Surgery in reference centers improves survival of sarcoma patients: a nationwide study

BACKGROUND

NETSARC (netsarc.org) is a network of 26 sarcoma reference centers with specialized multidisciplinary tumor boards (MDTB) aiming to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and expert pathological review are mandatory for sarcoma patients nationwide. In the present work, the impact of surgery in a reference center on the survival of sarcoma patients investigated using this national NETSARC registry.

PATIENTS AND METHODS

Patients' characteristics and follow-up are prospectively collected and data monitored. Descriptive, uni- and multivariate analysis of prognostic factors were conducted in the entire series (N = 35 784) and in the subgroup of incident patient population (N = 29 497).

RESULTS

Among the 35 784 patients, 155 different histological subtypes were reported. 4310 (11.6%) patients were metastatic at diagnosis. Previous cancer, previous radiotherapy, neurofibromatosis type 1 (NF1), and Li-Fraumeni syndrome were reported in 12.5%, 3.6%, 0.7%, and 0.1% of patients respectively. Among the 29 497 incident patients, 25 851 (87.6%) patients had surgical removal of the sarcoma, including 9949 (33.7%) operated in a NETSARC center. Location, grade, age, size, depth, histotypes, gender, NF1, and surgery outside a NETSARC center all correlated to overall survival (OS), local relapse free survival (LRFS), and event-free survival (EFS) in the incident patient population. NF1 history was one of the strongest adverse prognostic factors for LRFS, EFS, and OS. Presentation to an MDTB was associated with an improved LRFS and EFS, but was an adverse prognostic factor for OS if surgery was not carried out in a reference center. In multivariate analysis, surgery in a NETSARC center was positively correlated with LRFS, EFS, and OS [P < 0.001 for all, with a hazard ratio of 0.681 (95% CI 0.618-0.749) for OS].

CONCLUSION

This nationwide registry of sarcoma patients shows that surgical treatment in a reference center reduces the risk of relapse and death.

Isolation and partial characterization of an HIV-related virus occurring naturally in chimpanzees in Gabon

Two cases of wild-born chimpanzees which were positive for HIV-1 antibodies were observed in Gabon. These animals were never experimentally exposed to HIV-1 and had no history of inoculation with human blood products. A retrovirus was isolated from one of these chimpanzees. Several of the viral proteins from this virus, designated SIVcpz-GAB-1 (simian immunodeficiency virus from chimpanzee), differed in molecular weight from the known corresponding HIV/SIV proteins. The major gag protein of SIVcpz migrated on SDS-PAGE with a relative molecular mass of 25.5 and the outer membrane proteins were 110, 155 and 185 kD, respectively. SIVcpz did not induce severe cytopathic effects in human and chimpanzee lymphocytes. Antigenically, SIVcpz seems to be closer to HIV-1 than to HIV-2 and the other SIVs. Nucleic acid hybridization experiments appear to indicate that the virus is different from HIV-1 and HIV-2.

Peritoneal pseudomyxoma: results of a systematic policy of complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Pseudomyxoma peritonei (PMP) is characterized by progressive intraperitoneal accumulation of mucous and mucinous implants, usually derived from a ruptured, possibly malignant mucinous neoplasm of the appendix. Treatment based on complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is gaining support. The aim of this study was to identify pre- and perioperative factors of prognostic value.

METHODS

A total of 105 patients (with no residual tumours exceeding 2 mm) were treated with CCRS plus HIPEC based on oxaliplatin. Clinical, radiological, pathological factors and blood markers were analysed to determine their prognostic value for survival.

RESULTS

Mortality (7.6 per cent) and morbidity (67.6 per cent) were significantly correlated with peritoneal index, pathological grade and blood CA19.9 level. The median follow-up was 48 months. Seven patients died after hospital discharge. Overall and disease-free 5-year survival rates were 80.0 and 68.5 per cent respectively. The Cox model identified only two significant factors impacting on disease-free survival: CA19.9 level and pathological grade.

CONCLUSION

CCRS is the most effective treatment for PMP, and adding HIPEC prolongs long-term survival. Further strategies should focus on improving postoperative outcome in extended PMP.

Modified selection criteria for complete cytoreductive surgery plus HIPEC based on peritoneal cancer index and small bowel involvement for peritoneal carcinomatosis of colorectal origin

BACKGROUND

Complete cytoreductive surgery (CCRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is on the verge of becoming the gold standard treatment for selected patients presenting peritoneal metastases (PM) of colorectal origin. PM is scored with the peritoneal cancer index (PCI), which is the main prognostic factor. However, small bowel (SB) involvement could exert an independent prognostic impact.

