Scoring system for prediction of overall survival in patients with renal cell carcinoma T3aN0M0

Objective

We aim to create a new score to predict postoperative overall survival in patients with nonmetastatic T3aN0 renal cell carcinoma.

Methods

We reviewed the clinical data of adult patients who underwent radical nephrectomy for renal cell carcinoma between December 2007 and January 2022 in a single tertiary oncological institution. Clinical characteristics, clinical-pathological staging and histopathological characteristics were analysed. Survival analyses were determined using the Kaplan-Meier curve. A nomogram was established using Cox proportional hazard regression to identify the prognostic factors affecting the overall survival. The area under the curve, calibration curves and decision curve analysis were used to evaluate prognostic efficacy.

Results

We analyzed 362 patients classified as pT3aN0M0 stage with a median follow-up of 40 months. According to Cox univariate and multivariate analyses, weight loss greater than 5% in 6 months before surgery, stage V chronic kidney disease after radical nephrectomy, sarcomatoid pattern, and coagulative tumor necrosis were identified as predictors of overall survival. We developed a score and performed internal and external validation. The time-dependent receiver operating characteristic curve, area under the curve value and calibration curve analysis showed good prediction ability of the score. The nomogram can effectively predict and stratify overall survival after radical nephrectomy in patients with pT3aN0M0 renal cell carcinoma.

Conclusion

Patients with pT3aN0MO renal cell carcinoma exhibited different characteristics, and those with unfavourable characteristics deserve greater attention during follow-up. This nomogram provides an accurate prediction of overall survival after radical nephrectomy.

Outcome of patients with stage I immature teratoma after surveillance or adjuvant chemotherapy

Objective

Immature teratomas are rare malignant ovarian germ cell tumours, typically diagnosed in young women, where fertility-sparing surgery is the treatment of choice. The role of adjuvant chemotherapy in stage I disease remains controversial. We evaluated the impact of surveillance versus chemotherapy on the recurrence rate in stage I immature teratomas.

Methods

We collected a single centre retrospective series of patients with stage I immature teratomas treated with fertility-sparing surgery at San Gerardo Hospital, Monza, Italy, between 1980 and 2019. Potential risk factors for recurrence were investigated by multivariate logistic regression.

Results

Of the 74 patients included, 12% (9/74) received chemotherapy, while 88% (65/74) underwent surveillance. Median follow-up was 188 months. No difference in recurrence was found in stage IA/IB and IC immature teratomas [10% (6/60) vs. 28.6% (4/14) (P=0.087)], grade 1, grade 2, and grade 3 [7.1% (2/28) vs. 14.3% (4/28) vs. 22.2% (4/18) (p=0.39)], and surveillance versus chemotherapy groups [13.9% (9/65) vs. 11.1% (1/9)) (p = 1.00)]. In univariate analysis, the postoperative approach had no impact on recurrence. The 5-year disease-free survival was 87% and 90% in the surveillance and chemotherapy groups, respectively; the overall survival was 100% in both cohorts.

Conclusions

Our results support the feasibility of surveillance in stage I immature teratomas. Adjuvant chemotherapy may be reserved for relapses. However, the potential benefit of chemotherapy should be discussed, especially for high-risk tumours. Prospective series are warranted to confirm our findings.

What is already known on this topic

To date, no consensus has been reached regarding the role of adjuvant chemotherapy in stage I immature teratomas of the ovary. Some studies suggest that only surveillance is an acceptable choice. However, guidelines are not conclusive on this topic.

What this study adds

No difference in terms of recurrence was observed between the surveillance and the adjuvant chemotherapy group. All patients who relapsed were successfully cured with no disease-related deaths.

How this study might affect research practice or policy

Adjuvant chemotherapy should be appropriately discussed with patients. However, it may be reserved for relapse according to our data.

A meta-analysis comparing efficacy and safety between proton beam therapy versus carbon ion radiotherapy

BACKGROUND

This study aimed to compare the outcomes of proton beam therapy (PBT) and carbon ion radiotherapy (CIRT) by a systematic review and meta-analysis of the existing clinical evidence.

METHODS

A systematic literature search was performed to identify studies comparing the clinical outcomes of PBT and CIRT. The included studies were required to report oncological outcomes (local control [LC], progression-free survival [PFS], or overall survival [OS]) or adverse events.

RESULTS

Eighteen articles comprising 1857 patients (947 treated with PBT and 910 treated with CIRT) were included in the analysis. The pooled analysis conducted for the overall population yielded average hazard ratios of 0.690 (95% confidence interval (CI), 0.493-0.967, p = 0.031) for LC, 0.952 (95% CI, 0.604-1.500, p = 0.590) for PFS, and 1.183 (0.872-1.607, p = 0.281) for OS with reference to CIRT. The subgroup analyses included patients treated in the head and neck, areas other than the head and neck, and patients with chordomas and chondrosarcomas. These analyses revealed no significant differences in most outcomes, except for LC in the subgroup of patients treated in areas other than the head and neck. Adverse event rates were comparable in both groups, with an odds ratio (OR) of 1.097 (95% CI, 0.744-1.616, p = 0.641). Meta-regression analysis for possible heterogeneity did not demonstrate a significant association between treatment outcomes and the ratio of biologically effective doses between modalities.

CONCLUSION

This study highlighted the comparability of PBT and CIRT in terms of oncological outcomes and adverse events.

An update of oncologic and obstetric outcomes of radical trachelectomy for early-stage cervical cancer: The need for further minimally invasive treatment

AIMS

To investigate the oncologic and obstetric outcomes of radical trachelectomy (RT) in patients with early-stage cervical cancer and to evaluate the potential role of fertility-preserving treatments in improving pregnancy outcomes while oncologic status is stable.

METHODS

In this single-institution study, we analyzed the oncologic and obstetric outcomes of 67 patients with early-stage cervical cancer who underwent RT at Nagoya University Hospital.

RESULTS

The cancer recurrence rate (6.0%) and the mortality rate (1.5%) were comparable with those of previous studies. Of the 46 patients who attempted to conceive after RT, 19 (41.3%) became pregnant, and 16 gave birth. Of these 37.5% delivered at term, and delivery at less than 28 weeks of gestation occurred in 31.3% of pregnancies.

CONCLUSIONS

RT is a viable treatment option for selected patients with early-stage cervical cancer. However, the use of less invasive techniques, such as conization/simple trachelectomy and pelvic lymph node dissection, may improve pregnancy outcomes while oncologic status is stable.

Assessment of the differences in oncologic outcomes between patients with high-grade serous ovarian carcinoma and uterine serous carcinoma

AIM

To evaluate whether the recurrence rates, recurrence patterns, and survival outcomes differed according to the primary site of the tumor in patients with high-grade serous ovarian carcinoma (HGSOC) and uterine serous carcinoma (USC).

METHODS

The population of this multicenter retrospective study consisted of patients who had USC or HGSOC. Progression-free survival (PFS) and disease-specific survival (DSS) estimates were determined using the Kaplan-Meier method. Survival curves were compared using the log-rank test.

RESULTS

The study cohort consisted of 247 patients with HGSOC and 34 with USC. Recurrence developed in 118 (51.1%) in the HGSOC group and 14 (42.4%) in the USC group (p = 0.352). The median time to recurrence was 23.5 (range, 4-144) and 17 (range, 4-43) months in the HGSOC and USC groups, respectively (p = 0.055). The 3-year PFS was 52% in the HGSOC group and 47% in the USC group (p = 0.450). Additionally, 3-year DSS was 92% and 82% in the HGSOC and USC groups, respectively (p = 0.060).

CONCLUSIONS

HGSOC and USC are aggressive tumors with high recurrence and mortality rates in advanced stages. These two carcinomas, which are similar in molecular features and clinical management, may also have similar recurrence patterns, disease failure, and survival rates.

