Prognostic risk factors in 113 patients undergoing cephalic duodenopancreatectomy for distal cholangiocarcinoma

INTRODUCTION

Distal cholangiocarcinoma is a malignant epithelial neoplasia that affects the extrahepatic bile ducts, below the cystic duct. No relevant relationship between perioperative factors and worse long-term outcome has been proved.

OBJECTIVE

To analyze the risk factors for mortality and long-term recurrence of distal cholangiocarcinoma in resected patients.

MATERIALS AND METHODS

A single-center prospective database of patients operated on for distal cholangiocarcinoma between 1990 and 2021 was analyzed in order to investigate mortality and recurrence factors.

RESULTS

One hundred and thirteen patients have undergone surgery, with mean actuarial survival of 100.2 (76-124) months after resection. The bivariate study did not show differences between patients depending on age or preoperative variables studied. When multivariate analysis was performed, the presence of affected adenopathy was a risk factor for long-term mortality. The presence of affected lymph nodes, tumor recurrence, and biliary fistula during the postoperative period implied worse actuarial survival when comparing the Kaplan-Meier curves.

CONCLUSIONS

The presence of affected lymph nodes influence the prognosis of the disease. The occurrence of biliary fistula during postoperative cholangiocarcinoma distal could aggravate long-term outcomes, a finding that should be reaffirmed in future studies.

Impact of frailty on long-term outcomes after liver resection for hepatocellular carcinoma in elderly patients: A prospective study

BACKGROUND

sFrailty affects short-term outcomes after liver resection in elderly patients. However, frailty's effects on long-term outcomes after liver resection in elderly patients with hepatocellular carcinoma (HCC) are unknown.

METHODS

This prospective, single-center study included 81 independently living patients aged ≥65 years scheduled to undergo liver resection for initial HCC. Frailty was evaluated according to the Kihon Checklist, a phenotypic frailty index." We investigated and compared postoperative long-term outcomes after liver resection between patients with and without frailty.

RESULTS

Of the 81 patients, 25 (30.9%) were frail. The proportion of patients with cirrhosis, high serum alpha-fetoprotein level (≥200 ng/mL), and poorly differentiated HCC was higher in the frail group than in the nonfrail group (n = 56). Among the patients with postoperative recurrence, the incidence of extrahepatic recurrence was higher in the frail group than in the nonfrail group (30.8% vs. 3.6%, P = 0.028). Moreover, the proportion of patients who underwent repeat liver resection and ablation for recurrence who met the Milan criteria tended to be lower in the frail group than in the nonfrail group. Although there was no difference in disease-free survival between the two groups, the overall survival rate in the frail group was significantly worse than that in the nonfrail group (5-year overall survival: 42.7% vs. 77.2%, P = 0.005). Results of the multivariate analysis indicated that frailty and blood loss were independent prognostic factors for postoperative survival.

CONCLUSION

Frailty is associated with unfavorable long-term outcomes after liver resection in elderly patients with HCC.

Development and validation of a novel nomogram for postoperative overall survival of patients with primary gastric signet-ring cell carcinoma: a population study based on SEER database

BACKGROUND

Gastric signet ring cell carcinoma (GSRCC) is a highly malignant subtype of gastric cancer. We tried to establish and validate a nomogram using common clinical variables to achieve more personalized management.

METHODS

We analyzed patients with GSRCC in the Surveillance, Epidemiology, and End Results database between 2004 and 2017. The survival curve was calculated by the Kaplan-Meier method, and the difference in survival curve was tested by log-rank test. We used the cox proportional hazard model to evaluate independent factors of prognosis, and established a nomogram to predict 1-, 3- and 5- overall survival (OS). Harrell's consistency index and calibration curve were used to measure the discrimination and calibration of the nomogram. In addition, we used decision curve analysis (DCA) to compare the net clinical benefits of the nomogram and American Joint Committee on Cancer (AJCC) staging system.