AIM

To define an adequate cut-off for the PCI and to appraise whether SB involvement exerts an impact on this cut-off.

PATIENTS AND METHODS

Patients (n = 139) treated with CCRS plus HIPEC were prospectively verified and retrospectively analyzed. One hundred presented with SB involvement of different extents and at different locations.

RESULTS

All the patients with a PCI ≥ 15 exhibited SB involvement. Five-year overall survival was 48% when the PCI was <15 vs 12% when it was ≥ 15 (p < 0.0001. The multivariate analysis retained two prognostic factors: PCI ≥ 15 (p = 0.02, HR = 1.8), and the involvement of area 12 (lower ileum) (p = 0.001, HR = 3.1). When area 12 was invaded, it significantly worsened the prognosis: 5-year overall survival of patients with a PCI <15 and area 12 involved was 15%, close to that of patients with a PCI ≥ 15 (12%) and far lower than that of patients with a PCI <15 and no area 12 involvement (70%).

CONCLUSION

A PCI greater than 15 appears to be a relative contraindication for treatment of colorectal PM with CCRS + HIPEC. Involvement of the lower ileum is also a negative prognostic factor to be taken into consideration.

Variation in FCN1 affects biosynthesis of ficolin-1 and is associated with outcome of systemic inflammation

Ficolin-1 is a recognition molecule of the lectin complement pathway. The ficolin-1 gene FCN1 is polymorphic, but the functional and clinical consequences are unknown.The concentration of ficolin-1 in plasma and FCN1 polymorphisms in positions -1981 (rs2989727), -791 (rs28909068), -542 (rs10120023), -271 (rs28909976), -144 (rs10117466) and +7918 (rs1071583) were determined in 100 healthy individuals. FCN1 expression by isolated monocytes and granulocytes and ficolin-1 levels in monocyte culture supernatants were assessed in 21 FCN1-genotyped individuals. FCN1 polymorphisms were determined in a cohort of 251 patients with systemic inflammation. High ficolin-1 plasma levels were significantly associated with the minor alleles in position -542 and -144. These alleles were also significantly associated with high FCN1 mRNA expression. The level of ficolin-1 in culture supernatants was significantly higher in individuals homozygous for the minor alleles at positions -542 and -144. Homozygosity for these alleles was significantly associated with fatal outcome in patients with systemic inflammation. None of the other investigated polymorphisms were associated with FCN1 and ficolin-1 expression, concentration or disease outcome. Functional polymorphic sites in the promoter region of FCN1 regulate both the expression and synthesis of ficolin-1 and are associated with outcome in severe inflammation.

Soft tissue sarcoma in France in 2015: Epidemiology, classification and organization of clinical care

Four thousand new cases of soft tissue sarcomas are diagnosed each year in France, 23% of which are localized in the abdomen and pelvis; the treatment of non-metastatic tumor is based on wide surgical resection, the quality of which determines the long-term outcome. To ensure appropriate care, the European Society of Medical Oncology (ESMO) recommends that any patient with an unexplained soft tissue mass (of any size for deep lesions or of>5cm for superficial lesions) be referred to a specialized center with capacities for multidisciplinary team decision; appropriate imaging should be performed prior to treatment and a percutaneous image-guided needle biopsy should be routinely performed. In France, clinical and pathology networks (NetSarc and RRePS) currently offer patients a structured means to make a systematic diagnosis of soft tissue sarcoma and help to provide access to appropriate treatment in a specialized center.

Prevalence of HTLV-I and HTLV-II infection in Gabon, Africa: comparison of the serological and PCR results