The Current Trend of Fertility Preservation in Patients with Cervical Cancer

Although the incidence of most cancers increases with age, a considerable number of patients receive a diagnosis of cancer during their reproductive years. Young women wishing to get pregnant after cancer treatment should be provided consultation for fertility preservation and possible options. In patients with cervical cancer, hysterectomy is often inevitable because the uterus is located too close to the cervix. For young patients with cervical cancer who desire to get pregnant and whose lesion is confined to the cervix, sparing the uterus and, partially, the cervix should be prioritized as much as possible, while simultaneously ensuring favorable oncologic outcomes. In this review, we explore how to choose an adequate fertility-preserving procedure to achieve a balance between favorable oncologic outcomes and fertility and management during pregnancy after a radical trachelectomy in women with early-stage cervical cancer. For patients who require hysterectomy or radiation, evaluation of the ovarian condition and laparoscopic ovarian transposition followed by the use of artificial reproduction techniques and pregnancy by surrogacy should be discussed as options to achieve a successful pregnancy.

Chronic Obstructive Pulmonary Disease Is Associated with Worse Oncologic Outcomes in Early-Stage Resected Pancreatic and Periampullary Cancers

Pancreatic ductal adenocarcinoma (PDAC) is the 3rd leading cause of cancer mortality in the United States. Hypoxic and hypercapnic tumor microenvironments have been suggested to promote tumor aggressiveness. The objective of this study was to evaluate the association between chronic obstructive pulmonary disease (COPD) and oncologic survival outcomes in patients with early-stage PDAC and periampullary cancers. In this case-control study, patients who underwent a pancreaticoduodenectomy during 2014-2021 were assessed. Demographic, perioperative, histologic, and oncologic data were collected. A total of 503 PDAC and periampullary adenocarcinoma patients were identified, 257 males and 246 females, with a mean age of 68.1 (±9.8) years and a mean pre-operative BMI of 26.6 (±4.7) kg/m². Fifty-two percent of patients (N = 262) reported a history of smoking. A total of 42 patients (8.3%) had COPD. The average resected tumor size was 2.9 ± 1.4 cm and 65% of the specimens (N = 329) were positive for lymph-node involvement. Kaplan-Meier analysis showed that COPD was associated with worse overall and disease-specific survival (p < 0.05). Cox regression analysis showed COPD to be an independent prognostic factor (HR = 1.5, 95% CI 1.0-2.3, p = 0.039) along with margin status, lymphovascular invasion, and perineural invasion (p < 0.05 each). A 1:3 nearest neighbor propensity score matching was also employed and revealed COPD to be an independent risk factor for overall and disease-specific survival (OR 1.8 and OR 1.6, respectively; p < 0.05 each). These findings may support the rationale posed by in vitro laboratory studies, suggesting an important impact of hypoxic and hypercapnic tumor respiratory microenvironments in promoting therapy resistance in cancer.

Perianal Basal Cell Carcinoma-A Systematic Review and Meta-Analysis of Real-World Data

(1) Background: BCC is a sporadic disease that develops in areas of the skin not exposed to the sun. Perianal BCC, which occurs in the anorectal region, accounts for less than 0.2% of all BCC cases. There have been only a few reported cases of the disease, with fewer than 200 cases reported in total. Given the diagnostic challenges and potential for misdiagnosis, we conducted a systematic review of perianal basal cell carcinoma using real-world data to provide comprehensive and detailed information on the disease. (2) Methods: The study was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2020. Patients' clinical pathologic features, tumor characteristics, treatment modalities, and outcomes were presented. (3) Results: The results of 41 studies involving 140 patients were analyzed. The most common symptoms reported by patients at presentation were anorectal bleeding, pain, and pruritus. Ulceration was the most frequently observed tumor characteristic. The majority of patients underwent local excision as their primary treatment, with only eight patients experiencing a recurrence. Our analysis did not reveal any statistically significant differences in the outcomes of different treatment modalities. (4) Conclusions: Identifying perianal BCC poses a significant challenge as it closely resembles other anal diseases, thereby making it difficult to differentiate between the different conditions. However, a wide local excision with clear margins is considered an effective treatment option for most patients. Alternative treatments, such as radiotherapy, may be recommended for patients who are unable to undergo surgery.

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P=0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P=0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P=0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P=0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P=0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Robotic versus Laparoscopic Total Mesorectal Excision Surgery in Rectal Cancer: Analysis of Medium-Term Oncological Outcomes

Background. Robotic systems can overcome some limitations of laparoscopic total mesorectal excision (L-TME), thus improving the quality of the surgery. So far, many studies have reported the technical feasibility and short-term oncological results of robotic total mesorectal excision (R-TME) in treating rectal cancer (RC); however, only a few evaluated the survival and long-term oncological outcomes. The following study compared the medium-term oncological data, 3-year overall survival (OS), and disease-free survival (DFS) of L-TME and R-TME in patients with rectal cancer. Methods. In this retrospective study, records of patients (patients with stage I-III rectal cancer) who underwent surgery (127 cases of L-TME and 148 cases of R-TME) at the Gansu Provincial Hospital between June 2016 and March 2018 were included in the analysis. Kaplan-Meier analysis evaluated the 3-year OS and DFS for all patients treated with curative intent. Results. The conversion rate was significantly higher, and the postoperative hospital stay was significantly longer in the L-TME group than in the R-TME group (all P<.05). Major complications were significantly lower in the robotic group (P<.05). The 3-year DFS rate (for all stages) was 74.8% for L-TME and 85.8% for R-TME (P = .021). For disease stage III, the 3-year DFS and OS were significantly higher in the R-TME group (P<.05). Conclusion. R-TME can achieve better oncological outcomes and is more beneficial for RC patients compared with L-TME, especially for those with stage III rectal cancers. Nevertheless, further randomized controlled trials and a longer follow-up period are needed to confirm these findings.

Laparoscopic Lateral Lymph Node Dissection Based on Membrane Anatomy for Lower Rectal Cancer: Surgical Technique and Short-Term Outcomes

Background: Lateral lymph node dissection (LLND) is an effective treatment for metastatic lateral lymph nodes (LLNs) in lower rectal cancer, but with high complication rates due to a complicated procedure. This study aimed to introduce a new technique for LLND based on membrane anatomy to simplify the procedure and report short-term outcomes. Methods: Twenty-three patients with clinical stage II-III lower rectal cancer underwent three-dimensional (3D) laparoscopic total mesorectal excision (TME) plus LLND between July 2018 and December 2020. Demographic data, perioperative variables, and oncologic outcomes were recorded and analyzed. Complications were graded using the Clavien-Dindo (CD) score. Results: Based on the theory of "four fasciae and three spaces," we proposed a fascia-to-space surgical approach to perform LLND. 3D laparoscopic TME plus LLND was performed successfully in all patients. The mean operating time was 172 minutes with a mean blood loss of 85 mL. Postoperative complications were present in 5 (17.4%) patients (CD I-II), including a case of urinary retention. The median number of harvested LLNs was 9, and positive LLNs were detected in 7 (30.4%) patients. After a median follow-up of 26.5 months, 2 (8.7%) patients developed liver metastases, but no local recurrence. Conclusions: Laparoscopic LLND based on membrane anatomy is a safe, feasible, and reproducible procedure and thus worthy of clinical promotion. Further studies with long-term follow-up in larger patient series are still required.

Comparison of Clinical Outcomes between Robot-Assisted Partial Nephrectomy and Cryoablation in Elderly Patients with Renal Cancer

Advances in imaging technologies have increased the opportunities for treating small-diameter renal cell carcinomas (RCCs) in the elderly. This retrospective study based on real-world clinical practice compared perioperative complications, preoperative and postoperative renal function, recurrence-free survival, and overall survival in elderly patients with RCC who had undergone robot-assisted partial nephrectomy (RAPN) or percutaneous cryoablation (PCA). A total of 99 patients (aged ≥70 years), including 50 and 49 patients in the RAPN and PCA groups, respectively, were analyzed. In the entire cohort, Clavien-Dindo grade ≥3 complications occurred in only one patient who had undergone RAPN. Renal function was significantly lower in the postoperative period than in the preoperative period in both the RAPN and PCA groups. The recurrence-free survival and overall survival rates were worse in the PCA group than in the RAPN group, albeit not significantly. RAPN was considered a safe and effective method for treating RCCs in elderly patients. Moreover, although the recurrence rate was slightly higher in the PCA group than in the RAPN group, PCA was deemed to be a safe alternative, especially for treating patients in whom general anesthesia poses a high risk.