RESULTS

The prognosis nomogram predicting 1-, 3- and 5-years OS for patients with GSRCC is established for the first time. The C-index and AUC of nomogram were higher than that of the American Joint Committee on Cancer (AJCC) staging system in the training set. Our model also shows better performance than the AJCC staging system in the validation set, and importantly, DCA shows that our model has a better net benefit than the AJCC stage.

CONCLUSIONS

We have developed and validated a new nomogram and risk classification system, which is better than the AJCC staging system. It will help clinicians manage postoperative patients with GSRCC more accurately.

Significance of preoperative peripheral blood neutrophil-lymphocyte ratio in predicting postoperative survival in patients with multiple myeloma bone disease

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is often used to predict a poor prognosis in patients with tumors. This study investigated the preoperative peripheral blood NLR in predicting postoperative survival (POS) in patients with multiple myeloma bone disease (MMBD).

AIM

To evaluate whether NLR can be used to predict the prognosis of MMBD patients after surgery.

METHODS

The clinical data of 82 MMBD patients who underwent surgical treatments in Beijing Chao-yang Hospital were collected. The NLR was obtained from the absolute number of neutrophils and lymphocytes, calculated by the number of neutrophils and divided by the number of lymphocytes. The peripheral blood lymphocyte percentage was used as the major marker to analyze the change in characteristics of the immune statuses of multiple myeloma patients.

RESULTS

The NLR cut-off values of NLR ≥ 3 patients and NLR ≥ 4 patients were significantly correlated with POS. The 3- and 5-year cumulative survival rates of the high NLR group (NLR ≥ 3 patients) were 19.1% and 0.0%, respectively, which were lower than those of the low NLR group (NLR < 3 patients) (67.2% and 48.3%) (P = 0.000). In the high NLR group, POS (14.86 ± 14.28) was significantly shorter than that in the low NLR group (32.68 ± 21.76). Univariate analysis showed that the lymphocyte percentage 1 wk after the operation (19.33 ± 9.08) was significantly lower than that before the operation (25.72 ± 11.02). Survival analysis showed that postoperative chemotherapy, preoperative performance status and preoperative peripheral blood NLR ≥ 3 were independent risk factors for POS.

CONCLUSION

The preoperative peripheral blood NLR can predict POS in MMBD patients. MMBD patients with a high preoperative NLR (NLR ≥ 3) showed poor prognosis.

Impact of anastomotic leakage on postoperative survival of patients with colorectal cancer: A meta-analysis using propensity score matching studies

OBJECTIVE

To explore the influence of anastomotic leakage (AL) on postoperative survival in patients with colorectal cancer (CRC).

BACKGROUND

Although several studies have compared the postoperative survival of patients with CRC with and without AL, the background characteristics of the two groups were not aligned in most studies.

METHODS

We performed a comprehensive electronic search of the literature up to March 2020 to identify propensity score matching (PSM) studies that compared postoperative survival between CRC patients with and without AL. A meta-analysis was performed using random-effects models to calculate the risk ratio (RR) and 95% confidence interval (CI), and heterogeneity was analyzed using I (Akiyoshi et al., 2011) [2] statistics.

RESULTS

Four PSM studies involving a total of 1676 patients with CRC undergoing surgery were included in this meta-analysis. Among 234 patients who had AL, 163 (69.7%) survived at 5 years after surgery, whereas among 1422 patients who did not have AL, 1156 (81.3%) survived at 5 years after surgery. Background characteristics of the two groups were adjusted with PSM in all 4 studies. The result of the meta-analysis revealed a significant difference between the two groups (RR, 1.63; 95% CI, 1.09-2.45; P = 0.02; I² = 66%) in 5-year overall survival (OS).

CONCLUSIONS

The results of this meta-analysis demonstrate a significantly decreased 5-year OS in patients with CRC who had AL compared with patients with CRC who did not have AL.