A cluster sampling survey was performed in 1989 in Libreville, Gabon, to determine HTLV-I and HTLV-II prevalence and to compare the efficacy of polymerase chain reaction (PCR) and serology in detecting HTLV-I and HTLV-II infections. A total of 322 sera from adults were tested by ELISA and by Western blot (WB). The WB patterns were interpreted according to WHO criteria and those of the manufacturer. PCR analysis using primer pairs in the gag and pol region, with a specific probe for HTLV-I and HTLV-II, was performed on the lymphocytes of the 322 adults. In addition, 134/322 samples were re-tested with tax primers, in a second laboratory. Using WHO criteria, 8/322 (2.5%) samples were positive on WB and 25 were indeterminate; with the criteria of the kit, 26/322 (8.1%) were positive and 7 were indeterminate by WB. By PCR, 13 (4%) samples were positive, including 12 for HTLV-I (3.7%) and one for HTLV-II (0.3%). All 8 seropositive samples (by the WHO criteria) were positive by PCR, as were 4 out of 25 indeterminate samples. Only one out of 289 seronegative samples was positive by PCR. In contrast, only 12/26 positive samples by the kit criteria were confirmed by PCR. These results confirm the relatively high HTLV-I/II seroprevalence observed in Gabon. HTLV-I infection is preponderant, but HTLV-II is also present. The WHO criteria for WB give a better fit with PCR results than the kit criteria for WB. In the absence of a specific confirmatory test and based on the uncommon "seronegative" HTLV-I/II infection, the indication for PCR appears limited to the positive WB samples (to differentiate HTLV-I and II infection) and to the indeterminate WB samples.

Abdominal desmoplastic small round cell tumor without extraperitoneal metastases: Is there a benefit for HIPEC after macroscopically complete cytoreductive surgery?

Background

Desmoplastic Small Round Cell Tumor (DSRCT) is a rare disease affecting predominantly children and young adults and for which the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS) remains unknown.

Methods

To identify patients with DSRCT without extraperitoneal metastases (EPM) who underwent CCRS between 1991 and 2015, a retrospective nation-wide survey was conducted by crossing the prospective and retrospective databases of the French Network for Rare Peritoneal Malignancies, French Reference Network in Sarcoma Pathology, French Sarcoma Clinical Network and French Pediatric Cancer Society.

Results

Among the 107 patients with DSRCT, 48 had no EPM and underwent CCRS. The median peritoneal cancer index (PCI) was 9 (range: 2–27). Among these 48 patients, 38 (79%) had pre- and/or postoperative chemotherapy and 23 (48%) postoperative whole abdominopelvic radiotherapy (WAP-RT). Intraperitoneal chemotherapy was administered to 11 patients (23%): two received early postoperative intraperitoneal chemotherapy (EPIC) and nine HIPEC. After a median follow-up of 30 months, the median overall survival (OS) of the entire cohort was 42 months. The 2-y and 5-y OS were 72% and 19%. The 2-y and 5-y disease-free survival (DFS) were 30% and 12%. WAP-RT was the only variable associated with longer peritoneal recurrence-free survival and DFS after CCRS. The influence of HIPEC/EPIC on OS and DFS was not statistically conclusive.

Conclusion

The benefit of HIPEC is still unknown and should be evaluated in a prospective trial. The value of postoperative WAP-RT seems to be confirmed.

HIPEC for peritoneal carcinomatosis: does an associated urologic procedure increase morbidity?

PURPOSE

To report the incidence of urinary tract procedures performed during complete cytoreductive surgery (CCRS) plus intraperitoneal chemotherapy, and to report the types of procedure, specific morbidity, risk factors, and treatment.

METHODS

Data were extracted from a prospective database of patients with malignant peritoneal disease treated with CCRS plus intraperitoneal chemotherapy who had undergone a resection or suture of the bladder, ureter, or kidney. Patients were eligible whatever the tumor origin.

RESULTS

Between 1994 and 2010, among the 598 patients treated with CCRS plus intraperitoneal chemotherapy, 48 (8%) had undergone a resection or suture in the urinary tract. Procedures included 4 nephrectomies, 19 partial cystectomies, 8 surgically repaired bladder injuries, and 18 ureteral resections. Postoperative mortality was 4% and morbidity was 41%. Specific complications included 6 urinary fistulas (12%), two among the 27 bladder sutures (7%) and four among the 18 ureteral sutures (22%) (P = NS). In the multivariate analysis, the risk factors for urinary fistula were severe preoperative malnutrition (P = 0.05, relative risk [RR] = 7.3) and extensive peritoneal disease (peritoneal cancer index ≥20, P = 0.05, RR = 8.3). Urinary fistulas had been treated nonsurgically in most of the cases.

CONCLUSIONS

Associated urinary tract procedures had occurred in 8% of the cases but did not greatly increase morbidity. Therefore, urinary tract involvement or injury are not contraindications to performing CCRS plus intraperitoneal chemotherapy. Fistulas had complicated only 12% of urinary sutures, mainly in cases of malnutrition or extensive peritoneal disease.

Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra-low rectal cancer

AIMS

The only two procedures for surgical treatment of ultra-low rectal cancer without a permanent abdominal stoma are the intersphincteric resection (ISR) and the abdominoperineal resection (APR) plus a perineal pseudocontinent colostomy (PCC). This study compared functional results and quality of life following these two techniques.

METHODS

Between January 1995 and December 2011, 36 patients had undergone an ISR (n = 14) or a PPC (n = 22) for very low rectal cancer. The Cleveland Clinica Florida (Wexner) fecal incontinence questionnaire and the EORTC Quality of Life questionnaire QLQ-C30 and CR38 had been administered.

RESULTS

There were no differences in gender, age, the interval between surgery and questionnaire responses, preoperative TNM staging, perioperative treatment, the laparoscopic approach and circumferential margin involvement rate between the groups. The ISR and PPC led to no difference in quality of life (Qol) and continence with a median Wexner score of respectively 11 and 10 (P = 0.403) and a fecal incontinence rate of 58.2% and 41% (P = 0.221). The incontinent patients had experienced worse social functioning and tended to have worse overall health. The patients who had undergone ISR had more defecation problems and evacuation difficulties.

CONCLUSION

Qol and continence are similar between ISR and PPC.

Central retroperitoneal recurrences from colorectal cancer: are lymph node and locoregional recurrences the same disease?

BACKGROUND

Central retroperitoneal recurrences (CRRs) from colorectal carcinoma carry a poor prognosis. A CRR is sometimes defined as a locoregional recurrence (LR) and sometimes as a lymph node recurrence (NR). This study was conducted to determine the nature of CRR and evaluate prognostic factors after complete CRR resection.

METHODS

Between January 1988 and December 2008, 31 patients underwent a complete resection of CRR. CRRs were divided into NR (n = 23) and LR (n = 8), whether pathological examination disclosed lymph node involvement or not.

RESULTS

No differences were found between LR and NR regarding TNM stage, primary tumour location, time interval from primary tumour resection to CRR, number of metastatic sites, number of metastatic lesions and therapeutic management. The median preoperative CEA level was higher in the NR group (p = 0.003). After a median follow-up of 47 months NRs were associated with better overall survival (OS) (p = 0.03). Three-year OS and disease-free survival (DFS) in the LR and NR groups were 27% and 0% versus 81% and 26%, respectively. Twenty-seven (87%) patients developed a re-recurrence within a median interval of 15 months. The number of metastatic sites or lesions, the size of the CRR, the type of chemotherapy, radiotherapy, the interval between the primary resection and CRR and the TNM stage had no impact on OS.

CONCLUSION

LR in patients with CRR had a poorer prognosis than NR. A multimodality approach with complete resection may yield long-term survival for NR.

Toward a new strategy in desmoid of the breast?

AIM

To report initial results of observation as well as surgery in patients with desmoid tumors (DTs) of the breast, a rare tumor for which data are scarce.

PATIENTS AND METHODS

The initial approaches were categorized as either front-line loco-regional treatment [(surgery or radiotherapy group, SRG) n = 20] or initial observation [(no surgery/no radiotherapy group, NSRG) n = 11].

RESULTS

A total of 27 women and 4 men were assessed between 1992 and 2013 and included in this study. Patient characteristics were adequately balanced in the 2 groups. Fifteen patients (48.4%) had a past history of breast surgery in the previous 24 months. The median initial DT size on MRI was 50 mm. The median follow-up was 36 months. In the SRG, 8/20 patients (40%) experienced recurrence. The median time to recurrence was 29 months. During the study period, 6 patients in the SRG (30%) received a mastectomy at the time of diagnosis (n = 3) or at relapse (n = 3), 7 patients (35%) received a thoracic wall resection and 8 patients (40%) received radiotherapy at the time of diagnosis (n = 2) or at recurrence (n = 5). In the NSRG, the median tumor size change was -4 mm (range -13 to +20). Three patients changed treatment strategies during the observation period; one received surgery, and 2 were administered anti-hormonal treatment.

CONCLUSIONS

Loco-regional treatments of breast DTs resulted in undesired disfigurement. Front-line observation yielded encouraging results and could enable the identification of patients who require loco-regional treatment. This strategy needs further evaluation.

Prognostic significance of visible cardiophrenic angle lymph nodes in the presence of peritoneal metastases from colorectal cancers

BACKGROUND

Visible cardiophrenic angle lymph nodes (CPALN) (enlarged or not), detected on CT scan are correlated with the presence of peritoneal metastases (PM), and contribute to the diagnosis of PM in colorectal cancer patients.

