Cancer surgery: the last 25 years

Oncological Horizons: The Synergy of Medical and Surgical Innovations in Cancer Treatment

The landscape of cancer treatment has witnessed a remarkable transformation in recent years, marked by the convergence of medical and surgical innovations. Historically, cancer therapy faced challenges, including limited efficacy and severe side effects. This narrative review explores the historical progression of cancer treatments, shedding light on significant breakthroughs in both medical and surgical oncology. It comprehensively addresses the medical domain, covering chemotherapy, targeted therapies, immunotherapy, hormonal treatments, and radiological procedures. Simultaneously, it delves into the surgical realm, discussing the evolution of surgical techniques, minimally invasive procedures, and the role of surgery across various stages of cancer. The article emphasizes the fusion of medical and surgical approaches, highlighting neoadjuvant and adjuvant therapies and the significance of multidisciplinary tumor boards. It also addresses innovations, challenges, and the pivotal role of patient-centered care. Furthermore, it offers insights into the future directions and forecasts in the constantly evolving field of integrated oncological care. This review provides a comprehensive understanding of the dynamic and transformative nature of cancer treatment, reflecting the unwavering commitment of the medical and surgical communities in the ongoing fight against cancer.

Robot-Guided Ultrasonography in Surgical Interventions

INTRODUCTION

The introduction of robotic-guided procedures in surgical techniques has brought an increase in the accuracy and control of resections. Surgery has evolved as a technique since the development of laparoscopy, which has added to the visualisation of the peritoneal cavity from a different perspective. Multi-armed robot associated with real-time intraoperative imaging devices brings important manoeuvrability and dexterity improvements in certain surgical fields.

MATERIALS AND METHODS

The present study is designed to synthesise the development of imaging techniques with a focus on ultrasonography in robotic surgery in the last ten years regarding abdominal surgical interventions.

RESULTS

All studies involved abdominal surgery. Out of the seven studies, two were performed in clinical trials. The other five studies were performed on organs or simulators and attempted to develop a hybrid surgical technique using ultrasonography and robotic surgery. Most studies aim to surgically identify both blood vessels and nerve structures through this combined technique (surgery and imaging).

CONCLUSIONS

Ultrasonography is often used in minimally invasive surgical techniques. This adds to the visualisation of blood vessels, the correct identification of tumour margins, and the location of surgical instruments in the tissue. The development of ultrasound technology from 2D to 3D and 4D has brought improvements in minimally invasive and robotic surgical techniques, and it should be further studied to bring surgery to a higher level.

Oncological Outcomes of Segmentectomy versus Lobectomy in Clinical Stage I Non-Small Cell Lung Cancer up to Two Centimeters: Systematic Review and Meta-Analysis

Objective. In recent years, pulmonary segmentectomy has emerged as an alternative to lobectomy for the treatment of patients with clinical stage I non-small cell lung cancer. Considering the conflicting results reported in the literature, the oncological effectiveness of segmentectomy remains controversial. To provide new insight into oncological results, we reviewed the literature, including recent randomized trials. Methods. We performed a systematic review for surgical treatment of stage I NSCLC up to 2 cm using MEDLINE and the Cochrane Database from 1990 to December 2022. Primary outcomes for pooled analysis were overall and disease-free survival; secondary outcomes were postoperative complications and 30-day mortality. Results. Eleven studies were considered for the meta-analysis. The pooled analysis included 3074 and 2278 patients who received lobectomy and segmentectomy, respectively. The estimated pooled hazard ratio showed a similar hazard for segmentectomy compared to lobectomy in terms of overall and disease-free survival. The restricted mean survival time difference between the two procedures was statistically and clinically not significant for overall and disease-free survival. Nevertheless, the overall survival hazard ratio was time-dependent: segmentectomy was at a disadvantage starting from 40 months after surgery. Six papers reported 30-day mortality: there were no events on 1766 procedures. The overall relative risk showed that the postoperative complication rate was higher in segmentectomy compared to lobectomy, without statistical significance. Conclusions. Our results suggest that segmentectomy might be a useful alternative to lobectomy for stage I NSCLC up to 2 cm. However, this appears to be time-dependent; in fact, the risk ratio for overall mortality becomes unfavorable for segmentectomy starting at 40 months after surgery. This last observation, together with some still undefined questions (solid/non-solid ratio, depth of the lesion, modest functional savings, etc.), leave room for further investigations on the real oncological effectiveness of segmentectomy.