Preoperative maximal voluntary ventilation, hemoglobin, albumin, lymphocytes and platelets predict postoperative survival in esophageal squamous cell carcinoma

BACKGROUND

Preoperative pulmonary function plays an important role in selecting surgical candidates and assessing postoperative complications. Reduced pulmonary function is associated with poor survival in several cancers, but the prognostic value of preoperative pulmonary function in esophageal squamous cell carcinoma (ESCC) is unclear. Nutritional and systemic inflammation parameters are vital to cancer survival, and the combination of these parameters improves the prognostic value. The hemoglobin, albumin, lymphocytes and platelets (HALP) score is a novel prognostic indicator to reflect the nutritional and inflammation status, but the clinical effects of the HALP score combined with maximal voluntary ventilation (MVV), an important parameter of pulmonary function, have not been well studied in ESCC.

AIM

To investigate the prognostic value of MVV and HALP score for assessing postoperative survival of ESCC patients.

METHODS

Data from 834 ESCC patients who underwent radical esophagectomy with R0 resection were collected and retrospectively analyzed. Preoperative MVV and HALP data were retrieved from medical archives. The HALP score was calculated by the formula: Hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L)/platelets (/L). The optimal cut-off values of MVV and HALP score were calculated by the receiver operating characteristic curve analysis. The Kaplan-Meier method with log-rank test was used to draw the survival curves for the variables tested. Multivariate Cox proportional hazard regression models were used to analyze the independent prognostic factors for overall survival.

RESULTS

MVV was significantly associated with gender (P < 0.001), age at diagnosis (P < 0.001), smoking history (P < 0.001), drinking history (P < 0.001), tumor length (P = 0.013), tumor location (P = 0.037) and treatment type (P = 0.001). The HALP score was notably associated with gender (P < 0.001), age at diagnosis (P = 0.035), tumor length (P < 0.001) and invasion depth (P = 0.001). Univariate Cox regression analysis showed that low MVV and low HALP score were associated with worse overall survival (all P < 0.001). Multivariate analysis showed that low MVV and the HALP score were both independent risk factors for overall survival (all P < 0.001). The combination of MVV and HALP score improved the prediction performance for overall survival than tumor-node-metastasis. Also, low combination of MVV and HALP score was an independent risk factor for poor overall survival (P < 0.001).

CONCLUSION

MVV, HALP score and their combination are simple and promising clinical markers to predict overall survival of ESCC patients.

Aggressive recurrences determine oncologic outcomes after resection of liver metastases from primary right colon cancer: Results of a case-control study

BACKGROUND

Despite recent studies suggest that, among patients operated on for colorectal liver metastases (CLM), the primary tumor location may impact on postoperative survivals, results are still contrasting.

OBJECTIVE

evaluating survivals (overall (OS) and (DFS)) following liver resection of CLM from Right colon Cancer (RcC-CLM) versus Left colon Cancer (LcC-CLM), among patients undergoing preoperative chemotherapy (pCHT), identifying survival predictors, and investigating impact of recurrent disease pattern and management on survival.

METHODS

Among 727 patients operated for CLM(1989-2016), after excluding patients with primary transverse colon/rectum tumor and patients not receving pCHT, 297 patients were identified. Among them, 81 with RcC-CLM were matched 1:1 with LcC-CLM, according to CLM number and diameter, disease-free interval between primary tumor and CLM diagnosis, primary tumor N-status, and the presence of extrahepatic disease.

RESULTS

Overall, 66.7% of patients had multiple CLM, 21% had CLM>5 cm, 82.7% had DFI<12 months, 67.9% had N+ primary tumor, and 11.1% had extrahepatic disease at time of hepatectomy. RcC-CLM patients were similar to LcC-CLM in terms of demographic, clinical, perioperative, and pathologic characteristics. Patients operated for RcC-CLM, compared to LcC-CLM, had significantly shorter 5y-DFS(18% versus 39%) and 5y-OS(38% vs 65%). At multivariate analysis, being operated for RcC-CLM, compared to LcC-CLM, was the strongest predictor of recurrence (Hazard Ratio:2.265,p < .001) and death (HR:2.234,p = .001). Among 107 patients experiencing recurrent disease, curative recurrence resection was associated with higher 5y-OS(64% vs 17%; p < .001). However, recurrence resection was less frequently feasible among RcC-CLM(26%) patients, compared to LcC-CLM(44%,p = .05).

