art Narrative Review. Dig Surg 2024; 41:92-102. [PMID: 38447545 DOI: 10.1159/000535995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/02/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Prognosis of perihilar cholangiocarcinoma (PHCC) is poor, and curative-intent resection is the most effective treatment associated with long-term survival. Surgery is technically demanding since it involves a major hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Furthermore, to achieve negative margins, it may be necessary to perform concomitant vascular resection or pancreatoduodenectomy. Despite this aggressive approach, recurrence is often observed, considering 5-year recurrence-free survival below 15% and 5-year overall survival that barely exceeds 40%. SUMMARY The literature reports that survival rates are better in patients with negative margins, and surprisingly, R0 resections range between 19% and 95%. This variability is probably due to different surgical strategies and the pathologist's expertise with specimens. In fact, a proper pathological examination of residual disease should take into consideration both the ductal and the radial margin (RM) status. Currently, detailed pathological reports are lacking, and there is a likelihood of misinterpreting residual disease status due to the missing of RM description and the utilization of various definitions for surgical margins. KEY MESSAGES The aim of PHCC surgery is to achieve negative margins including RM. More clarity in reporting on RM is needed to define true radical resection and consistent design of oncological studies for adjuvant treatments.
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Affiliation(s)
- Mario De Bellis
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy,
| | - Maria Gaia Mastrosimini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Paola Capelli
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Alaimo
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Simone Conci
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Sara Pecori
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Dentistry, Gynecology, and Pediatrics, Division of General and Hepatobiliary Surgery, University of Verona, G.B. Rossi University Hospital, Verona, Italy
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Boerner T, Carr R, Hsu M, Tan KS, Sigel C, Tang L, Harrington C, Ku GY, Ilson DH, Janjigian YY, Wu AJ, Sihag S, Bains MS, Bott MJ, Isbell JM, Park BJ, Jones DR, Molena D. Prognostic value of circumferential radial margin involvement in esophagectomy for esophageal cancer: a case series. Int J Surg 2023; 109:3251-3261. [PMID: 37549056 PMCID: PMC10651231 DOI: 10.1097/js9.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/01/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Residual tumor at the proximal or distal margin after esophagectomy is associated with worse survival outcomes; however, the significance of the circumferential resection margin (CRM) remains controversial. In this study, we sought to evaluate the prognostic significance of the CRM in patients with esophageal cancer undergoing resection. MATERIALS AND METHODS We identified patients who underwent esophagectomy for pathologic T3 esophageal cancer from 2000 to 2019. Patients were divided into three groups: CRM- (residual tumor >1 mm from the CRM), CRM-close (residual tumor >0 to 1 mm from the CRM), and CRM+ (residual tumor at the surgical CRM). CRM was also categorized and analyzed per the Royal College of Pathologists (RCP) and College of American Pathologists (CAP) classifications. RESULTS Of the 519 patients included, 351 (68%) had CRM-, 132 (25%) had CRM-close, and 36 (7%) had CRM+. CRM+ was associated with shorter disease-free survival [DFS; CRM+ vs. CRM-: hazard ratio (HR), 1.53 [95% CI, 1.03-2.28]; P =0.034] and overall survival (OS; CRM+ vs. CRM-: HR, 1.97 [95% CI, 1.32-2.95]; P <0.001). Survival was not significantly different between CRM-close and CRM-. After adjustment for potential confounders, CAP+ was associated with poor oncologic outcomes (CAP+ vs. CAP-: DFS: HR, 1.47 [95% CI, 1.00-2.17]; P =0.050; OS: HR, 1.93 [95% CI, 1.30-2.86]; P =0.001); RCP+ was not (RCP+ vs. RCP-: DFS: HR, 1.21 [95% CI, 0.97-1.52]; P =0.10; OS: HR, 1.21 [95% CI, 0.96-1.54]; P =0.11). CONCLUSION CRM status has critical prognostic significance for patients undergoing esophagectomy: CRM+ was associated with worse outcomes, and outcomes between CRM-close and CRM- were similar.