Endoscopic papillectomy or pancreaticoduodenectomy for ampullary lesions: a single center retrospective cohort study

BACKGROUND

This study aimed to compare post-operative morbidity, mortality, and completeness of resection following endoscopic vs. radical surgical resection for ampullary lesions.

METHODS

A retrospective analysis of the prospectively collected data from a surgical database for patients with ampullary lesions at our institution was performed. All consecutive patients undergoing endoscopic papillectomy (EP) or pancreaticoduodenectomy (PD) for ampullary lesions between 2007 and 2021 were eligible for this analysis.

RESULTS

A total of 85 patients were included of whom 42 underwent EP whereas 43 received a PD. The resected lesion was a tubulovillous adenoma in 26 patients (61.9%) in the EP cohort, and 37 patients (86.0%) in the PD cohort had adenocarcinomas. The completeness of resection was equal in both cohorts. Significantly more patients of the PD cohort had to undergo reinterventions. After a mean follow up of 36 months (EP) vs. 16 months (PD), the rate of tumor recurrence did not differ between both groups.

CONCLUSION

Equivalently high completeness of resection rates and correspondingly low recurrence rates can be achieved after EP and PD. Our results regarding residual tumor and recurrence rates show that even large tumors can be resected endoscopically with high primary success and completeness of resection rates.

Correlation between T stage and lymph node metastasis in rectal cancer treated with preoperative chemoradiotherapy

Background:

Depth of tumor is a risk factor for lymph node metastasis in rectal cancer, but impact of yield pathologic T (ypT) stage on lymph node involvement in rectal cancer remains unclear. The aim of this study was to evaluate the correlation between ypT stage and lymph node metastasis.

Methods:

From January 2010 to December 2015, 602 patients who were diagnosed with rectal cancer and treated with neoadjuvant chemoradiotherapy (CRT) followed by radical operation were reviewed retrospectively. The correlations between ypT stage and lymph node status and survival were evaluated.

Results:

On pathology, 179 (29.7%) patients exhibited regional lymph node metastasis. Lymph node metastasis was seen in 8.5% of ypT0 patients, 20% of ypT1, 18.4% of ypT2, 47.5% of ypT3, and 27.3% of ypT4. Positive lymph node metastasis was correlated with ypT stage. In addition, the difference of lymph node metastasis in ypT stage subgroups was statistically significant (p < 0.001). Five-year disease-free survival was significantly different in the ypT stage subgroups (88.7% versus 86.7% versus 82.6% versus 64.7% versus 72.7%, p < 0.001), as was 5-year overall survival (96.2% versus 90.0% versus 95.8% versus 80.0% versus 90.9%, p < 0.001).

Conclusion:

YpT stage is associated with lymph node metastasis in rectal cancer treated with neoadjuvant CRT and radical operation, and ypT0 patients exhibited an 8.5% lymph node metastasis rate. Therefore, the decision for local excision or the watch-and-wait strategy for rectal cancer treated with neoadjuvant CRT and predicted to show a pathologic complete response should be considered with caution.

Outcomes of radical prostatectomy in a 20-year localized prostate cancer single institution series in China

The long-term survival outcomes of radical prostatectomy (RP) in Chinese prostate cancer (PCa) patients are poorly understood. We conducted a single-center, retrospective analysis of patients undergoing RP to study the prognostic value of pathological and surgical information. From April 1998 to February 2022, 782 patients undergoing RP at Queen Mary Hospital of The University of Hong Kong (Hong Kong, China) were included in our study. Multivariable Cox regression analysis and Kaplan-Meier analysis with stratification were performed. The 5-year, 10-year, and 15-year overall survival (OS) rates were 96.6%, 86.8%, and 70.6%, respectively, while the 5-year, 10-year, and 15-year PCa-specific survival (PSS) rates were 99.7%, 98.6%, and 97.8%, respectively. Surgical International Society of Urological Pathology PCa grades (ISUP Grade Group) ≥4 was significantly associated with poorer PSS (hazard ratio [HR] = 8.52, 95% confidence interval [CI]: 1.42-51.25, P = 0.02). Pathological T3 stage was not significantly associated with PSS or OS in our cohort. Lymph node invasion and extracapsular extension might be associated with worse PSS (HR = 20.30, 95% CI: 1.22-336.38, P = 0.04; and HR = 7.29, 95% CI: 1.22-43.64, P = 0.03, respectively). Different surgical approaches (open, laparoscopic, or robotic-assisted) had similar outcomes in terms of PSS and OS. In conclusion, we report the longest timespan follow-up of Chinese PCa patients after RP with different approaches.

An Observational Study of Trifluridine/Tipiracil-Containing Regimen Versus Regorafenib-Containing Regimen in Patients With Metastatic Colorectal Cancer

Background

There are no randomized control trials comparing the efficacy of trifluridine/tipiracil and regorafenib in patients with metastatic colorectal cancer (mCRC). Herein, we conducted an observational study to compare the oncologic outcomes of trifluridine/tipiracil-containing regimen (TAS-102) and regorafenib-containing regimen (REG) in patients with mCRC.

Material and method

Patients who were diagnosed to have mCRC in 2015 to 2021 and treated with TAS-102-containing regimen or REG-containing regimen were recruited. Monotherapy or combination therapy were all allowed in this study. Oncologic outcomes were presented with progression-free survival (PFS), overall survival (OS), overall response rate (ORR) and disease control rate (DCR).

Results

A total of 125 patients were enrolled into our study, accounting for 50 patients with TAS-102 and 75 patients with REG. Of these patients, 64% were treated with TAS-102 or REG monotherapy, while the remaining were treated with TAS-102 combination or REG combination. In general, the median PFS and OS were 3.7 versus 2.0 months (P = 0.006) and 9.2 versus 6.8 months (P = 0.048) in TAS-102 and REG, respectively. The ORR and DCR were 44% versus 20% (P < 0.001) and 72% versus 43% (P < 0.001) in TAS-102 and REG, respectively. As for treatment strategies, the survival were significantly longer in combination than in monotherapy, no matter in TAS-102 or REG group. Multivariate analysis showed TAS-102 and combination therapy were independent predictor associated with better survival.

Conclusions

Our results suggested that TAS-102 had better oncologic outcomes than REG in patients with mCRC, especially in combination. Further prospective trials are warranted to confirm our results.

Special Considerations of Anastomotic Leak in Patients with Rectal Cancer

Anastomotic leak in patients with rectal cancer has the potential to cause worse oncologic outcomes in addition to major morbidity and mortality risk of this dreaded complication. Anatomic location of the rectal cancer determines the ability to perform a restorative operation and the height of the anastomosis in relation to the anal canal. Clinical staging dictates the need for neoadjuvant treatment (such as chemotherapy and radiation) which may also contribute to anastomotic leak risk. In addition to oncologic outcomes, anastomotic leak can impact bowel function, the need for permanent stoma, and long-term quality of life. This study will discuss special considerations for anastomotic leak prevention and clinical implications of this complication in patients with rectal cancer.

Long-Term Outcomes and Causes of Death among Medullary Thyroid Carcinoma Patients with Distant Metastases

Distant metastasis is a poor prognostic factor in medullary thyroid carcinoma (MTC), but the significance of differentiating the characteristics according to the site of distant metastasis remains unclear. This study aimed to evaluate the clinical characteristics and long-term oncologic outcomes in MTC patients with distant metastasis. We identified 46 MTC patients with distant metastasis between 1994 and 2019. Clinical characteristics were compared based on the timing of the detection of distant metastasis. Additionally, survival rates following the detection of distant metastasis were evaluated to compare the clinical significance of metastatic site. The detailed causes of death were also investigated. Of the 46 patients, 15 patients (32.6%) had synchronous distant metastasis and 31 patients (67.4%) had metachronous distant metastasis. There was no clinical difference between these two groups except regarding initial surgical extent. The lung (52.2%) was the most common metastatic site, followed by the bone (28.3%), mediastinum (19.6%), liver (17.4%), adrenal gland (4.3%), brain (4.3%), kidney (2.2%), and pancreas (2.2%). Patients with bone metastasis and multisite metastasis had significantly worse prognoses than those with lung metastasis (hazard ratio: 5.42; p = 0.044 and hazard ratio: 6.11; p = 0.006). Complications due to the progression of distant metastasis, airway obstruction due to tracheal invasion, and complications related to chemotherapy were leading causes of death. In conclusion, there was no difference in clinical characteristics according to the timing of distant metastasis. Oncological outcomes differed by metastatic site.