OBJECTIVE

To study whether visible CPALN exert a prognostic impact on survival after complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CCRS + HIPEC) treating PM.

PATIENTS AND METHODS

From 1999 to 2010, 114 patients with colorectal cancer and PM were treated with CCRS + HIPEC. CPALN were depicted in 64% of cases. The impact of visible CPALN on survival was investigated retrospectively.

RESULTS

The mean peritoneal cancer index (PCI) score was 9.2, 21% of the patients had presented with associated liver metastases, and 71% of the women with ovarian metastases. Median follow-up was 3.9 years. Visible CPALN had no impact on OS nor on DFS, unlike the PCI score which was unequivocably the most potent prognostic factor in the multivariate analysis.

CONCLUSION

Although some arguments might suggest that CPALN are malignant, paradoxically, we found that visible CPALN did not exert a positive nor a negative impact on survival after CCRS + HIPEC.

SYNOPSIS

Visible cardiophrenic angle lymph nodes (CPALN) on CT-scan are strongly associated with the presence of peritoneal metastases. But this study demonstrates that the presence of CPALN has no prognostic impact after optimal cytoreductive surgery plus HIPEC.

Options and outcome for reconstruction after extended left hemicolectomy

AIM

A tension-free anastomosis is required to minimize anastomotic leakage after an extended left colectomy when the residual transverse colon is too short to spontaneously reach the pelvis. To resolve this problem, colonic rotation with a right colonic transposition (RCT) or even with a complete intestinal derotation (CID) is mandatory. This study compared these two techniques.

METHOD

Between January 2001 and December 2011, 39 patients had undergone right colonic transposition (n = 29) or complete intestinal derotation (n = 10) after an extended left colectomy. All anastomotic complications had been recorded during the follow up.

RESULTS

No differences were found between right colonic transposition and complete intestinal derotation in terms of patient characteristics, surgical indications, therapeutic features and risk factors for anastomotic leakage (sex, American Society of Anesthesiology (ASA) score, diabetes, bevacizumab use, colorectal anastomotic level or protective stoma use). Ligature of the middle colic artery was significantly more frequent with right colonic transposition than with complete intestinal derotation (82.7% vs 50%; P = 0.04). An additional colonic resection tended to be required more often in the right colonic transposition group than in the complete intestinal derotation group (55.1% vs 20%; P = 0.054). The anastomotic complication rate was 10.2% and was not significantly different between right colonic transposition and complete intestinal derotation (6.9% vs 20%, P = 0.24).

CONCLUSION

Both colonic rotation techniques are feasible and safe. The right colonic transposition and complete intestinal derotation techniques yielded similar results in terms of colorectal anastomotic complications, but right colonic transposition required ligature of the middle colic artery and additional colonic resection tended to be required more frequently.

Comparison between the minimum margin defined on preoperative imaging and the final surgical margin after hepatectomy for cancer: how to manage it?

BACKGROUND

The liver surgeon's decision to operate is based on imaging studies. However, no clear practical guidelines are available enabling surgeons to safely predict tumor-free margins after a partial hepatectomy. The aim of this retrospective study is to provide surgeons with simple and easily applicable practical guidelines.

METHODS

We retrospectively stringently selected 42 anatomical right or left hepatectomies whose main characteristic was to pass along the median hepatic vein, which was preserved. This vein is an easily visualized anatomical landmark on preoperative imaging and is never transgressed by the surgeon. We compared the minimum distance between the tumor and this vein measured on preoperative imaging, and the minimum tumor-free excision margin measured on the specimen by the pathologist.

RESULTS

The median tumor-free excision margin was 5 mm at pathological analysis, significantly different (P < .0001) from the tumor-free margin measured on preoperative imaging (15 mm). The mean difference between these two measurements was 10 +/- 4 mm (median, 9 mm). This difference was partly the result of the transection and partly the result of technical deviations in relation to the ideal resection line.

CONCLUSIONS

The liver surgeon must consider that roughly a 5 to 8 mm tumor-free margin will disappear during hepatectomy when comparing measurements on the basis of preoperative imaging versus tumor-free specimen margins. If the histologically assessed minimum 2-mm tumor-free margin is added, the surgeon must plan to have a 7 to 10 mm tumor-free margin on preoperative imaging. However, few technical solutions exist that would enable the surgeon to increase the safety margin in borderline cases.