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Affiliation(s)
| | | | - Meier Hsu
- Department of Epidemiology and Biostatistics
| | - Kay See Tan
- Department of Epidemiology and Biostatistics
| | | | | | | | | | | | | | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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3
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Brac B, Dufour C, Behal H, Vanderbeken M, Labreuche J, Leteurtre E, Mariette C, Eveno C, Piessen G, Renaud F. Is There an Optimal Definition for a Positive Circumferential Resection Margin in Locally Advanced Esophageal Cancer? Ann Surg Oncol 2021; 28:8337-8346. [PMID: 34514523 DOI: 10.1245/s10434-021-10707-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/09/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two definitions of a positive circumferential resection margin (CRM) in esophageal cancer coexist: one by the College of American Pathologists (CAP) (CRM = 0 mm) and another by the Royal College of Pathologists (RCP) (CRM ≤ 1 mm). This study aimed to evaluate the prognostic value of both definitions in esophageal cancer and to identify a new cutoff value for the CRM to predict survival. METHODS Patients who underwent curative esophageal resection for locally advanced (≥ pT3) adenocarcinoma or squamous cell carcinoma were selected from 2007 to 2016. The CRM was reassessed using an ocular micrometer. Overall survival (OS) and disease-free survival were estimated with uni- and multivariate analyses. RESULTS The study enrolled 283 patients: 48 with a positive CRM according to the CAP definition and 171 with a positive CRM according to the RCP definition. In the multivariate analysis, a positive CRM according to both definitions was significantly associated with a poor OS (CAP: hazard ratio [HR], 2.26, p < 0.001; RCP: HR, 1.42, p = 0.035). A CRM of 0 mm was predictive of a worse OS and DFS than a CRM of 1 mm or less (p < 0.0001), whereas no significant difference was found between a CRM greater than 1 mm and a CRM of 1 mm or less, indicating that the CAP definition was more accurate for predicting prognosis and recurrence. New cutoff CRM values of 100 µm in squamous cell carcinoma and 200 µm in adenocarcinoma were optimal for predicting OS. CONCLUSION The CAP definition was more accurate for predicting prognosis and recurrence. The study identified a new cutoff value of CRM according to histologic type.
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Affiliation(s)
- B Brac
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France
| | - C Dufour
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - H Behal
- CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, University of Lille, Lille, France
| | - M Vanderbeken
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France
| | - J Labreuche
- CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, University of Lille, Lille, France
| | - E Leteurtre
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - C Mariette
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - C Eveno
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - G Piessen
- Department of Digestive and Oncological Surgery, University of Lille, Claude Huriez University Hospital, Lille, France.,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France
| | - F Renaud
- Institute of Pathology, Lille University Hospital, Lille, Cedex, France. .,CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity, Plasticity and Resistance to Therapies, University of Lille, Lille, France.
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St-Amour P, Winiker M, Sempoux C, Fasquelle F, Demartines N, Schäfer M, Mantziari S. The "Real R0": A Resection Margin Smaller Than 0.1 cm is Associated with a Poor Prognosis After Oncologic Esophagectomy. Ann Surg Oncol 2021; 28:7095-7106. [PMID: 34041624 PMCID: PMC8519834 DOI: 10.1245/s10434-021-10121-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 12/09/2022]
Abstract
Background Although resection margin (R) status is a widely used prognostic factor after esophagectomy, the definition of positive margins (R1) is not universal. The Royal College of Pathologists considers R1 resection to be a distance less than 0.1 cm, whereas the College of American Pathologists considers it to be a distance of 0.0 cm. This study assessed the predictive value of R status after oncologic esophagectomy, comparing survival and recurrence among patients with R0 resection (> 0.1-cm clearance), R0+ resection (≤ 0.1-cm clearance), and R1 resection (0.0-cm clearance). Methods The study enrolled all eligible patients undergoing curative oncologic esophagectomy between 2012 and 2018. Clinicopathologic features, survival, and recurrence were compared for R0, R0+, and R1 patients. Categorical variables were compared with the chi-square or Fisher’s test, and continuous variables were compared with the analysis of variance (ANOVA) test, whereas the Kaplan-Meier method and Cox regression were used for survival analysis. Results Among the 160 patients included in this study, 113 resections (70.6%) were R0, 34 (21.3%) were R0+, and 13 (8.1%) were R1. The R0 patients had a better overall survival (OS) and disease-free survival (DFS) than the R0+ and R1 patients. The R0+ resection offered a lower long-term recurrence risk than the R1 resection, and the R status was independently associated with DFS, but not OS, in the multivariate analysis. Both the R0+ and R1 patients had significantly more adverse histologic features (lymphovascular and perineural invasion) than the R0 patients and experienced more distant and locoregional recurrence. Conclusions Although R status is an independent predictor of DFS after oncologic esophagectomy, the < 0.1-cm definition for R1 resection seems more appropriate than the 0.0-cm definition as an indicator of poor tumor biology, long-term recurrence, and survival. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10121-y.
