Global Cancer Surgery: pragmatic solutions to improve cancer surgery outcomes worldwide

The first Lancet Oncology Commission on Global Cancer Surgery was published in 2015 and serves as a landmark paper in the field of cancer surgery. The Commission highlighted the burden of cancer and the importance of cancer surgery, while documenting the many inadequacies in the ability to deliver safe, timely, and affordable cancer surgical care. This Commission builds on the first Commission by focusing on solutions and actions to improve access to cancer surgery globally, developed by drawing upon the expertise from cancer surgery leaders across the world. We present solution frameworks in nine domains that can improve access to cancer surgery. These nine domains were refined to identify solutions specific to the six WHO regions. On the basis of these solutions, we developed eight actions to propel essential improvements in the global capacity for cancer surgery. Our initiatives are broad in scope, pragmatic, affordable, and contextually applicable, and aimed at cancer surgeons as well as leaders, administrators, elected officials, and health policy advocates. We envision that the solutions and actions contained within the Commission will address inequities and promote safe, timely, and affordable cancer surgery for every patient, regardless of their socioeconomic status or geographic location.

Guidelines from the Brazilian society of surgical oncology regarding indications and technical aspects of neck dissection in papillary, follicular, and medullary thyroid cancers

Objective

The purpose of these guidelines is to provide specific recommendations for the surgical treatment of neck metastases in patients with papillary, follicular, and medullary thyroid carcinomas.

Materials and methods

Recommendations were developed based on research of scientific articles (preferentially meta-analyses) and guidelines issued by international medical specialty societies. The American College of Physicians' Guideline Grading System was used to determine the levels of evidence and grades of recommendations. The following questions were answered: A) Is elective neck dissection indicated in the treatment of papillary, follicular, and medullary thyroid carcinoma? B) When should central, lateral, and modified radical neck dissection be performed? C) Could molecular tests guide the extent of the neck dissection?

Results and conclusion

Recommendation 1: Elective central neck dissection is not indicated in patients with cN0 well-differentiated thyroid carcinoma or in those with noninvasive T1 and T2 tumors but may be considered in T3-T4 tumors or in the presence of metastases in the lateral neck compartments. Recommendation 2: Elective central neck dissection is recommended in medullary thyroid carcinoma. Recommendation 3: Selective neck dissection of levels II-V should be indicated to treat neck metastases in papillary thyroid cancer, an approach that decreases the risk of recurrence and mortality. Recommendation 4: Compartmental neck dissection is indicated in the treatment of lymph node recurrence after elective or therapeutic neck dissection; "berry node picking" is not recommended. Recommendation 5: There are currently no recommendations regarding the use of molecular tests in guiding the extent of neck dissection in thyroid cancer.

Perioperative Cancer Care in the Context of Limited Resources during the COVID-19 Pandemic: Brazilian Society of Surgical Oncology Recommendations

BACKGROUND

As the COVID-19 pandemic moves from rich to poor nations, the healthcare systems of developing countries have to deal with this extra burden. As cancer care cannot stop and surgery is the main mechanism for cure and palliation, it is important to provide safe and rational access to cancer surgery during the COVID-19 pandemic.

METHODS

From April 1st to May 1st, the committee of the Brazilian Society of Surgical Oncology (BSSO) was responsible for reviewing the literature and writing recommendations for perioperative cancer care in the context of limited resources during the pandemic. The recommendations were submitted to the BSSO board of directors. The orientations that were not consensual were removed and the suggestions were added to the text. From May 15 to 30th, the committee revised the recommendations, aligned them with the objectives of the work and standardize the text.

DISCUSSION

The rational use of resources to reduce the risk of surgical cancer patients being operated on during the incubation period of a corona virus infection is important in this context. Prevalence of corona virus in the region, the need for surgery, surgical complexity, patient age and comorbidities, and availability of corona virus testing are central aspects in this matter and are discussed.

CONCLUSIONS

We present a protocol, focused on the patients' outcomes, for safe and rational use of resources to reduce the risk of surgical cancer patients being operated on during the virus incubation period, in the context of areas with limited resources.