Transoral Laser Microsurgery for Glottic Cancer in Patients Over 75 Years Old

Objectives/Hypothesis

Laryngeal squamous cell carcinoma (LSCC) has a non‐negligible incidence in elderly patients. However, there is still no clear indication on the ideal treatment for early‐intermediate glottic LSCC in this specific age group. Both surgical and nonsurgical approaches may be burdened by complications and sequelae that negatively impact patient's health. In this setting, carbon dioxide transoral laser microsurgery (CO₂ TOLMS) is a promising minimally invasive treatment option.

Study Design

Retrospective case series in a single tertiary academic institution.

Methods

Patients who underwent CO₂ TOLMS for Tis‐T3 glottic LSCC from 1997 to 2017 were reviewed. Demographic, clinical, and tumor characteristics, as well as postoperative complications were recorded. Overall (OS), disease‐specific (DSS), recurrence‐free (RFS), laryngo‐esophageal dysfunction free survivals (LEDFS), and organ preservation (OP) were calculated.

Results

A total of 134 patients (mean age, 80 ± 4 years; median, 79; range, 75–93) were included in the study. Seven lesions were classified as pTis, 65 as pT1a, 22 as pT1b, 35 as pT2, and 5 as pT3. No treatment‐related death was observed. Twenty‐eight (20.9%) patients reported 10 surgical and 19 medical complications. Five‐year OS, DSS, RFS, LEDFS, and OP were 68.9%, 95.4%, 79.5%, 66%, and 92.5%, respectively. Age and comorbidities were associated with OS and LEDFS. Advanced T categories were negatively correlated with OS, DSS, RFS, LEDFS, and OP. Age and comorbidities were not significant risk factors for complications.

Conclusions

CO₂ TOLMS can be considered a valuable therapeutic approach for selected Tis‐T3 glottic LSCC even in the elderly given its favorable oncologic outcomes and minimal aggressiveness.

Level of Evidence

4 Laryngoscope, 132:135–141, 2022

Intraoperative pathology consultation during urological surgery: Impact on final margin status and pitfalls of frozen section diagnosis

Despite recent improvements in diagnostic and surgical techniques in urological oncology, positive resection margin remains a significant concern for surgeons. Meanwhile, intraoperative pathology consultation with frozen section assessment (FSA), particularly for histological diagnosis of the lesions incidentally found or enlarged or sentinel lymph nodes, generally provides critical information which enables immediate decision making for optimal patient care. The intraoperative evaluation of surgical margins is also often requested, although there are some differences in its application between institutions and surgeons. Importantly, it remains to be determined whether intraoperative FSA indeed contributes to reducing the risk of final positive margins and thereby improving long-term patient outcomes. This review summarizes available data indicating the potential impact of FSA at the surgical margins during urological surgeries, including radical or partial cystectomy, partial nephrectomy, radical prostatectomy, penectomy, and orchiectomy. The accuracy and pitfalls of the intraoperative consultation/FSA diagnosis are also discussed.

Partial Nephrectomy Versus Radical Nephrectomy for Clinical T2 or Higher Stage Renal Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The choice of surgical method for clinically diagnosed T2 or higher stage kidney cancer remains controversial. Here, we systematically reviewed and collected published comparative studies on renal function, oncologic outcomes, and perioperative results of partial nephrectomy (PN) versus radical nephrectomy (RN) for larger renal tumors (T2 and above), and performed a meta-analysis.

EVIDENCE ACQUISITION

Following searches of PubMed, Web of Science, and Embase, the original studies on PN vs. RN in the treatment of T2 renal cancer were screened through strict inclusion and exclusion criteria. RevMan 5.4 was used for data analysis of the perioperative results, renal function, and oncologic outcomes of the two surgical methods for T2 renal tumor therapy. The weighted mean difference was used as the combined effect size for continuous variables, while the odds ratio (OR) or risk ratio (RR) was used as the combined effect size for binary variables. Both variables used a 95% confidence interval (CI) to estimate statistical accuracy. In cases with low heterogeneity, the fixed-effects model was used to pool the estimated value; otherwise, the random-effects model was used when significant heterogeneity was detected.

RESULTS

Fifteen retrospective studies including 5,056 patients who underwent nephrectomy (PN: 1975, RN: 3081) were included. The decline in estimated GFR (eGFR) after PN was lower than RN [(MD: -11.74 ml/min/1.73 m2; 95% CI: -13.15, -10.32; p < 0.00001)]. The postoperative complication rate of PN was higher than that of PN (OR: 2.09; 95% CI: 1.56, 2.80; p < 0.00001)], and the postoperative overall survival (OS) of PN was higher than that of RN (HR: 0.77; 95% CI: 0.65, 0.90; p = 0.002), and tumor recurrence (RR, 0.69; 95% CI: 0.53, 0.90; p = 0.007). No obvious publication bias was found in the funnel chart of the OS rates of the two groups of patients.

CONCLUSIONS

PN is beneficial for patients with T2 renal tumors in terms of OS and renal function protection. However, it is also associated with a higher risk of surgical complications.

Predicting Factors for Oncological and Functional Outcome in Hypopharyngeal Cancer

OBJECTIVES/HYPOTHESIS

Hypopharyngeal squamous cell carcinoma (SCC) is a rare but aggressive malignancy, with low survival rates and high incidence of tumor and treatment-related morbidity. This study aims to analyze the long-term oncologic and functional outcomes of a large cohort of patients and to determine prognostic factors.

STUDY DESIGN

Retrospective cohort study.

METHODS

The records of all patients diagnosed with hypopharyngeal SCC and treated with curative intent at our tertiary referral center were reviewed. Patient and initial disease characteristics, features, and complications of primary treatment, recurrence patterns, and corresponding treatments and the oncologic and functional long-term outcome were determined.

RESULTS

For a total of 179 patients, primary radiotherapy (RT) was the predominant treatment modality (78%), whereas 22% underwent primary surgery. The median, 2-year, and 5-year overall survival (OS) for the study cohort were 47 months, 64% and 43%. The median survival after first and second relapse was 7 and 6 months, respectively. The 2 and 5-year relapse-free survival (RFS) was 52% and 36%. The median RFS after first relapse and salvage treatment was 9 months. A nodal status of ≥cN2 (HR = 1.89, CI:1.21-3.05, P < .005) and any other primary tumor localization than pyriform sinus (HR = 1.60, CI: 1.04-2.42, P < .05) were identified as independent risk factors for shorter OS and RFS. Regarding functional outcome, the 2- and 5-year laryngectomy-free-survival was 55% and 37%, respectively.

CONCLUSIONS

In this large cohort with long-term follow-up, any other primary tumor localization than pyriform sinus and a nodal status of ≥cN2 were identified as risk factors for reduced OS and RFS.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1543-E1549, 2021.

Association between lactate dehydrogenase levels and oncologic outcomes in metastatic prostate cancer: A meta-analysis

Purpose

Previous studies have provided evidence of the high expression of lactate dehydrogenase (LDH) in multiple solid tumors; however, its prognostic relationship with metastatic prostate cancer (mPCa) remains controversial. We performed a meta‐analysis to better understand the prognostic potential of LDH in mPCa.

Methods

In our investigation, we included PubMed, Embase, Web of Science, and Cochrane Library as web‐based resources, as well as studies published before January 2020 on the predictive value of LDH in mPCa. We independently screened the studies according to the inclusion and exclusion criteria, evaluated the quality of the literature, extracted the data, and used RevMan 5.3 and STATA12.0 software for analysis.