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Affiliation(s)
- Penelope St-Amour
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michael Winiker
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Christine Sempoux
- Institute of Pathology, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - François Fasquelle
- Institute of Pathology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland. .,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Styliani Mantziari
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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5
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Impact of radial margins after esophagectomy for esophageal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:2313-2322. [PMID: 33714649 DOI: 10.1016/j.ejso.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The prognostic significance of radial margin (RM) involvement in esophagectomy cancer specimens is unclear. Our study investigated survival and recurrence rates between different depths of RM involvement. MATERIALS AND METHODS We retrospectively analyzed 1103 esophagectomies at our institution from 2005 to 2019. Patients were grouped by three-tier stratification: negative RM > 1 mm away, direct RM involvement at 0 mm, and close RM between 0 mm and 1 mm. Survival, loco-regional and distant recurrences were analyzed. RESULTS 1103 esophageal cancer patients were analyzed. 389 patients had recurrence (35.3%). Median survival (13.2 months) and recurrence rates (71%) were worst with direct RM (p < 0.001) as compared to negative RM (median survival not achieved within 5-years from surgery and 30%). Without nodal involvement, RM involvement of <1 mm was associated with decreased overall survival, and overall, loco-regional and distant recurrence-free survival compared to negative RM (log rank p-value <0.05). In those with persistent nodal disease, only direct RM was associated with decreased overall and loco-regional recurrence-free survival as compared to negative margins (p < 0.05). Direct RM tended to do worse compared to close RM in terms of median survival and trended worse for recurrence. Direct RM (baseline negative RM), but not close RM, was an independent RF in a multivariable Cox model for worse overall survival (HR 2.74; p < 0.001), recurrence-free survival (HR 1.96; p = 0.019), and loco-regional recurrence-free survival (HR 3.19; p = 0.011). CONCLUSION RM involvement affects survival and recurrence. Tumor at 0 mm remained an independent RF for worse survival and overall and loco-regional recurrence.
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Li Y, Du L, Wang Y, Gu Y, Zhen X, Hu X, Sun X, Dong H. Modeling the Cost-effectiveness of Esophageal Cancer Screening in China. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:33. [PMID: 32944005 PMCID: PMC7488134 DOI: 10.1186/s12962-020-00230-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/02/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This study aimed to examine the cost-effectiveness of one-time standard endoscopic screening with Lugol's iodine staining for esophageal cancer (EC) in China. METHODS A Markov decision analysis model with eleven states was built. Individuals aged 40 to 69 years were classified into six age groups in five-year intervals. Three different strategies were adopted for each cohort: (1) no screening; (2) one-time endoscopic screening with Lugol's iodine staining with an annual follow-up for low-grade intraepithelial neoplasia (LGIN); and (3) one-time endoscopic screening with Lugol's iodine staining without follow-up. Quality-adjusted life-years (QALYs) indicated the effectiveness of the model. The incremental cost-effectiveness ratio (ICER) was used as the evaluation indicator. Sensitivity analysis was performed to assess the robustness of the model. RESULTS One-time screening with follow-up was the undominated strategy for individuals aged 40-44 and 45-49 years, which saved USD 10,942.57 and USD 6611.73 per QALY gained compared to nonscreening strategy. For those aged 50-69 years, the nonscreening scenarios were undominated. One-time screening without follow-up was the extended dominated strategy. Compared to screening strategies without follow-up, all the screening strategies with follow-up were more cost-effective, with the ICER increasing from 299.57 USD/QALY for individuals aged 40-44 years to 1617.72 USD/QALY for individuals aged 65-69 years. Probabilistic sensitivity analysis (PSA) supported the results of the base case analysis. CONCLUSIONS One-time EC screening with follow-up targeting individuals aged 40-49 years was the most cost-effective strategy.
