"Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study"

BACKGROUND

Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce.

METHODS

This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival.

RESULTS

Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%.

CONCLUSIONS

The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.

Long-term outcomes in ypT0 rectal cancers: An international multi-centric investigation on behalf of Italian Society of Surgical Oncology Young Board (YSICO)

AIM

To investigate the outcome and pattern of survivals of rectal cancer patients presenting a complete or nearly complete tumor response after neo-adjuvant treatment.

METHODS

Young surgeons <40 years old affiliated to the Italian Society of Surgical Oncology (YSICO) from 13 referral centers for colorectal cancer treatment, were invited to participate a retrospective study. Records from patients treated from 2005 to 2015 with a pathological diagnosis of ypT0/ypTis were retrieved and pooled in a common data-base for statistical purposes. All clinical and pathological variables were reviewed. Univariate and multivariate analyses were conducted with the end-point of survivals.

RESULTS

Two hundreds and sixty-one patients were analyzed including 237 ypT0 and 24 ypTis. Nodal positive patients were 8.7%. More than sixty-six percent of the patients did not perform adjuvant chemotherapy, with a statistical difference comparing N0 versus N+ patients (66.8% vs 40.9%, p 0.02). Mean follow-up was of 47.6 months. Twenty-two relapses were observed, 91.6% at a distant site. The mean time to recurrence was of 35.3 months. On univariate analysis, the use of adjuvant chemotherapy correlated with better OS exclusively in ypT0N + patients and not in ypT0N0. Univariate and multivariate analyses documented nodal positivity as the only prognostic factor correlated with a worse OS.

CONCLUSION

Recurrences were mostly diagnosed at a distant site and within the third year of follow-up. Nodal positivity was the only variable independently correlated with a worse OS. Univariate analysis documented a benefit for the use of adjuvant chemotherapy treatment exclusively in ypT0N + rectal cancers.

A pilot study assessing the efficacy of posterior tibial nerve stimulation in the treatment of low anterior resection syndrome

BACKGROUND

Low anterior resection for rectal cancer often results in severe bowel dysfunction, specifically low anterior resection syndrome (LARS), with symptoms such as incontinence, urgency, and frequent bowel movements. Percutaneous tibial nerve stimulation (PTNS) resulted in a high rate of success in patients with fecal incontinence. The aim of this study was to evaluate the effectiveness of treatment with PTNS in LARS and to identify predictors of the outcome of the technique.

METHODS

The study was conducted from May 2012 to April 2015 at the Alvaro Cunqueiro Hospital, University Hospital Complex of Vigo, Spain. Ten patients with LARS were recruited consecutively. All patients underwent 2 sessions per week (30 min each one) for 6 weeks. Patients were followed for 3 weeks, and those who had a significant clinical improvement were recruited to a second phase of PTNS. Some patients presenting with relapse during follow-up underwent an additional phase of PTNS. Outcome measures included Wexner scores, quality of life scores, and urgency of defecation.

RESULTS

Three patients did not complete the treatment due to poor response in the first phase. Incontinence was reduced in the remaining seven of ten patients. The median Wexner score at initial patient evaluation was 14 (IQR 10.75-18.5), which decreased to 10 (IQR 6.5-18) after treatment (p = 0.034). A statistically significant improvement was demonstrated in quality of life scale, lifestyle, depression, and daily defecation urgency (p < 0.05). LARS Score improvement was observed in five patients (50%) with a total resolution of LARS in 2 (20%).

CONCLUSIONS

PTNS is an ambulatory treatment that could play an important role in the context of a multimodal treatment approach in patients with LARS. It could be a first-line treatment to identify non-responders to conservative management who need different and more invasive treatments.