CONCLUSIONS

resection of RcC-CLM, compared to LcC-CLM, is associated with worse survivals, probably related to a different pattern of recurrence precluding recurrence resection among RcC-CLM patients.

Haemoglobin, albumin, lymphocyte and platelet predicts postoperative survival in pancreatic cancer

BACKGROUND

Systemic inflammation and nutrition status play an important role in cancer metastasis. The combined index of hemoglobin, albumin, lymphocyte, and platelet (HALP), consisting of haemoglobin, albumin, lymphocytes, and platelets, is considered as a novel marker to reflect both systemic inflammation and nutrition status. However, no studies have investigated the relationship between HALP and survival of patients with pancreatic cancer following radical resection.

AIM

To evaluate the prognostic value of preoperative HALP in pancreatic cancer patients.

METHODS

The preoperative serum levels of hemoglobin, albumin, lymphocyte counts, and platelet counts were routinely detected in 582 pancreatic adenocarcinoma patients who underwent radical resection. The relationship between postoperative survival and the preoperative level of HALP was investigated.

RESULTS

Low levels of HALP were significantly associated with lymph node metastasis (P = 0.002), poor tumor differentiation (P = 0.032), high TNM stage (P = 0.008), female patients (P = 0.005) and tumor location in the head of the pancreas (P < 0.001). Low levels of HALP were associated with early recurrence [7.3 mo vs 16.3 mo, P < 0.001 for recurrence-free survival (RFS)] and short survival [11.5 mo vs 23.6 mo, P < 0.001 for overall survival (OS)] in patients with resected pancreatic adenocarcinoma. A low level of HALP was an independent risk factor for early recurrence and short survival irrespective of sex and tumor location.

CONCLUSION

Low levels of HALP may be a significant risk factor for RFS and OS in patients with resected pancreatic cancer.

The effects of cement fixation on survival in elderly patients with hip hemiarthroplasty: a nationwide cohort study

BACKGROUND

Hip hemiarthroplasty (HHA) is a common treatment for hip fractures in the elderly population. Because of the fatal effects of bone cement implantation syndrome, the safety of cement utilization to enhance implant firmness in the femur is controversial. The aim of this study was to investigate the postoperative survival of elderly patients receiving HHA with and without cement fixation.

METHODS

Claim data from the National Health Insurance Database and the National Register of Deaths Database were used for analysis in this retrospective cohort study. From 2008 to 2014, 25,862 patients aged 80 years or older treated with hip hemiarthroplasty were included in the analysis. A Cox proportional risk model was used to analyse the effects of cement utilization on postoperative mortality.

RESULTS

The cemented group had a significantly higher mortality risk than the non-cemented group within 7, 30, 180 days and 1 year after the operation. The effect of bone cement on postoperative mortality was significantly stronger within 7 days than within 30, 180 days and 1 year. In addition, the male gender, age > 85 years and higher score on the Charlson Comorbidity Index were also risk factors for mortality (p < 0.05). Patients who received HHA in lower-volume hospitals had higher mortality rates within 180 days and 1 year than those in higher-volume hospitals. Compared with patients who were operated on by high-volume surgeons, those who received surgery performed by lower-volume surgeons were more likely to die within 30 days (aHR = 1.22), 180 days (aHR = 1.16) and 1 year (aHR = 1.19), respectively.

CONCLUSIONS

The postoperative mortality rate of elderly patients undergoing HHA was significantly higher in the cemented group than in the non-cemented group.

An elevated neutrophil-to-lymphocyte ratio predicts a poor postoperative survival in primary hepatocellular carcinoma patients with a normal preoperative serum level of alpha-fetoprotein

PURPOSE

Although alpha-fetoprotein (AFP) is a useful prognostic marker in patients with hepatocellular carcinoma (HCC), a recent study has shown that the preoperative neutrophil-to-lymphocyte ratio (NLR) is also associated with the postoperative survival in such patients.