Clinical outcomes of patients with gastric cancer according to pre and post-neoadjuvant chemotherapy PD-L1 immunohistochemistry (IHC) expression

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Background: The incidence, prognostic and predictive impacts of PD-L1 expression in locally advanced gastric cancer is unknown. We aimed to determine the expression of PD-L1 by CPS in the pre-treatment biopsy and surgical specimens of patients (pts) with gastric cancer who received neoadjuvant therapy and its association with pathological response and survival outcomes. Methods: Retrospective cohort of pts treated at a cancer center from 2007 to 2017. Pts with confirmed gastric or GEJ adenocarcinoma who received neoadjuvant treatment and curative-intent D2 surgery were included. Gastric stump tumors and those who had a total esophagectomy were excluded. Clinical data were obtained from medical charts. Biopsy samples and a tissue microarray with the most representative areas of the surgical specimen were used to detect PD-L1 IHC expression with 22C3 phamDx antibody. Results were analyzed using the CPS score. Overall and DFS survival included the Kaplan-Meier product-limit estimator in an ITT analysis and a Cox regression was used to obtain crude and adjusted HR for prognostic factors. Results: 270 pts were included: median age was 58.9 years, most (51.5%) had cT3-T4N+ stages, 45% had diffuse histology and 87.8% completed the preoperative regimen. 13% had a pCR, while 53% had minimal tumor regression. With a median follow-up of 60.3 months (CI 95% 54.7 – 65.8), the median OS and DFS were not reached. 11.4% of biopsies and 18.6% of surgical specimens had positive CPS, with a median score of 3 (IQR 2,0 – 7,5) and 9 (IQR 5.0 – 20.0) respectively. In 18.9% of paired samples the PD-L1 expression was found to be negative in the biopsy sample and positive in the surgical specimen. PD-L1 expression was neither associated with pathologic response after neoadjuvant chemotherapy, nor with survival outcomes. Conclusions: PD-L1 expression on the setting of locally advanced gastric cancer was low and it was different when biopsy and surgical specimens were compared. No impact on survival results could be detected. [Table: see text]

Survival outcomes of patients with pathological stage I gastric cancer using the competing risks survival method

Background

Patients with stage I gastric cancer are considered to have an exquisite prognosis. Nonetheless, the fact that some patients experience disease relapse highlights that a subgroup might benefit from multimodality treatment. We aimed to evaluate the survival of patients with stage I gastric cancer and look for harbingers of gastric cancer recurrence.

Methods

We looked for patients with stage I gastric cancer treated exclusively with surgery from 1996 to 2015. The competing risks survival method was used to allow for concurrent causes of mortality. Also, we calculated subdistribution hazards (SH) to reveal factors associated with cancer recurrence and death from unrelated causes.

Results

A total of 185 patients constitute the study population. Thirty-seven patients had pT2N0 tumors. Most patients (80.5%) were treated with D2 lymphadenectomy. The probability of relapse at 5 years was 3.0% and 8.6% in the study population and the pT2N0 subgroup, respectively. Among all 26 deaths, only six were related to gastric cancer. In multivariate analysis, perineural invasion (PNI) was associated with increased risk of gastric cancer recurrence.

Conclusions

The prognosis of stage I gastric cancer treated with D2 lymphadenectomy is excellent. PNI may indicate higher likelihood of recurrence. Further work in this field should account for the higher risk of death from unrelated causes.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives-a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG)

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION

Background

: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors.

Aim

: In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established.

Method:

Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy.

Results

: The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent.

Conclusion

: Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

KRAS gene mutation in a series of unselected colorectal carcinoma patients with prognostic morphological correlations: a pyrosequencing method improved by nested PCR

INTRODUCTION

Inhibition of EGFR is a strategy for treating metastatic colorectal cancer (CRC) patients. KRAS sequencing is mandatory for selecting wild-type tumor patients who might benefit from this treatment. DNA from formalin-fixed paraffin-embedded (FFPE) tissues is commonly used for routine clinical detection of mutations, and its amplification succeeds only when all preanalytical histological processes have been controlled. In cases that are not properly processed, the DNA results can be poor, with low peak pyrosequencing findings. We designed and tested a pair of forward and reverse primers for a nested PCR method, followed by pyrosequencing, in a single Latin American institution series of 422 unselected CRC patients, correlating KRAS mutations with pathological and clinical data.