Result

From the 38 published studies, the records of 9813 patients with mPCa were included in this meta‐analysis. We observed that higher levels of LDH in patients with mPCa were significantly associated with poorer overall survival (OS) (HR = 2.17, 95% CI: 1.91‐2.47, P < .00001) and progression‐free survival (PFS) (HR = 1.60, 95% CI: 1.20‐2.13, P = .001). The subgroup analyses indicated that the negative prognostic impact of higher levels of LDH on the oncologic outcomes of mPCa was significant regardless of ethnicity, publication year, sample size, analysis type, treatment type, age, and disease state.

Conclusion

Our analysis suggested the association between a higher level of LDH and poorer OS and PFS in patients with mPCa. As a parameter that can be conveniently evaluated, the LDH levels should be included as a valuable biomarker in the management of mPCa.

The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage.

METHODS

The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I² , and bias was evaluated by funnel plot and Begg's test.

RESULTS

A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12).

CONCLUSIONS

The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.

Unusual presentation of upper urinary tract urothelial carcinoma in Taiwan: Direct comparison from Taiwan-Japan UTUC Collaboration Cohort

OBJECTIVES

To carry out a comparison of upper urinary tract urothelial carcinoma characteristics and behavior between patients in Taiwan and Japan.

METHODS

A Taiwan urinary tract urothelial carcinoma cohort was obtained from Kaohsiung Chang Gung Memorial Hospital, and a Japan urinary tract urothelial carcinoma cohort from Hirosaki University Hospital. The inclusion criteria were urinary tract urothelial carcinoma patients who underwent radical nephroureterectomy. Those who received perioperative chemotherapy were excluded. Finally, 765 patients in the Taiwan cohort and 325 in the Japan cohort were analyzed. The end-point of this study was to study the natural course of urinary tract urothelial carcinoma within 5 years between these two groups.

RESULTS

The main finding was that urinary tract urothelial carcinoma patients in Taiwan were younger (P < 0.001), more were women (P < 0.001), with low-stage disease (P < 0.001), with more chronic kidney disease (P < 0.001), with less smoking history (P < 0.001), with more bladder cancer history (P = 0.002), with more multifocal (P < 0.001) and less high-grade disease (P = 0.015), as well as less lymphovascular invasion (P < 0.001) and more squamous differentiation (P < 0.001). However, the multivariate Cox regression analysis showed no racial difference in oncologic outcome, such as intravesical recurrence, systemic recurrence or cancer-specific death in primary and propensity-matched cohorts. Bladder cancer history was found to be the most important factor predicting intravesical recurrences, whereas stage was strongly associated with systemic recurrence and cancer specific mortality.

CONCLUSIONS

The clinical characteristics of urinary tract urothelial carcinoma in Taiwan are significantly different from those of urinary tract urothelial carcinoma in Japan. However, there is no racial difference in stage-specific oncologic outcome after standard nephroureterectomy.

Low-dose-rate brachytherapy for prostate cancer: A 15-year experience in Japan

The history of prostate brachytherapy has passed one century. In 1983, modern low-dose-rate prostate brachytherapy using a transrectal ultrasound-guided procedure was introduced. In the early 1990s, low-dose-rate brachytherapy was introduced and rapidly spread across the USA due to its excellent oncological control, cost-effectiveness and technically easy procedure. Since low-dose-rate brachytherapy was introduced in Japan (2003), over 15 years have passed. More than 43 000 patients have undergone low-dose-rate brachytherapy. Japanese urologists and radiation oncologists are on course with leading brachytherapists in the USA. A nationwide prospective cohort study, J-POPS, was initiated in 2005. The J-POPS group also provides educational programs including an annual novel training course in low-dose-rate brachytherapy to familiarize urologists, radiation oncologists and pathologists with the procedure. Important information on Japanese patients has accumulated, especially by the J-POPS study group. The Japanese investigators reported excellent oncological outcomes of low-dose-rate brachytherapy, showing equivalent or superior efficacy to surgery in low- to intermediate-risk patients, and superior efficacy in high-risk patients using the surgery biochemical recurrence definition (prostate-specific antigen cut-off value of 0.2 ng/mL). Two randomized controlled studies (SHIP study: intermediate risk, and TRIP study: high risk) carried out by the J-POPS group are ongoing, and an additional follow-up study (J-POPS 2 study) has been started to evaluate survival outcomes over longer follow-up periods. Low-dose-rate brachytherapy is expected to provide a survival benefit, which must be confirmed by further studies with longer follow-up periods in the future.

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

Current trends in the features of male thyroid cancer: Retrospective evaluation of their prognostic value

This study aimed to compare the clinicopathologic characteristics and oncologic outcomes of papillary thyroid cancer (PTC) patients according to sex. Then, we validated prognostic variables to determine whether sex is a significant prognostic factor for PTC.Between January 2007 and December 2010, 1232 men and 7276 women PTC patients underwent surgery. The patient characteristics and 5-year oncologic outcomes were compared. The stepwise Cox proportional hazards model determined the significance of survival variables.Men PTC patients had more lymph node (LN) metastases than women, both in the total (P < .0001) and hemithyroidectomy (P < .0001) patients. Men and women showed similar 5-year recurrence-free survivals, both in total (P = .815) and hemithyroidectomy (P = .148) patients. The tumor size and the number of positive central nodes were associated with tumor recurrence, but not sex.Sex was not an independent prognostic factor for tumor recurrence. Multicenter clinical studies with long-term follow-ups are needed to validate these results.

Cervical laser vaporization for women with cervical intraepithelial neoplasia-3

OBJECTIVE

This study evaluated outcomes of laser vaporization of the cervix for women with cervical intraepithelial neoplasia (CIN)-3.

METHODS

We retrospectively reviewed 161 consecutive patients with CIN3 who were treated with cervical laser vaporization between January 2008 and December 2012. At each follow-up visit, histologically confirmed CIN2, CIN3 and invasive carcinoma were defined as treatment failures, as were high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells that cannot exclude HSIL with subsequent treatment or lost to follow-up. Primary endpoints included long-term follow-up (at least 5 years of regular hospital visits) and treatment failure rate. Treatment failure rates were estimated by the Kaplan-Meier method.

RESULTS

Patients' median age was 31 years old. Median follow-up period was 67 months (interquartile range: 52-74 months). Over 5 years, 70.8% continued their follow-up visits, but significantly more patients aged ≥35 years did so (86.4%) than did those aged ≤34 years (61.8%, P = 0.0009). Treatment failure was observed in 14 (8.7%) patients, 1 of whom progressed to invasive cancer (0.6%). Cumulative treatment failure rates were 1-year: 5.1%, 2-year: 6.4% and 5-year: 9.5%. Among patients who suffered treatment failures, 57.1% initial failures occurred within the first year and 71.4% within the first 2 years.

CONCLUSIONS

Long-term oncologic outcomes of cervical vaporization in CIN3 remain at a suboptimal level. The importance of a minimum of 5 years of regular hospital visits should be emphasized to patients with CIN3 who are candidates for cervical laser vaporization, especially those aged ≤34 years.

Clinical Significance of Multiparametric Magnetic Resonance Imaging as a Preoperative Predictor of Oncologic Outcome in Very Low-Risk Prostate Cancer

Currently, multiparametric magnetic resonance imaging (mpMRI) is not an indication for patients with very low-risk prostate cancer. In this study, we aimed to evaluate the usefulness of mpMRI as a diagnostic tool in these patients. We retrospectively analyzed the clinical and pathological data of individuals with very low-risk prostate cancer, according to the NCCN guidelines, who underwent mpMRI before radical prostatectomy at our institution between 2010 and 2016. Patients who did not undergo pre-evaluation with mpMRI were excluded. We analyzed the factors associated with biochemical recurrence (BCR) using Cox regression model, logistic regression analysis, and Kaplan–Meier curve. Of 253 very low-risk prostate cancer patients, we observed 26 (10.3%) with BCR during the follow-up period in this study. The median follow-up from radical prostatectomy was 53 months (IQR 33–74). The multivariate Cox regression analyses demonstrated that the only factor associated with BCR in very low-risk patients was increase in the pathologic Gleason score (GS) (HR: 2.185, p-value 0.048). In addition, multivariate logistic analyses identified prostate specific antigen (PSA) (OR: 1.353, p-value 0.010), PSA density (OR: 1.160, p-value 0.013), and suspicious lesion on mpMRI (OR: 1.995, p-value 0.019) as the independent preoperative predictors associated with the pathologic GS upgrade. In our study, the pathologic GS upgrade after radical prostatectomy in very low-risk prostate cancer patients demonstrated a negative impact on BCR and mpMRI is a good prognostic tool to predict the pathologic GS upgrade. We believe that the implementation of mpMRI would be beneficial to determine the treatment strategy for these patients.