OBJECTIVE

To investigate the significance of the NLR in patients with primary HCC (p-HCC) showing a normal preoperative AFP.

METHODS

Among 478 p-HCC patients undergoing curative surgery, 112 who had a normal AFP (< 8 ng/ml) were enrolled. The patients were divided into two groups: group A, who did not have an elevated NLR (≤ 3.2); and group B, who had an elevated NLR (> 3.2). Uni- and multivariate analyses were performed to compare clinical features with the overall survival (OS).

RESULTS

A multivariate analysis of the clinical features showed that the NLR (> 3.2/≤ 3.2) (hazard ratio 2.366; 95% CI 1.069-5.235; P = 0.034) was closely associated with the OS, along with the age (> 65/≤ 65 years) (P = 0.033). Group B had a significantly lower survival ratio than group A in terms of not only the OS (P = 0.013), but also the cancer-specific survival (P = 0.002) and relapse-free survival (P = 0.039).

CONCLUSIONS

An elevated NLR (> 3.2) is predictive of a poor survival in patients with primary HCC (p-HCC) showing normal AFP levels.

Complications and reoperations after surgery for 647 patients with spine metastatic disease

BACKGROUND CONTEXT

Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival.

PURPOSE

We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers.

OUTCOME MEASURES

Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death.

METHODS

We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival.

RESULTS

From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49-0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00-2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97-2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02-2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06-5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07-2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17-1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09-1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery.

CONCLUSIONS

Three or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.

Postoperative survival of EGFR-TKI-targeted therapy in non-small cell lung cancer patients with EGFR 19 or 21 mutations: a retrospective study

Background

The aim of this retrospective study is to identify epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer patients and to compare the long-term postoperative outcomes in different EGFR-TKI-targeted therapy effects between the different EGFR mutation groups.

Methods

A total of 2094 postoperative non-small cell lung cancer (NSCLC) patients with EGFR gene detection were collected in the Department of Pathology in the Cancer Hospital Chinese Academy of Medical Sciences from January 2003 to January 2014. Three hundred sixty-three patients were treated with EGFR tyrosine kinase inhibitor (TKI) after surgery: 184 harbored the exon 19 deletion mutation and 179 cases carried the exon 21 L858R point mutation. The end points included progression-free survival (PFS), overall survival (OS), and the response rate.

Results

OS was increased in the EGFR exon 19 deletion group compared with the exon 21 L858R point mutation group (92 vs. 65 months; P < 0.001). But the median PFS did not differ between two groups (12 vs 14 months). The objective response rate (ORR) in 19 deletion group was increased compared with L858R mutation patients (28.35 vs. 22.73%). The disease control rate (DCR) of patients with 19 deletion benefited more from targeted therapy, compared with L858R group (93.71 vs. 84.31%, P = 0.014). In 19 deletion group, a high ORR and DCR were noted in patients treated with icotinib, 16 out of 18 achieved stable disease (SD), and the DCR in this population was 100%.

Conclusions

EGFR subtypes could influence the postoperative survival of NSCLC patients with TKI-targeted therapy.

The revision of 8th edition TNM stage criteria is more accurate in prediction postoperative survival for SCLC patients

OBJECTIVES

The 8th edition TNM lung cancer classification was enacted in January 2017. An important change is the old T2a was revised to new T2a and T2b. Whether a postoperative survival difference exists between the two stages is still undefined. The purpose of this study is to investigate the postoperative outcomes of small cell lung cancer (SCLC) patients and compare the survival difference between the two stages.

METHODS

Data of patients with SCLC who underwent surgery between October 2005 and August 2013 at our institute were reviewed. A total number of 194 patients were enrolled and were reclassified according to the 8th edition TNM stage. Survival was determined by Kaplan-Meier analysis, the log-rank test was used to compare survival differences.