MATERIALS AND METHODS

Patient DNA samples from tumors were obtained by scraping or laser microdissection of cells from FFPE tissue and extracted using a commercial kit. DNA was first amplified by PCR using 2 primers that we designed; then, nested PCR was performed with the amplicon from the preamplification PCR using the KRAS PyroMark™ Q96 V2.0 kit (Qiagen). Pathological data were retrieved from pathology reports.

RESULTS

KRAS mutation was observed in 33% of 421 cases. Codon 12 was mutated in 76% of cases versus codon 13 in 24%. Right-sided CRCs harbored more KRAS mutations than left-sided tumors, as did tumors that presented with perineural invasion.

CONCLUSION

Our findings in this Latin American population are consistent with the literature regarding the frequency of KRAS mutations in CRC, their distribution between codons 12 and 13, and type of nucleotide substitution. By combining nested PCR and pyrosequencing, we achieved a high rate of conclusive results in testing KRAS mutations in CRC samples - a method that can be used as an ancillary test for failed assays by conventional PCR.

Expression of immunohistochemical markers in ampullary cancer (AC) and association with behavior

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Background: Curiously, the ampulla is formed by the union of two distinct types of mucosa: intestinal (GI) and pancreatobiliary(PB). Based on this fact, ACs could have different biologic behaviors. Methods: Between 1999 and 2012 we performed a retrospective analysis of patients with AC that underwent a pancreaticoduodenectomy (PD) with curative intent in our institution and the expressions of immunohistochemical markers related to GI origin (CK20 and CDX2) and to PB origin: (CK7 and MUC1) and its association with outcomes. Results: Twenty-seven patients underwent (PD), (M:F=15:12), median age was 62 (range33-83), 85.2% had R0 resection, 29.6% had positive lymph-nodes, 44.4% had perineural invasion, 22.2% had vascular invasion, 29.6% had lymphatic invasion, 59.2% had moderately differentiated tumors. AJCC stage pathologic grouping was: I=33.3%, II=37%, III= 29.6%; Median follow-up was 33.8 months. Relapse free survival was 43% in 3 years and overall survival was 53.7% in 5 years. The relapse rate was 59.2% and the majority of these relapses (69%) were distant metastasis without local relapse. Only positive lymph-node status (p=0,004, HR: 5.99) and R1 resection (R1: p=0.015, HR: 8.75) were independent prognostic factors for relapse on multivariate analysis. Among the patients, 21 were evaluated for the expression of immunohistochemical markers. Ten AC were classified into TGI type, 9 into PB type and 2 into unusual. An association between PB type and positive lymph node status (p=0.05) and more advanced stage (p=0.05) was found (Fisher’s exact test). There was no difference in relapse and survival between the histological subtypes, however, more PB patients had received adjuvant therapy. Conclusions: Histological subtypes of AC may have different behavior, but they are frequently neglected during decision of adjuvant therapy.

Expression of growth and cell proliferation factors in gastric carcinomas: The association with poor overall survival on patients with intestinal type

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Background: Gastric carcinomas (GC) express a variety of growth factors and cell proliferation acting in the mechanisms of tumor invasion and spread. The expression of angiogenic factors such as vascular endothelial growth factor (VEGF) has been demonstrated in diffuse type GC, whereas expression of growth factors is associated with intestinal-type carcinomas. Objective: To study the immunohistochemical expression of proteins associated with growth factors and cell proliferation in GC. Methods: We studied 400 GC, arranged in duplicates in 2 blocks of tissue microarray (TMA). Immunohistochemistry was performed using antibodies: c-MET (Novocastra), TGFbetaI (Santa Cruz), TGFbetaII (Santa Cruz), c-erbB-2 (Dako) and VEGF (Santa Cruz). Cases were considered positive for TGFbetaI, TGFbetaII and VEGF when cytoplasmic staining was observed in more than 10% of tumor cells. Positive cases for c-met and c-erbB-2 were detected when strong staining on the membrane cells was observed in more than 10% of neoplastic cells. Results: Expression of TGFbetaI, TGFbetaII and VEGF were detected in 314/385 (81%), 370/382 (96%) and 333/366 (90%) of GC. 333/376 (88%) cases were positive for c-met and 54/385 (14%) for c-erbB-2. Intestinal type carcinomas were more often positive for TGFbetaII (p = 0.01), VEGF (p = 0.001), c-met (p = 0.01), and c-erbB-2 (p = 0.001). According to univariate statistical analyzes expressions of TGFbeta II, c-met and c-erbB-2 were independent factors associated with overall survival of patients with GC. Conclusions: The proteins associated with growth factors and cell proliferations are differentially expressed in intestinal type of GC. Our findings pointed them out as biological factors associated with worse prognosis and important therapeutic targets.