Prognostic value of RKIP and p-ERK in gastric cancer

BACKGROUND

The mitogen-activated protein kinase (MAPK) signaling pathway participates in several steps of tumour development and is considered a prominent therapeutic target for the design of chemotherapeutic agents. We evaluated the expressions of extracellular signal-regulated kinase (ERK), mitogen-activated protein kinase (MEK), an upstream regulator of ERK, and Raf kinase inhibitor protein (RKIP), and investigated correlations of these expressions with clinicopathological features and outcomes in gastric cancer.

METHODS

Tumour samples were obtained from 105 patients with gastric adenocarcinomas who underwent radical gastrectomy. The expressions of phosphorylated ERK (p-ERK), phosphorylated MEK (p-MEK), and RKIP were analysed by immunohistochemical staining.

RESULTS

Expression of RKIP, p-MEK, and p-ERK was found in 69 (66%), 54 (51%), and 64 (61%) of all tumours, respectively. RKIP expression negatively correlated with the depth of invasion (p < 0.001), lymph node involvement (p = 0.028), and Union for International Cancer Control (UICC) stage (p = 0.007). RKIP expression was associated with significantly longer relapse-free survival (RFS) (p = 0.0033), whereas p-MEK was not (p = 0.79). Patients with p-ERK expression had slightly, but not significantly shorter RFS than those without such expression (p = 0.054). Patients with positive p-ERK and negative RKIP expression had significantly shorter RFS than the other patients (p < 0.001). The combination of RKIP and p-ERK expression was an independent prognostic factor (hazard ratio, 2.4; 95% confidence interval, 1.3 - 4.6; p = 0.008).

CONCLUSIONS

Our results demonstrated that loss of RKIP was associated with tumour progression and poor survival. Negative RKIP expression combined with positive p-ERK expression was an independent predictor of poor outcomes in patients with gastric cancer.

Prognostic significance of glycoprotein pMQ1 in breast cancer

BACKGROUND

A novel glycoprotein, pMQ1, is positively correlated with increasing histological grade in malignant astrocytomas. Cerebral metastases from breast cancer have also been found to contain pMQ1-positive cells. This study aimed to determine the role of pMQ1 in primary breast cancer.

METHODS

Breast cancer specimens were analysed for pMQ1 by immunohistochemistry. The expression of pMQ1 was correlated with conventional prognostic indicators. Kaplan-Meier analyses were performed to compare clinical outcome between pMQ1-positive and pMQ1-negative tumours.

RESULTS

pMQ1 was expressed in most of the breast cancer specimens. The surrounding normal tissue margins and benign breast tissues always lacked pMQ1 expression. A significant positive correlation was observed between pMQ1 expression and histological grade, the presence of lymphovascular invasion and Nottingham Prognostic Index. Cancers that were pMQ1 positive were significantly more likely to develop a local recurrence.

CONCLUSION

pMQ1 appears to be a tumour-associated protein. The positive correlation of pMQ1 with histological grade, presence of lymphovascular invasion and Nottingham Prognostic Index suggests that it confers an adverse prognosis.

Increased expression of mitogen-activated protein kinase and its upstream regulating signal in human gastric cancer

AIM: To investigate the expression of mitogen-activated protein kinases (MAPKs) and its upstream protein kinase in human gastric cancer and to evaluate the relationship between protein levels and clinicopathological parameters.

METHODS: Western blot was used to measure the expression of extracellular signal-regulated kinase (ERK)-1, ERK-2, ERK-3, p38 and mitogen or ERK activated protein kinaseMEK-1 proteins in surgically resected gastric carcinoma, adjacent normal mucosa and metastatic lymph nodes from 42 patients. Immunohistochemistry was employed for their localization.