RESULTS

Surgical resection included 165 lobectomy or bilobectomy, 19 sublobectomy and 10 pneumonectomy. There were 159 patients received chemotherapy, 35 underwent surgery alone. The 5-year survival rate and median survival time (MST) of whole group was 34.5% and 45 months. For patients who received similar therapy (surgery plus chemotherapy) in N0 stage, the MST of T2a stage was 83 months, significantly longer than 62 months in T2b stage (P = 0.017).

CONCLUSIONS

In the 8th edition TNM lung cancer stage criteria, the postoperative survival of T2a is superior to T2b for non-metastatic SCLC at N0 stage.

Inflammation-based prognostic system predicts postoperative survival of esophageal carcinoma patients with normal preoperative serum carcinoembryonic antigen and squamous cell carcinoma antigen levels

BACKGROUND

The Glasgow Prognostic Score (GPS) is an established inflammation-based system that is used to predict the prognosis for several types of malignancies. In this retrospective study, we assessed the postoperative survival of 725 patients with non-metastatic esophageal squamous cell carcinoma who had normal preoperative serum tumor marker levels according to the GPS.

METHODS

Among 1394 patients who underwent esophagectomy between August 2006 and December 2010, 725 with normal preoperative serum levels of carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC-Ag) were enrolled. All demographic, pathologic, and survival data were analyzed retrospectively. Uni- and multivariate analyses were performed to evaluate the relationship with overall survival. The Kaplan-Meier analysis and log-rank tests were used to compare the survival curves between patients with GPS 0 (group A) and 1 or 2 (group B).

RESULTS

Patients in group A exhibited significantly better 3- and 5-year cancer-specific survival (CSS) rates (0.780 and 0.759, respectively) than those in group B (0.624 and 0.605, respectively). Multivariate Cox regression analysis revealed that age, tumor length, pathological tumor-node-metastasis (pTNM) stage, venous invasion, lymph node metastasis, serum albumin and C-reactive protein levels, and GPS were associated with postoperative survival of these patients. Further multivariate analysis confirmed that GPS was an independent prognostic factor. The Kaplan-Meier analysis and log-rank tests demonstrated a significant difference in CSS between groups A and B (P = 0.001).

CONCLUSIONS

GPS may be a valuable prognostic indicator for esophageal cancer patients with normal preoperative CEA and SCC-Ag serum levels.

Intramedullary nailing has sufficient durability for metastatic femoral fractures

Background

Surgical treatment options of femoral metastases include intramedullary nailing (IMN) and endoprosthetic reconstruction (EPR). Previous studies have demonstrated functional and oncological advantages of EPR over IMN. The purpose of this study was to (1) report the durability of IMN and (2) establish the indication of IMN for femoral metastases.

Methods

In 2003–2013, among 186 surgically treated femoral metastasis cases, we retrospectively reviewed 80 consecutive IMN cases in 75 patients, including 14 pathological and 66 impending fractures. For the decision of surgical procedure (IMN, EPR, or plating), the following factors are considered: (1) fracture pattern (impending or pathological fracture), (2) Mirels’ score (≥8 or <8), (3) fracture site (femoral head, neck, intertrochanter, subtrochanter, diaphysis, or distal), (4) number of metastases (solitary or multiple), and (5) patient’s estimated prognosis. Patient demographics, postoperative survival, implant survival, and early postoperative mortality were reviewed.

Results

The patients were 37 males and 38 females, with a mean age of 60.1 (20–84) years. Average follow-up period was 11.4 (1–77) months. The most common fracture site was the subtrochanter (46/80), followed by the diaphysis (26/80) and the intertrochanter (8/80). The most common primary tumor was lung cancer (24/80, 32 %), followed by breast cancer (24 %) and melanoma (15 %). With the exception of six cases, all patients underwent postoperative radiotherapy to the affected whole femur. The postoperative patient survival was 14.2 and 8.4 % at 2 and 3 years from surgery, respectively, while the implant survival rate remained 94.0 % at both 2 and 3 years. Three out of 46 subtrochanteric cases required revision surgeries because of proximal breakage of implant 4–50 months after initial surgery for femoral metastases, but all were replaced by mega-prosthesis and did not need further operation until their death. Early postoperative fatal complications were observed in three patients, all of which were pulmonary dysfunction.