Surgical treatment of gastrointestinal stromal tumours combined with imatinib treatment: a retrospective cohort analysis

Background

Targeted therapies changed the treatment concepts of gastrointestinal stromal tumours significantly. As only possibility to cure surgical resection is the cornerstone of therapy. Thus it is necessary to find out which patients will benefit most regarding modality (neo- or adjuvant) and duration of chemotherapy.

Methods

In a retrospective cohort analysis the medical records of all consecutive patients treated in the department of general and visceral surgery of the university hospital Tübingen between 2004 and 2015 were investigated. Recurrence and survival outcomes were calculated using the Kaplan-Meier method.

Results

Tumor location of GIST was gastric in 32, small bowel in 14, rectum in 3 and extraintestinal in 3 patients. Median tumor size was 46 mm. Median mitotic index was 4 per 50 hpf. Resection was achieved R0 in 46 patients, R1 in 4 patients and R2 in 2 patients. Mean overall survival was 58.9 months (range, 46-73 months). Mean recurrence free survival was 45.6 months (range, 36-57 months). Mean overall survival was 58.9 months (range, 46-73 months). Risk factors for recurrence were tumor location and high mitotic index Ki-67.

Conclusions

The prognosis of GIST after surgical resection is favourable. Survival prognosis are excellent. Analysis of KI-67 mitotic index predicted best oncologic outcome.

Oncologic outcomes in patients with 1-cm to 4-cm differentiated thyroid carcinoma according to extent of thyroidectomy

BACKGROUND

Recent guidelines advocate unilateral thyroidectomy for low-risk 1-cm to 4-cm differentiated thyroid cancer (DTC). This study was designed to examine the association between the extent of thyroidectomy and oncologic outcomes in patients with 1-cm to 4-cm DTC.

MATERIALS AND METHODS

From April 1978 to December 2011, 16 057 patients with DTC underwent thyroidectomy at Yonsei University Hospital. Among them, 5266 (32.8%) patients were classified as having 1-cm to 4-cm DTC and were enrolled in this study. Clinicopathologic features and prognostic results (disease-free survival [DFS] and disease-specific survival [DSS] rates) were analyzed by retrospective medical record review. The mean follow-up duration was 57.3 ± 58.1 months.

RESULTS

Of tumor subtypes in the study group, papillary thyroid carcinoma was the most common (97.5%) and follicular thyroid carcinoma occurred at a rate of 2.5%. In this study, the mean tumor size was 1.84 ± 0.74 cm. Patients had extrathyroidal extension (69.3%), multiplicity (35.1%), bilaterality (26.4%), central lymph node metastasis (53.0%), and lateral neck node metastases (19.9%). Of the 5266 patients, 4292 (81.5%) underwent total thyroidectomy and 974 (18.5%) had lobectomies. Recurrence rates in the total thyroidectomy and lobectomy groups were 5.7% and 9.4%, respectively. The lobectomy group had lower DFS (P = .007) and higher DSS (P = .034) than the total thyroidectomy group. A multivariate analysis for DFS revealed that tumor size, N classification, and extent of thyroidectomy were independent risk factors. On multivariate analysis, independent risk factors for DSS were age, sex, tumor size, and M classifications.

CONCLUSION

Although extent of thyroidectomy does not affect DSS, total thyroidectomy is beneficial for reducing recurrence in patients with 1-cm to 4-cm DTC. However, if such tumors have such low-risk features as being unifocal, intrathyroidal, and lymph node metastasis-negative, extent of thyroidectomy does not affect oncologic outcome and lobectomy may be sufficient.

Effect of cancer characteristics and oncological outcomes associated with laparoscopic colorectal resection converted to open surgery: A meta-analysis

BACKGROUND

Although laparoscopic colorectal cancer resection is an oncologically safe procedure equivalent to open resection,the effects of conversion of a laparoscopic approach to an open approach remain unclear.This study evaluated the cancer characteristic and oncological outcomes associated with conversion of laparoscopic colorectal resection to open surgery.

METHOD

We conducted searches on PubMed, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. We included the literature published until 2018 that examined the impact of laparoscopic conversion to open colorectal resection. Only randomized control trials and prospective studies were included. Each study was reviewed and the data were extracted. Fixed-effects methods were used to combine data, and 95% confidence intervals (CIs) were used to evaluate the outcomes.

RESULTS

Twelve studies with 5427 patients were included. Of these, 4672 patients underwent complete laparoscopic resection with no conversion (LAP group), whereas 755 underwent conversion to an open resection (CONV group). The meta-analysis showedsignificant differences between the LAP group and converted (CONV) group with respect to neoadjuvant therapy (P = .002), location of the rectal cancer (P = .01), and recurrence (P = .01). However, no difference in local recurrence (P = .17) was noted between both groups.

CONCLUSION

Conversion of laparoscopic to open colorectal cancer resection is influenced by tumor characteristics. Conversion of laparoscopic surgery for colorectal cancer is associated with a worse oncological outcome.

Fast and accurate vision-based stereo reconstruction and motion estimation for image-guided liver surgery

Image-guided liver surgery aims to enhance the precision of resection and ablation by providing fast localisation of tumours and adjacent complex vasculature to improve oncologic outcome. This Letter presents a novel end-to-end solution for fast stereo reconstruction and motion estimation that demonstrates high accuracy with phantom and clinical data. The authors’ computationally efficient coarse-to-fine (CTF) stereo approach facilitates liver imaging by accounting for low texture regions, enabling precise three-dimensional (3D) boundary recovery through the use of adaptive windows and utilising a robust 3D motion estimator to reject spurious data. To the best of their knowledge, theirs is the only adaptive CTF matching approach to reconstruction and motion estimation that registers time series of reconstructions to a single key frame for registration to a volumetric computed tomography scan. The system is evaluated empirically in controlled laboratory experiments with a liver phantom and motorised stages for precise quantitative evaluation. Additional evaluation is provided through testing with patient data during liver resection.

Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis

Introduction

The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups.

Material and methods

Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates.

Results

Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1–100.5 vs. PN: 38.5 months, range 20.5–72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up.

Conclusions

Our results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.

These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.

Meta-analysis of studies comparing oncologic outcomes of radical prostatectomy and brachytherapy for localized prostate cancer

Background

The aim of this study was to compare oncologic outcomes of radical prostatectomy (RP) with brachytherapy (BT).

Methods

A literature review was conducted according to the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We included studies reporting comparative oncologic outcomes of RP versus BT for localized prostate cancer (PCa). From each comparative study, we extracted the study design, the number and features of the included patients, and the oncologic outcomes expressed as all-cause mortality (ACM), PCa-specific mortality (PCSM) or, when the former were unavailable, as biochemical recurrence (BCR). All of the data retrieved from the selected studies were recorded in an electronic database. Cumulative analysis was conducted using the Review Manager version 5.3 software, designed for composing Cochrane Reviews (Cochrane Collaboration, Oxford, UK). Statistical heterogeneity was tested using the Chi-square test.

Results

Our cumulative analysis did not show any significant difference in terms of BCR, ACM or PCSM rates between the RP and BT cohorts. Only three studies reported risk-stratified outcomes of intermediate- and high-risk patients, which are the most prone to treatment failure.