Surgical issues after neoadjuvant treatment for gastric cancer

Gastric carcinoma is one of the most frequent malignancies in the world and its clinical behavior depends on the metastatic potential of the tumour. Particularly, lymphatic metastasis is one of the main predictor of tumour recurrence and survival and current pathologic staging systems reflect the concept that lymphatic spread is the most relevant prognostic factor in patients resected with curative intent. This is deducted by the observation that two thirds of gastric cancers in the western world present at an advanced stage, with nearly 85% of tumors accompanied by lymph node metastasis at diagnosis. To date most therapeutic efforts are directed toward individualization of therapeutic protocols, tailoring the extent of resection integrated by the administration of preoperative and postoperative treatment. The goal of such strategies is to improve prognosis towards the achievement of a curative resection (R0-resection) with minimal morbidity and mortality, with better postoperative quality of life. A brief review of literature about preoperative therapy for gastric carcinoma will be herein illustrated. The rationale and the general drawbacks of preoperative treatments will be both discussed in order to demonstrate its value in terms of safety and efficacy.

Response to neoadjuvant chemotherapy and effects of tumor regression in gastric cancer

AIMS

Aim of this study is the evaluation of the effects induced by neoadjuvant chemotherapy (NACT) and its impact on survival on a series of locally advanced gastric carcinomas.

METHODS

Downstaging was assessed comparing pre-treatment clinical and laparoscopic staging with post-operative pathologic staging on 30 consecutive patients who completed a 3-year follow-up. Tumor downstaging and the grade of pathologic response were included in a statistical correlation between tumor regression induced by NACT and 3-year survival.

RESULTS

In this series tumor downstaging was obtained in 13 out of 30 patients. After the completion of 3-year follow-up, overall survival was >37.5months with an overall survival rate of 56.7%; this figure reached up to 70.8% in those cases who benefited from a R0-resection (24/30 patients: R0-resection rate 80.0%).

CONCLUSIONS

In this study the 3-year survival for locally advanced gastric cancer treated by NACT prior to "D2" surgical resection, compares favourably with historical series treated by surgery alone. Patients who obtained T-downstaging and subsequently benefited from a R0-resection had a definitely better chance of cure, according to a complete 3-year follow-up.

[Clinical significance and prognostic value of tumor maximum diameter in gastric carcinoma]

Maximum tumor diameter (MTD) is considered by many authors as an important prognostic factor in gastric cancer and, in some series, is reported to be strongly correlated with depth of infiltration. Aim of this study was to evaluate the prognostic value of tumor diameter in a monoistitutional series of 153 gastric cancer patients. The Spearman correlation coefficient was also calculated between MTD and other known prognostic factors. For statistical analysis, patients were grouped as follows: MTD 1, < or = 40 mm, and MTD2, > 40 mm. In our series, MTD resulted significantly linked to survival at univariate analysis (p = 0.0001), but multivariate analysis did not evidence MTD as an independent prognostic indicator. The Spearman correlation test documented that MTD2 is strongly correlated with tumor depth (pT), nodal status (pN) and p-stage (p < 0.01) and is a good predictor of locally advanced stage. This retrospective study showed that patients with larger tumor are at an increased risk for tumor advancement and, therefore, MTD could represent a useful parameter for choosing the most appropriate therapeutic strategy.

[T-downstaging after neoadjuvant chemotherapy in locally advanced gastric carcinoma]

Only a limited number of trials on neoadjuvant chemotherapy for resectable advanced gastric cancer have been planned or conducted up to date, still in recent years this treatment strategy has been considered by many the most promising tool in order to improve survival of locally advanced tumors of the stomach. Aim of this study is to evaluate the clinical significance and the possible impact on survival of tumor downstaging after neoadjuvant chemotherapy followed by D2-gastrectomy in an accurately staged and thoroughly selected group of 30 locally advanced gastric cancer patients, with a complete follow-up of at least 3 years. In our series, T-downstaging was observed in 43.3% of patients; this parameter, along with other known prognostic factors, was found to be significantly associated with survival (p <0.05). Moreover, T-downstaging induced by preoperative chemotherapy was significantly associated with absence of residual tumor (R0) and no lymph node metastases (ypN0) (p <0.05). At multivariate analysis, R0-resection was the only independent prognostic factor (HR 9.439, p <0.0001). According to our results we feel encouraged to consider neoadjuvant chemotherapy a promising modality for increasing the R0-percentage by tumor downstaging.