Prognosis and patterns of failure after curative pancreaticoduodenectomy for early-stage ampullary adenocarcinomas

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Background: Ampullary cancer (AC) is a rare malignancy. There is no consensus about the role of adjuvant radiotherapy and chemotherapy, mainly for early-stage tumors. Methods: Between 2007 and 2012 we performed a retrospective analysis of patients with AC that underwent a pancreaticoduodenectomy (PD) with curative intent in our institution. Results: Twenty-four patients underwent (PD), (M:F=13:11), median age was 63 (range35-83), 87% had R0 resection, median of resected lymph-nodes was 8.5 (range 2-30), 29% had positive lymph-nodes, 46% had perineural invasion, 21% had vascular invasion, 29% had lymphatic invasion, 50% had tumors > 2 cm, 54% had moderately differentiated tumors. AJCC stage pathologic grouping was: I=37,5%, II=29%, III=33%; Median follow-up was 27 months, median progression free survival was 29 months and median overall survival was 101 months. Only lymph-node status was independent prognostic factor for disease free survival on multivariate analysis (p=0,045, HR: 7,8). Among patients with early-stage tumors (n=13), only one received adjuvant therapy. The relapse rate was 23% and 50%, for stage I and IIa tumors, respectively. Among the recurrences, 80% of relapses were distant metastasis without local relapse. In patients with stage IIb and III tumors (n=11), 63,6% received adjuvant treatment (57% chemotherapy and 43% radiochemotherapy). The relapse rate was 100% and 75%, respectively, and 66% of these relapses were distant metastasis without local relapse. 75% of patients who had local recurrence had tumors in stage IIb or III. Conclusions: Our study shows a high disease relapse rate in well-operated patients, even in early-stage tumors, with no nodal involvement, mainly with distant disease. The majority of patients who had local relapses had a more advanced stage and systemic relapses associated. This information can help guide decisions on the choice of adjuvant therapy.

HER2 status and histopathologic findings related to tumor regression in gastric carcinomas treated with preoperative chemotherapy

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Background: Neoadjuvant chemotherapy is now the standard of care of patients with resectable gastric carcinomas (GC). Predictive molecular markers and histopathological evidence of tumour response to chemotherapy are not widely available. In this study we evaluated HER2 status and histopathological features associated with tumor regression in 36 GC treated with neoadjuvant chemotherapy followed by surgery.

Methods: 36 patients had received ECF, DCF or ECX chemotherapy prior the surgery. The entire tumor beds of the specimens were histologically evaluated. HER2 expression by immunohistochemistry was detected in the biopsy and gastrectomy specimens.

Results: 46% of the cases were intestinal type, 40% were diffuse and 14% were unclassified. Nine patients had major clinical and radiological response (CRR) characterized by presence of viable tumor cells less than 50% of the tumor with increased fibrosis (>50%). Three cases had complete CRR showing tumor beds totally replaced by fibrosis. The remaining cases had minimal CRR characterized by viable tumor cells in more than 50% and minimal fibrosis. Necrosis was not found; mucinous metaplasia was observed in three cases of the major CRR. Inflammatory infiltrated was found in all cases. The downstaging of T-stage seems to be greater in the intestinal type than diffuse type (80% vs 44%). HER2+ (score 3) was detected in 16,6% of the biopsy specimen. Only 1 case was HER2+ in the biopsy and in the gastrectomy tissue. All the HER2+ GC showed minimal CRR.

Conclusions: The ratio of viable tumor cells and fibrosis is directly associated with tumor response to preoperative chemotherapy. The chemotherapy regimens seem to collaborate to downstaging rates; however the treatment of HER2+ GC group could be improved by the use of Ttrastuzumab.