Conclusions

our analysis suggested that RP and BT may have similar oncologic outcomes. However, the analysis included a limited number of studies, and most of them were retrospective, making it impossible to derive any definitive conclusion, especially for intermediate- and high-risk patients. In this scenario, appropriate urologic counseling remains of utmost importance.

Preoperative chemoradiotherapy creates an opportunity to perform sphincter preserving resection for low-lying locally advanced rectal cancer based on an oncologic outcome study

Low-lying locally advanced rectal cancer (LARC) after preoperative chemoradiotherapy (CRT) can be surgically removed by either abdominperineal resection (APR) or sphincter preserving resection (SPR). This retrospective cohort study of 251 consecutive patients with low lying LARC who underwent CRT followed by radical surgery in a single institute, between March 2003 and November 2012, aimed to compare the oncological benefits between the two groups. 3-year disease free survival (DFS), overall survival (OS), cumulative incidence of recurrence and postoperative complications were compared between the two approaches. With median follow-up of 48.6 months, SPR group had higher 3-year DFS rate (86.4% vs 73.6%, P=0.023) and lower incidence of distant recurrence (12.0% vs 23.7%, P=0.026). The postoperative complications, incidence of local recurrence and the 3-year OS were comparable between the two groups. Pathologic T and N stage were the independent predictors for 3-year DFS (P=0.020 and P<0.001). In conclusion, our study suggest that low-lying LARC patients with a significant response to preoperative CRT can benefit from the advantage of SPR in preserving the anal sphincter function without compromising their oncologic outcome.

Is the pathological regression level of metastatic lymph nodes associated with oncologic outcomes following preoperative chemoradiotherapy in rectal cancer?

Purpose

The oncologic impact of the lymph node (LN) regression level after preoperative chemoradiotherapy (PCRT) has not been thoroughly evaluated. Hence, this study aimed to examine whether the regression level of metastatic LNs following PCRT is associated with oncologic outcomes in rectal cancer.

Results

The optimal number of cut points for LRG sum was determined to be three. The three LRG groups demonstrated different distributions according to the ypT and ypN stages (p < 0.001 for both). However, the distribution of the LRG groups was not associated with the TRG of the primary tumor (p = 0.527). The RFS significantly differed according to the LRG groups (p = 0.001). Moreover, the differences in RFS remained when the LRG groups were analyzed within each separate ypN stage. The LRG group was confirmed as a factor associated with RFS in the multivariate analysis (p=0.018), while the ypN stage was not (p=0.4).

Patients and Methods

We analyzed the outcomes of 142 rectal cancer patients diagnosed with ypN1 disease after PCRT followed by radical resection. The pathological responses of the primary tumor and LNs to PCRT were evaluated using the tumor regression grade (TRG) and LN regression grade (LRG), respectively. The impact of LRG on recurrence-free survival (RFS) was analyzed. The K-adaptive partitioning for survival data method was applied to determine the optimal number of cut points for the LRG-sum and the optimal number of subgroups.

Conclusion

The LRG as an indicator of response to PCRT should be considered as a prognostic determinant in rectal cancer patients. Future large-scale prospective studies are needed to confirm this finding.

Association of immunologic markers from complete blood counts with the response to preoperative chemoradiotherapy and prognosis in locally advanced rectal cancer

We investigated retrospectively whether immunologic markers from a complete blood count (CBC) are associated with the responsiveness to preoperative chemoradiotherapy (PCRT) and oncologic outcomes in 984 patients with locally advanced rectal cancer (LARC) who also underwent radical surgery from 2005 to 2013. CBC parameters including the neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), and platelet to lymphocyte ratio (PLR) were recorded. Pathologic responses to PCRT were evaluated in the resected specimens using the tumor regression grade system. The cut-off values of the immunologic markers were calculated to analyze their association with recurrence-free survival (RFS). One hundred ninety-five patients achieved total regression of their primary tumor. By receiver operating characteristic analysis, NLR, PLR, and LMR could not distinguish total regression from residual disease after PCRT. The NLR, LMR and PLR cut-off values were 1.7, 6.8 and 92.88, respectively. By univariate analysis, low NLR (≤1.7), high LMR (>6.8) and high PLR (>92.88) were indicators of a favorable RFS outcome. By multivariate analysis, high PLR was associated with an improved RFS (HR, 0.649; 95% CI, 0.473-0.89; P=0.007). High NLR (>1.7) was an independent negative prognostic factor for RFS in stage II (HR, 1.868; 95% CI, 1.08-3.109; P=0.025) and high PLR was a positive prognostic factor in stage III (HR, 0.675; 95% CI, 0.421-0.957; P=0.03). Immunologic markers derived from CBCs are independently associated with the RFS outcome in LARC patients treated with PCRT followed by radical resection. However, these markers are not predictive of total primary tumor regression after PCRT.

Oncologic and obstetric outcomes of early stage cervical cancer with abdominal radical trachelectomy: Single-institution experience

AIM

Radical trachelectomy (RT) is a widely used fertility-sparing treatment for patients with early cervical cancer (CCA). RT, however, is an investigational treatment, and its gynecological and obstetric efficacy are being investigated. We retrospectively assessed the efficacy of abdominal RT (ART) as a fertility-sparing surgery.

METHODS

From 2010 to 2014, patients with stage IA2-IB1 CCA (tumor ≤2 cm) who wished to preserve their fertility underwent ART. The major outcomes were mortality, recurrence, pregnancy complications, and obstetric outcome.

RESULTS

Twenty-eight patients received ART. Adjuvant chemotherapy was performed in seven patients because of lymphovascular space invasion. During the median follow-up of 43 months, no recurrences occurred. Twelve women attempted to conceive, and eight of them became pregnant. A total of five children were born, and one baby was full term. Three cases of second trimester, and one case of third trimester preterm births were recorded.

CONCLUSIONS

Fertility was preserved after ART in a moderate number of patients. The pregnancy and birth rates after ART have been improving, and increasing the full-term birth rate is the next goal. In addition, development of further types of minimally invasive surgery for CCA can be expected.

Impact of anastomotic leakage on long-term oncologic outcome and its related factors in rectal cancer

Anastomotic leakage (AL) is a well-known cause of morbidity after low anterior resection (LAR) for rectal cancer, but its impact on oncologic outcome is not well understood. The aim of this study is to investigate the impact of AL on long-term oncologic outcome and to identify factors associated with AL that may affect prognosis after LAR for rectal cancer.A retrospective analysis of patients who underwent curative resection for rectal cancer without diverting stoma was performed. To investigate AL related factors that may be associated with oncologic outcome, Clavien-Dindo grades, prognostic nutritional indices (PNI) and inflammatory indices were included.One hundred and one patients out of a total of 1258 patients developed postoperative AL, giving an AL rate of 8.0%. Patients with AL showed poorer disease-free survival (DFS), than patients without AL (hazard ratio [HR] = 1.6; 95% confidence intervals [CI]: 1.1-2.5; P = 0.01). In patients who developed AL, age over 60 (HR = 2.2; 95% CI: 1.1-4.7; P = 0.033), advanced pathologic stage (HR = 2.4; 95% CI: 1.4-4.0; P = 0.001), suppressed neutrophil-proportion (≤80%) (HR = 2.6; 95% CI: 1.2-5.8; P = 0.019) and PNI <36 (HR = 3.5; 95% CI: 1.2-9.6; P = 0.018) were associated with poorer DFS.AL was associated with poorer DFS. In patients with AL, a suppressed neutrophil-proportion and decreased PNI below 36 were associated with tumor recurrence.

Prognostic factors after salvage radiotherapy alone in patients with biochemical recurrence after radical prostatectomy

OBJECTIVES

To evaluate the oncological outcome and to assess prognostic factors of salvage radiotherapy alone in patients with biochemical recurrence after radical prostatectomy.

METHODS

We reviewed our single institution, prospectively maintained database of 2043 patients who underwent radical prostatectomy between September 1995 and December 2011. In this cohort, 149 patients who developed biochemical recurrence after radical prostatectomy and received salvage radiotherapy alone after pelvic magnetic resonance imaging were included. Three-dimensional conformal radiotherapy or intensity-modulated radiotherapy was delivered with a median dose of 70.0 Gy (66.0-78.0 Gy) or 67.2 Gy (64.8-70.0 Gy). Kaplan-Meier and Cox regression analyses were carried out.