[Ratio of lymph node metastasis in gastric carcinoma after D2 gastrectomy]

The classification of lymph node metastasis in patients with gastric carcinoma is controversial. In the past, all systems used for this disease defined N classification by the location of lymph node metastases relatively to the primary tumor. In the 1997, the UICC and AJCC redefined the pathologic nodal status on the basis of the number of involved nodes rather than their location. More recently, the ratio between the number of metastatic and the total examined lymph nodes has been proposed as a new quantitative staging system. Aim of our study was to clarify the outcome of the ratio of the metastatic lymph nodes (RML) in a monoinstitutional series of 164 patient with primary gastric cancer who underwent gastrectomy with D2 lymph node dissection. Our data showed that ratio of metastatic lymph nodes is a simple, convenient, and reproducible staging system with an ability to predict surgical results and it is an independent prognostic factor after D2-gastrectomy.

Neural anatomy of the transverse carpal ligament

Carpal tunnel syndrome is one of the most commonly diagnosed disorders of the upper extremity. The etiology of the neuropathy is known to be associated with many disorders, with the etiology of carpal tunnel syndrome mainly attributable to ischemia of the median nerve. The purpose of this study was to determine the presence of neural elements within the transverse carpal ligament. Fourteen transverse carpal ligaments were harvested from seven male and seven female fresh frozen cadavers with an average age of 76 years. The tissues were stained with S-100 using a standard immunoperoxidase technique used to localize neural tissue. The transverse carpal ligament consisted of interwoven bundles of fibrous connective tissue. It was found to have an intraligamentous and extraligamentous neural network consisting mostly of free nerve endings and pacinian corpuscles. Ruffini's corpuscles were not identified. This study showed that there is neural innervation to the transverse carpal ligament. Pacinian corpuscles have been shown to be mechanoreceptors which respond to changes in joint position, whereas free nerve endings have been identified as nociceptors. Neural innervation were present in the transverse carpal ligament, and the nociceptive information relayed by these neural elements may contribute to the pain associated with carpal tunnel syndrome. In addition to being a mechanical wrist stabilizer, the transverse carpal ligament also may play a role in proprioception of the wrist.

Infrared spectroscopy of human tissue. I. Differentiation and maturation of epithelial cells in the human cervix

Infrared spectral results for the different epithelial layers of human cervical squamous tissue are reported. The layers, representing different cellular maturation stages, exhibit quite different spectral patterns. Thus, infrared spectroscopy presents a powerful tool to monitor cell maturation and differentiation. Furthermore, a detailed understanding of the spectra of the individual layers of tissue permit a proper interpretation of the state of health of cells exfoliated from such tissue. Part II of this series describes the use of the spectral information presented here to interpret the infrared spectra of exfoliated cells.

Infrared spectroscopy of human tissue. II. A comparative study of spectra of biopsies of cervical squamous epithelium and of exfoliated cervical cells

A comparison of infrared absorption spectra obtained from the different layers of squamous epithelium from the human cervix, and infrared spectra obtained from exfoliated cervical cells, is presented. Infrared spectroscopy has been shown (in part I of this series) to be a sensitive tool to monitor maturation and differentiation of human cervical cells; therefore, this spectroscopic technique provides new insights into the composition and state of health of exfoliated cells.

Neurohistology of the subacromial space

Subacromial decompression is one of the most commonly performed shoulder procedures. Debridement of the subacromial soft tissues is a critical part of the procedure. However, the extent of soft tissue debridement is not well defined. The purpose of this study was to identify neural elements within the soft tissues composing the subacromial space. Using special immunohistochemical stains and electron microscopy, neural elements were identified within the subacromial bursa, rotator cuff tendon, biceps tendon and tendon sheath, and transverse humeral ligament. There was a significantly richer supply of free nerve fibers in the bursa compared with the other tissues. The nociceptive information relayed by these fibers may be responsible for the pain associated with impingement syndrome.

Case report 784: Fibrous dysplasia of the second pedal digit

In summary, we have reported on an unusual form of fibrous dysplasia, presumptively monostotic, localized to the middle phalanx of the second pedal digit, and presenting as a mass. Monostotic fibrous dysplasia of phalanges of the foot is rare, but should be considered in the differential diagnosis of a mass in the foot.