RESULTS: Compared with normal tissues, the protein levels of ERK-1 (integral optical density value 159526±65760 vs 122807±65515, P = 0.001), ERK-2 (168471±95051 vs 120469±72874, P<0.001), ERK-3 (118651±71513 vs 70934±68058, P<0.001), P38 (104776±51650 vs 82930±40392, P = 0.048) and MEK-1 (116486±45725 vs 101434±49387, P = 0.027) were increased in gastric cancer tissues. Overexpression of ERK-3 was correlated to TNM staging [average ratio of integral optic density (IOD)_tumor: IOD_normal in TNM I, II, III, IV tumors was 1.43±0.34, 5.08±3.74, 4.99±1.08, 1.44±1.02, n = 42, P = 0.023] and serosa invasion (4.31±4.34 vs 2.00±2.03, P = 0.037). In poorly differentiated cancers (n = 33), the protein levels of ERK-1 and ERK-2 in stage III and IV tumors were higher than those in stage I and II tumors (2.64±3.01 vs 1.01±0.33, P = 0.022; 2.05±1.54 vs 1.24±0.40, P = 0.030). Gastric cancer tissues with either lymph node involvement (2.49±2.91 vs 1.03±0.36, P = 0.023; 1.98±1.49 vs 1.24±0.44, P = 0.036) or serosa invasion (2.39±2.82 vs 1.01±0.35, P = 0.022; 1.95±1.44 vs 1.14±0.36, P = 0.015) expressed higher protein levels of ERK-1 and ERK-2. In Borrmann II tumors, expression of ERK-2 and ERK-3 was increased compared with Borrmann III tumors (2.57±1.86 vs 1.23±0.60, P = 0.022; 5.50±5.05 vs 1.83±1.21, P = 0.014). Borrmann IV tumors expressed higher p38 protein levels. No statistically significant difference in expression of MAPKs was found when stratified to tumor size or histological grade (P>0.05). Protein levels of ERK-2, ERK-3 and MEK-1 in metastatic lymph nodes were 2-7 folds higher than those in adjacent normal mucosa. The immunohistochemistry demonstrated that ERK-1, ERK-2, ERK-3, p38 and MEK-1 proteins were mainly localized in cytoplasm. The expression of MEK-1 in gastric cancer cells metastasized to lymph nodes was higher than that of the primary site.

CONCLUSION: MAPKs, particularly ERK subclass are overexpressed in the majority of gastric cancers. Overexpression of ERKs is correlated to TNM staging, serosa invasion, and lymph node involvement. The overexpression of p38 most likely plays a prominent role in certain morphological subtypes of gastric cancers. MEK-1 is also overexpressed in gastric cancer, particularly in metastatic lymph nodes. Upregulation of MAPK signal transduction pathways may play an important role in tumorigenesis and metastatic potential of gastric cancer.

Curative treatment of gastric cancer: towards a multidisciplinary approach?

Despite marked decreases in incidence over the last century, particularly in developed countries, gastric cancer is still the second-most common tumor worldwide. Surgery remains the gold standard for the cure of locoregional disease. However, in most countries, the diagnosis is made at an advanced stage, and the 5-year survival for surgically resectable disease stays far below 50%. The efficacy of chemotherapy and/or radiation therapy in addition to surgery has been actively studied over the last 30 years. Unfortunately, with few exceptions, most studies of adjuvant therapy in gastric cancer have given deceiving results. The purpose of this review is to address the reasons for our failure to objectivate an improvement in the cure of gastric cancer with adjuvant treatment in most trials, and to consider potential solutions. The low efficacy of chemotherapy regimens available up to now may have hampered our progress. In addition, many previous studies suffered limitations of design or methodology (e.g. low accrual, inadequate disease stage selection, inadequate surgical treatment) that may have obscured a treatment effect. Furthermore, the reduced treatment tolerance of post-gastrectomy patients, perhaps due to their poor nutritional status, results in decreased or delayed adjuvant systemic therapy, with potential adverse consequences in its efficacy. Among potential solutions, the arrival of new drugs, taxanes and topoisomerase I inhibitors in particular, which have shown encouraging results in metastatic disease, may increase the impact of chemotherapy in a multidisciplinary treatment approach. Pre-treatment with chemotherapy and/or radiation therapy prior to surgery may also be advantageous, averting the problems associated with post-surgical treatment. Such an approach has been shown to be feasible in phase II studies, and is relatively well tolerated by patients. Several carefully designed randomized phase III trials are underway to answer this question.

Trends in breast cancer mortality in Asturias, Spain

While breast cancer mortality rates are subsiding or beginning to decline in many western countries, in Spain they are increasing. We have studied breast cancer mortality rates in Asturias (Spain) by using the age-period-cohort model for the period of 1975-1994. There was an increase in the adjusted rates. The increase of relative risk of death in the period 1990-1994, in relation to that in 1975-1979, was 43%. There is a tendency for successive cohorts to have higher age-specific rates than previous cohorts. Trends in breast cancer mortality rates have been driven predominantly by birth cohort rate trends over the last decades in Asturias, suggesting that the changes in breast cancer mortality have been largely influenced by changes in aetiological factors.