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Affiliation(s)
- Yuanyuan Li
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Lingbin Du
- Department of Cancer Prevention, Institute of Cancer Research and Basic Medical Science of Chinese Academy of Sciences, Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, 38 Banshan Guangqiao Rd., 310022 Hangzhou, Zhejiang China
| | - Youqing Wang
- Department of Cancer Prevention, Institute of Cancer Research and Basic Medical Science of Chinese Academy of Sciences, Cancer Hospital of University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, 38 Banshan Guangqiao Rd., 310022 Hangzhou, Zhejiang China
| | - Yuxuan Gu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xuemei Zhen
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xiaoqian Hu
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Xueshan Sun
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
| | - Hengjin Dong
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Rd., 310058 Hangzhou, Zhejiang China
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Tang XY, Huang MX, Han SQ, Chang Y, Li ZP, Kao XM, Chen YY, Liu C, Huang YD, Chen YT, Lei ZJ, Chu XY. The Circumferential Resection Margin Is a Prognostic Predictor in Colon Cancer. Front Oncol 2020; 10:927. [PMID: 32670875 PMCID: PMC7332859 DOI: 10.3389/fonc.2020.00927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/12/2020] [Indexed: 12/05/2022] Open
Abstract
Objective: This study aimed to investigate the potential value of circumferential resection margin (CRM) in colon cancer prognostics. Summary Background Data: CRM has been extensively studied as an important prognostic factor in rectal and esophageal cancer, but not in colon cancer. Methods: Data from 6,681 CRM-positive patients and 25,908 CRM-negative patients diagnosed with colon cancer in 2010–2015 were obtained from the Surveillance, Epidemiology, and End Results database. Statistical analysis methods utilized included the chi-square test, Kaplan-Meier estimates, Cox proportional, and X-tile software analyses. Results: After propensity score matching, CRM positivity was found to be negatively related with survival (P < 0.001). X-tile software identified 0 and 30 mm as optimal cutoff values (P < 0.001) for prognosis, which was applicable only in stage II–IV patients. A 20 and 33% risk decrease were observed in patients with CRM between 0 and 30 mm [95% confidence interval (CI) = 0.76–0.84], and larger than 30 mm (95% CI = 0.62–0.71), respectively. Chemotherapy strongly benefited prognosis with a hazard ratio of 0.36 (95% CI = 0.34–0.38) for overall survival (OS). Patients with a CRM value of 0–30 mm seemed to benefit most from chemotherapy compared with other groups. CRM and number of regional lymph nodes are independent risk factors, and the latter is a good substitute for CRM in AJCC stage I patients. Conclusion: CRM positivity is a strong unfavorable survival indicator for colon cancer patients. A better outcome is expected with CRM values larger than 30 mm. This cutoff value only applied to stage II–IV patients. For stage I patients, number of regional lymph nodes is a good substitute to predict survival. Chemotherapy was another favorable prognostic factor, especially for patients with a CRM value between 0 and 30 mm.
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Affiliation(s)
- Xin-Yi Tang
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China.,School of Medicine, Nanjing University, Nanjing, China
| | - Meng-Xi Huang
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China
| | - Si-Qi Han
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China
| | - Yue Chang
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China
| | - Zhi-Ping Li
- Department of Medical Oncology, Jinling Hospital, Nanjing Clinical School of Southern Medical University, Nanjing, China
| | - Xiao-Ming Kao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yan-Yan Chen
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China
| | - Chao Liu
- Department of Medical Oncology, Jinling Hospital, Nanjing Clinical School of Nanjing Medical University, Nanjing, China
| | - Ya-Di Huang
- Department of Medical Oncology, Jinling Hospital, Nanjing Clinical School of Southern Medical University, Nanjing, China
| | - Yi-Tian Chen
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China
| | - Zeng-Jie Lei
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China.,Department of Medical Oncology, Jinling Hospital, Nanjing Clinical School of Southern Medical University, Nanjing, China
| | - Xiao-Yuan Chu
- Department of Medical Oncology, School of Medicine, Jingling Hospital, Nanjing University, Nanjing, China.,Department of Medical Oncology, Jinling Hospital, Nanjing Clinical School of Southern Medical University, Nanjing, China
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8
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Rahman SA, Walker RC, Lloyd MA, Grace BL, van Boxel GI, Kingma BF, Ruurda JP, van Hillegersberg R, Harris S, Parsons S, Mercer S, Griffiths EA, O'Neill JR, Turkington R, Fitzgerald RC, Underwood TJ. Machine learning to predict early recurrence after oesophageal cancer surgery. Br J Surg 2020; 107:1042-1052. [PMID: 31997313 PMCID: PMC7299663 DOI: 10.1002/bjs.11461] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/11/2019] [Accepted: 11/13/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Early cancer recurrence after oesophagectomy is a common problem, with an incidence of 20-30 per cent despite the widespread use of neoadjuvant treatment. Quantification of this risk is difficult and existing models perform poorly. This study aimed to develop a predictive model for early recurrence after surgery for oesophageal adenocarcinoma using a large multinational cohort and machine learning approaches. METHODS Consecutive patients who underwent oesophagectomy for adenocarcinoma and had neoadjuvant treatment in one Dutch and six UK oesophagogastric units were analysed. Using clinical characteristics and postoperative histopathology, models were generated using elastic net regression (ELR) and the machine learning methods random forest (RF) and extreme gradient boosting (XGB). Finally, a combined (ensemble) model of these was generated. The relative importance of factors to outcome was calculated as a percentage contribution to the model. RESULTS A total of 812 patients were included. The recurrence rate at less than 1 year was 29·1 per cent. All of the models demonstrated good discrimination. Internally validated areas under the receiver operating characteristic (ROC) curve (AUCs) were similar, with the ensemble model performing best (AUC 0·791 for ELR, 0·801 for RF, 0·804 for XGB, 0·805 for ensemble). Performance was similar when internal-external validation was used (validation across sites, AUC 0·804 for ensemble). In the final model, the most important variables were number of positive lymph nodes (25·7 per cent) and lymphovascular invasion (16·9 per cent). CONCLUSION The model derived using machine learning approaches and an international data set provided excellent performance in quantifying the risk of early recurrence after surgery, and will be useful in prognostication for clinicians and patients.