Calcium-acidic phospholipid-phosphate complexes in human hydroxyapatite-containing pathologic deposits

The deposition of calcium-containing crystals in tissues is due to a combination of factors: elevation in the concentrations of precipitating ions, formation of specific nucleators, and removal of macromolecules that inhibit crystal deposition. This study tested the hypothesis that calcium acidic phospholipid phosphate complexes, which promote hydroxyapatite deposition both in vitro and in vivo, are associated only with hydroxyapatite deposits, and furthermore, that the presence of these complexes is associated with all such hydroxyapatite deposits. Lipid analysis of 76 surgical specimens containing evidence of pathologic calcification (35 hydroxyapatite, 35 calcium pyrophosphate dihydrate, and 6 containing other crystalline materials) had mean complexed acidic phospholipid contents of 8.7, 1, and 0.012, (microgram/mg demineralized dry weight) respectively. Tissues that contained larger, more perfect hydroxyapatite crystals based on x-ray diffraction analyses, had a higher complexed acidic phospholipid content (7.5 +/- 4 micrograms/mg demineralized dry weight, N = 16) than tissues with poorly crystallized hydroxyapatite (3.9 +/- 2 micrograms/mg, N = 11). Histologically, tissues containing larger crystals were characterized by cell or tissue necrosis. Poorly crystalline deposits were found in tissues showing little or no evidence of cell necrosis or tissue degeneration.

Bone disease in prolonged parenteral nutrition: osteopenia without mineralization defect

A metabolic bone disease characterized by a mineralization defect, low plasma 1,25(OH)2D, and hypercalciuria has been described in patients receiving prolonged total parenteral nutrition (TPN). Because the practice of TPN differs from center to center, we investigated 13 home TPN patients to determine whether they had similar or different bone abnormalities. They had received TPN for a mean period of 51 +/- 38 mo. Bone pain occurred in six patients and two had multiple vertebral and rib fractures (with trauma in one patient). Bone pain was mild to moderate and not incapacitating. Bone histomorphometry showed reduced bone volume, reduced osteoid with normal resorption and calcification rates. These abnormalities were associated with hypercalciuria, but the plasma levels of 1,25(OH)2D were normal. Abnormalities in bone metabolism in this group of patients suggest a fundamental decrease in bone matrix-formation rather than a mineralization defect as the underlying mechanism.

Lack of lipid involvement in nonosseous tissue repair

Calcium-acidic phospholipid-phosphate complexes (Ca-PL-PO4) have been implicated in the onset of tissue mineralization in healing fracture callus as well as in normal osteogenesis. Although these complexes are not found in nonmineralizing normal tissues, the possibility that they are more involved in healing phenomena than in actual mineralization cannot be excluded. The present study confirms that Ca-PL-PO4 complexes are only involved with osseous repair. In healing skin at 5, 8, and 11 days after wounding, Ca-PL-PO4 concentration was not significantly elevated (percentage complexed lipid P/total lipid P: 3.7, 2.4, and 3.8, respectively) relative to the value found for normal skin (2 +/- 2%), although the total lipid phosphorus content at 8 and 11 days was increased.

The Haglund syndrome: initial and differential diagnosis

Haglund syndrome is a common cause of posterior heel pain, characterized clinically by a painful soft-tissue swelling at the level of the achilles tendon insertion. On the lateral heel radiograph the syndrome is characterized by a prominent calcaneal bursal projection, retrocalcaneal bursitis, thickening of the Achilles tendon, and a convexity of the superficial soft tissues at the level of the Achilles tendon insertion, a "pump-bump." An objective method for evaluating prominence of the bursal projection is measurement using the parallel pitch lines. This measurement helps to identify patients with Haglund syndrome and patients predisposed to develop this condition, and also to differentiate local causes of posterior heel pain from systemic causes. The parallel pitch line measurement was determined in 10 symptomatic feet and 78 control feet and the results were analyzed statistically.

Epicardial nodules: a possible sign of coronary endarteritis with hypoplastic right heart syndrome

Hypoplastic heart syndromes in infancy have been associated with an unusual obliterative coronary endarteritis. Only one case was revealed amont the 16 autopsies performed over the past ten years at The Johns Hopkins Hospital on infants with the hypoplastic right heart syndrome. Grossly visible epicardial nodules at the time of autopsy prompted further investigation in this case and should be considered markers of this unusual entity.