Conclusions

The performance of IMN in this study was satisfactory although a large portion of sub- and intertrochanter metastases were included. Broader indication including these parts should be considered, for IMN has advantages such as lower cost and less invasiveness and even an implant failure can be revised by mega-prosthetic reconstruction.

Prognosis after resection for hepatitis B virus-associated intrahepatic cholangiocarcinoma

AIM: To investigate the prognostic factors after resection for hepatitis B virus (HBV)-associated intrahepatic cholangiocarcinoma (ICC) and to assess the impact of different extents of lymphadenectomy on patient survival.

METHODS: A total of 85 patients with HBV-associated ICC who underwent curative resection from January 2005 to December 2006 were analyzed. The patients were classified into groups according to the extent of lymphadenectomy (no lymph node dissection, sampling lymph node dissection and regional lymph node dissection). Clinicopathological characteristics and survival were reviewed retrospectively.

RESULTS: The cumulative 1-, 3-, and 5-year survival rates were found to be 60%, 18%, and 13%, respectively. Multivariate analysis revealed that liver cirrhosis (HR = 1.875, 95%CI: 1.197-3.278, P = 0.008) and multiple tumors (HR = 2.653, 95%CI: 1.562-4.508, P < 0.001) were independent prognostic factors for survival. Recurrence occurred in 70 patients. The 1-, 3-, and 5-year disease-free survival rates were 36%, 3% and 0%, respectively. Liver cirrhosis (HR = 1.919, P = 0.012), advanced TNM stage (stage III/IV) (HR = 2.027, P < 0.001), and vascular invasion (HR = 3.779, P = 0.02) were independent prognostic factors for disease-free survival. Patients with regional lymph node dissection demonstrated a similar survival rate to patients with sampling lymph node dissection. Lymphadenectomy did not significantly improve the survival rate of patients with negative lymph node status.

CONCLUSION: The extent of lymphadenectomy does not seem to have influence on the survival of patients with HBV-associated ICC, and routine lymph node dissection is not recommended, particularly for those without lymph node metastasis.

Routine lymph node dissection may be not suitable for all intrahepatic cholangiocarcinoma patients: Results of a monocentric series

AIM: To investigate the indications for lymph node dissection (LND) in intrahepatic cholangiocarcinoma patients.

METHODS: A retrospective analysis was conducted on 124 intrahepatic cholangiocarcinoma (ICC) patients who had undergone surgical resection of ICC from January 2006 to December 2007. Curative resection was attempted for all patients unless there were metastases to lymph nodes (LNs) beyond the hepatoduodenal ligament. Prophylactic LND was performed in patients in whom any enlarged LNs had been suspicious for metastases. The patients were classified according to the LND and LN metastases. Clinicopathologic, operative, and long-term survival data were collected retrospectively. The impact on survival of LND during primary resection was analyzed.

RESULTS: Of 53 patients who had undergone hepatic resection with curative intent combined with regional LND, 11 had lymph nodes metastases. Whether or not patients without lymph node involvement had undergone LND made no significant difference to their survival (P = 0.822). Five patients with multiple tumors and involvement of lymph nodes underwent hepatic resection with LND; their survival curve did not differ significantly from that of the palliative resection group (P = 0.744). However, there were significant differences in survival between patients with lymph node involvement and a solitary tumor who underwent hepatic resection with LND and the palliative resection group (median survival time 12 mo vs 6.0 mo, P = 0.013).

CONCLUSION: ICC patients without lymph node involvement and patients with multiple tumors and lymph node metastases may not benefit from aggressive lymphadenectomy. Routine LND should be considered with discretion.