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Affiliation(s)
- S. A. Rahman
- Cancer Sciences UnitUniversity of SouthamptonSouthamptonUK
| | - R. C. Walker
- Cancer Sciences UnitUniversity of SouthamptonSouthamptonUK
| | - M. A. Lloyd
- Cancer Sciences UnitUniversity of SouthamptonSouthamptonUK
| | - B. L. Grace
- Cancer Sciences UnitUniversity of SouthamptonSouthamptonUK
| | - G. I. van Boxel
- Department of SurgeryUniversity Medical CentreUtrechtthe Netherlands
| | - B. F. Kingma
- Department of SurgeryUniversity Medical CentreUtrechtthe Netherlands
| | - J. P. Ruurda
- Department of SurgeryUniversity Medical CentreUtrechtthe Netherlands
| | | | - S. Harris
- Department of Public Health Sciences and Medical StatisticsUniversity of SouthamptonSouthamptonUK
| | - S. Parsons
- Department of SurgeryNottingham University Hospitals NHS TrustNottinghamUK
| | - S. Mercer
- Department of SurgeryPortsmouth Hospitals NHS TrustPortsmouthUK
| | - E. A. Griffiths
- Department of Upper Gastrointestinal SurgeryUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - J. R. O'Neill
- Cambridge Oesophagogastric CentreAddenbrookes Hospital, Cambridge University Hospitals Foundation TrustCambridgeUK
| | - R. Turkington
- Centre for Cancer Research and Cell BiologyQueen's University BelfastBelfastUK
| | - R. C. Fitzgerald
- Hutchison/Medical Research Council Cancer UnitUniversity of CambridgeCambridgeUK
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9
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Knight WRC, Yip C, Wulaningsih W, Jacques A, Griffin N, Zylstra J, Van Hemelrijck M, Maisey N, Gaya A, Baker CR, Kelly M, Gossage JA, Lagergren J, Landau D, Goh V, Davies AR, Ngan S, Qureshi A, Deere H, Green M, Chang F, Mahadeva U, Gill‐Barman B, George S, Dunn J, Zeki S, Meenan J, Hynes O, Tham G, Iezzi C. Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus. BJS Open 2019; 3:767-776. [PMID: 31832583 PMCID: PMC6887675 DOI: 10.1002/bjs5.50211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/24/2019] [Indexed: 02/06/2023] Open
Abstract
Background A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma. Methods Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed. Results A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092). Conclusion The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.