RESULTS

With a median follow up of 82 months (range 20-153 months), 55 patients (36.9%) failed salvage radiotherapy. The 5-year salvage radiotherapy failure-free probability was 53.6%. On multivariate analysis, pre-salvage radiotherapy prostate-specific- antigen ≥ 1.0 ng/mL (P = 0.003, hazard ratio 3.592, 95% confidence interval 1.522-8.579), pathological stage ≥ T3a (P = 0.004, hazard ratio 2.261, 95% confidence interval 1.290-3.833), pathological Gleason score ≥ 7 (P = 0.018, hazard ratio 5.501, 95% confidence interval 1.577-21.221), prostate-specific antigen doubling time < 12 months (P = 0.014, hazard ratio 2.243, 95% confidence interval 1.177-4.275) and no visible lesion on pelvic magnetic resonance imaging (P = 0.016, hazard ratio 2.068, 95% confidence interval 1.268-3.501) were independent prognostic factors of salvage radiotherapy failure after radical prostatectomy.

CONCLUSIONS

Pre-salvage radiotherapy prostate-specific antigen ≥ 1.0 ng/mL, pathological stage ≥ T3a, pathological Gleason score ≥ 7, prostate-specific antigen doubling time < 12 months and no visible lesion on pelvic magnetic resonance imaging are prognostic factors of salvage radiotherapy failure after radical prostatectomy. We should consider additional treatment in patients with these factors for favorable outcomes.

Evidence on effectiveness of intensity-modulated radiotherapy versus 2-dimensional radiotherapy in the treatment of nasopharyngeal carcinoma: Meta-analysis and a systematic review of the literature

BACKGROUND

Current management of nasopharyngeal carcinoma (NPC) uses radiotherapy (RT) as the curative treatment modality. Radiation delivery techniques for NPC can be achieved using 2D conventional RT or intensity-modulated radiotherapy (IMRT).

METHODS

A systematic review and meta-analysis of the literature was undertaken to assess the effectiveness of IMRT versus 2D conventional RT in primary treatment of NPC.

RESULTS

IMRT showed better results than 2D conventional RT in terms of local control, regional control, and overall survival, but when stratified, only in T4, N2, and stage III were the differences that were seen. Objective saliva measurements and physician-graded xerostomia were better in IMRT. However, patient-reported xerostomia showed minimal improvement only in IMRT. The evidence of superiority of IMRT over 2D conventional RT is not clear.

CONCLUSION

In the absence of more clinical data demonstrating the superiority of IMRT in the treatment of nasopharyngeal carcinoma, 2D conventional RT seems to be a reasonable treatment option, especially in limited resource settings. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2130-E2142, 2016.

Laparoscopic complete mesocolic excision with central vascular ligation in right colon cancer: Long-term oncologic outcome between mesocolic and non-mesocolic planes of surgery

AIM

To analyze our experience in translating the concept of total mesorectal excision to "no-touch" complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing "mesocolic" to less radical "non-mesocolic" planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome.

METHOD

A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation.

RESULTS

Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes.

CONCLUSION

In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of "standard" surgery, significantly impacting loco-regional control and thus overall survival.

Uniportal complete video-assisted thoracoscopic lobectomy with systematic lymphadenectomy

Video-assisted thoracoscopic surgery (VATS) has permeated our thoracic surgical practice and now will develop in depth towards a next level of minimally invasive surgery (MIS). Irrespective of generation gaps and diversified perception within thoracic community, more and more surgical teams are adapting to the uniportal lobectomy. This video demonstrates a case undergoing uniportal VATS lobectomy with systematic lymphadenectomy for lung cancer. We here describe our technique for uniportal approach by using a combination of double-jointed and endoscopic instruments to combat the four major obstacles: (I) interference of the thoracoscope, stapler and the instrumentation in and out of the thoracic cavity? (II) whether the field of vision is enough or not without the other 1-3 ports to improve the exposure? (III) the optimal stapler introduction angle especially for upper and middle lobes resection? (IV) more importantly, the oncologic validity of uniportal procedures as well as the reduction of postoperative morbidity? We believe, uniportal VATS lobectomy with systematic lymphadenectomy is technically safe and feasible and alternative approach to conventional thoracoscopic lobectomy in lung cancer treatment. The issues of patient acceptability, the cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future through multi-institution randomized controlled trials and long-term follow-up.

Laparoscopic radical prostatectomy: 10 years of experience at a single institution

BACKGROUND/AIM

The Urological Clinic of the S. Orsola-Malpighi University Hospital, Bologna has been carrying out laparoscopic radical prostatectomy since 2002. In this study, we report the results after 10 years of LRP, analyzing in particular the oncological and functional aspects.

PATIENTS AND METHODS

Between March 2002 and August 2011, 400 patients underwent laparoscopic radical prostatectomy. Cancer control, recovery of continence and potency were evaluated at 1, 3, 6 and 12 months. All data were retrospectively collected on the basis of thorough clinical and pathological examination.

RESULTS

Follow-up ranged from 10 to 122 months. Pathological examination revealed pT2 and pT3 cancers in 63.5% and 36.5% of patients, respectively. The incidence of positive surgical margins and biochemical relapse rate was 33.8% and 12.0%, respectively.

CONCLUSION

10 Years after the first laparoscopic radical prostatectomy was performed at our Center, we can state that it is a reliable alternative to traditional surgery, with satisfactory oncological and functional results.

Nineteen-year oncologic outcomes and the benefit of elective neck dissection in salivary gland adenoid cystic carcinoma

BACKGROUND

The purposes of this study were to evaluate the oncologic outcomes of salivary gland adenoid cystic carcinoma (ACC) and to confirm the benefits of elective neck dissection.

METHODS

We reviewed the records of 61 consecutive patients with ACC. Surgery was performed in all patients.

RESULTS

The occult metastasis rate was 15.38% (4 of 26 patients) and no regional recurrence in the elective neck dissection group was identified. Among 4 clinically node positive (cN+) patients, regional metastasis was identified in 3 through therapeutic neck dissection. Regional recurrence was identified in 4 patients (4 of 31) who had never undergone elective neck treatment of clinically node negative (cN-) status, exclusively. Overall regional metastases (overall N+) were identified in 11 patients. The overall survival rate was 84.99% at 5 years, 81.13% at 10 and 15 years in (overall N-) status, contrary to 56.82% at 5 years and 28.41% at 10 years in overall N+ status (p = .025).

CONCLUSION

Careful follow-up of regional status is important, and proper therapeutic and elective neck treatment can achieve regional control in ACC. Elective neck dissection is recommendable and can provide valuable staging and prognostic information.

Clinical characteristics and treatment outcomes of colorectal cancer in renal transplant recipients in Korea

PURPOSE

Transplant recipients in Asia appear to be at a higher risk for developing colorectal cancer (CRC). This study was performed to identify the clinicopathological features and oncologic outcomes of CRC in post-renal transplants in Korea.

MATERIALS AND METHODS

We retrospectively reviewed the records of 17 patients with CRC out of 2,630 recipients who underwent renal transplantation between 1994 and 2007. These patients (transplant group) were compared with general CRC patients (n=170, control group) matched, based on the closest date of surgery to the transplant group.

RESULTS

During 29.7 months of the median follow- up period, the recurrent and survival rates from recurrence were worse in the transplant group than in the control group (35.2% versus 15.2%; p=0.048 and p=0.025). The 2-year patient survival rate of the transplant group was significantly worse than the control group in advanced cancer (stages III-IV; 45.7% versus 71.6%; p=0.023). In early cancer (stages 0-I), there was no significant difference in 5-year patient survival rate between the two groups (100% versus 92.6%, respectively; p=0.406).

CONCLUSION

In spite of a poor prognosis of advanced CRC in the transplant group, the early stage CRC of the transplant group showed a comparable oncologic outcome compared with the control group. Regular screening and early detection of CRC are essential in the post-transplant setting.