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Affiliation(s)
- W. R. C. Knight
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
| | - C. Yip
- School of Biomedical Engineering and Imaging Sciences, King's College London
| | - W. Wulaningsih
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - A. Jacques
- Department of Radiology, Guy's and St Thomas' Hospital, London, UK
| | - N. Griffin
- Department of Radiology, Guy's and St Thomas' Hospital, London, UK
| | - J. Zylstra
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - M. Van Hemelrijck
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - N. Maisey
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - A. Gaya
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - C. R. Baker
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - M. Kelly
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
| | - J. A. Gossage
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - J. Lagergren
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - D. Landau
- Department of Oncology, Guy's and St Thomas' Hospital, London, UK
| | - V. Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London
- Cancer Epidemiology and Population Health Associated Research Group, King's College London
| | - A. R. Davies
- Department of Surgery, Guy's and St Thomas' Oesophago‐Gastric Centre, King's College London
- School of Cancer and Pharmaceutical Sciences, King's College London
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Lost in translation: confusion on resection and dissection planes hampers the interpretation of pathology reports for perihilar cholangiocarcinoma. Virchows Arch 2019; 475:435-443. [PMID: 31446465 PMCID: PMC6828829 DOI: 10.1007/s00428-019-02621-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/04/2019] [Accepted: 07/11/2019] [Indexed: 01/03/2023]
Abstract
In perihilar cholangiocarcinoma (PHC), interpretation of the resection specimen is challenging for pathologists and clinicians alike. Thorough and correct reporting is necessary for reliable interpretation of residual disease status. The aim of this study is to assess completeness of PHC pathology reports in a single center and assess what hampers interpretation of pathology reports by clinicians. Pathology reports of patients resected for PHC at a single expert tertiary center drafted between 2000 and 2018 were assessed. Reports were assessed regarding completeness, according to the guideline of the International Collaboration on Cancer Reporting (ICCR). A total of 146 reports were assessed. Prognostic tumor characteristics such as vasoinvasive growth and perineural growth were missing in 30/146 (34%) and 22/146 (15%), respectively. One or more planes were missing in 94/146 (64%) of the reports, with the periductal dissection plane missing in 51/145 (35%). Residual disease could be re-classified from R0 to R1 in 22 patients (15%). Reasons for R1 in these patients were the presence of a positive periductal dissection plane (n = 2), < 1-mm margin at the periductal dissection plane (n = 11), or liver parenchyma (n = 9). Completeness of reports improved significantly when drafted by an expert HPB pathologist. This study demonstrates that pathology reporting of PHC is challenging. Reports are frequently incomplete and often do not incorporate assessment of all resection planes and the dissection plane. The periductal dissection plane is frequently overlooked, but is a major cause of residual disease.
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11
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Evans R, Bundred JR, Kaur P, Hodson J, Griffiths EA. Meta-analysis of the influence of a positive circumferential resection margin in oesophageal cancer. BJS Open 2019; 3:595-605. [PMID: 31592511 PMCID: PMC6773635 DOI: 10.1002/bjs5.50183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 04/23/2019] [Indexed: 01/05/2023] Open
Abstract
Background The evidence regarding the prognostic impact of a positive circumferential resection margin (CRM) in oesophageal cancer is conflicting, and there is global variability in the definition of a positive CRM. The aim of this study was to determine the impact of a positive CRM on survival in patients undergoing oesophagectomy for oesophageal cancer. Methods A systematic review and meta‐analysis was performed. PubMed and Embase databases were searched for articles to May 2018 examining the effect of a positive CRM on survival. Cohort studies written in English were included. Meta‐analyses of univariable and multivariable hazard ratios (HRs) were performed using both Royal College of Pathologists (RCP) and College of American Pathologists (CAP) criteria. Risk of bias was assessed using the Newcastle–Ottawa Scale. Egger regression, and Duval and Tweedie trim‐and‐fill statistics were used to assess publication bias. Results Of 133 studies screened, 29 incorporating 6142 patients were finally included for analysis. Pooled univariable HRs for overall survival in patients with a positive CRM were 1·68 (95 per cent c.i. 1·48 to 1·91; P < 0·001) and 2·18 (1·84 to 2·60; P < 0·001) using RCP and CAP criteria respectively. Subgroup analyses demonstrated similar results for patients by T category, neoadjuvant therapy and tumour type. Pooled HRs from multivariable analyses suggested that a positive CRM was independently predictive of a worse overall survival (RCP: 1·41, 1·21 to 1·64, P < 0·001; CAP: 2·37, 1·60 to 3·51, P < 0·001). Conclusion A positive CRM is associated with a worse prognosis regardless of classification system, T category, tumour type or neoadjuvant therapy.
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Affiliation(s)
- R Evans
- Department of Upper Gastrointestinal Surgery University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - J R Bundred
- Department of Upper Gastrointestinal Surgery University Hospitals Birmingham NHS Foundation Trust Birmingham UK.,College of Medical and Dental Sciences University of Birmingham Birmingham UK
| | - P Kaur
- Department of Upper Gastrointestinal Surgery University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - J Hodson
- Institute of Translational Medicine University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - E A Griffiths
- Department of Upper Gastrointestinal Surgery University Hospitals Birmingham NHS Foundation Trust Birmingham UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences University of Birmingham Birmingham UK
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