Role of microsatellite instability and HER2 positivity in locally advanced esophago-gastric cancer patients treated with peri-operative chemotherapy

PURPOSE

Neoadjuvant chemotherapy (NAC) significantly improved the prognosis of patients with locally advanced gastric cancer (LAGC). Several biomarkers, including HER2 and MMR/MSI are crucial for treatment decisions in the advanced stage but, currently, no biomarkers can guide the choice of NAC in clinical practice. Our aim was to evaluate the role of MSI and HER2 status on clinical outcomes.

METHODS

We retrospectively collected LAGC patients treated with NAC and surgery +/- adjuvant chemotherapy from 2006 to 2018. HER2 and MSI were assessed on endoscopic and surgical samples. Pathologic complete response (pCR) rate, overall survival (OS), and event-free survival (EFS) were estimated and evaluated for association with downstaging and MSI.

RESULTS

We included 76 patients, 8% were classified as MSI-H, entirely consistent between endoscopic and surgical samples. Six percent of patients were HER2 positive on endoscopic and 4% on surgical samples. Tumor downstaging was observed in 52.5% of cases, with three pCR (5.1%), none in MSI-H cancers. According to MSI status, event-free survival (EFS) and overall survival (OS) were higher for MSI-H patients to MSS [EFS not reached vs 30.0 months, p = 0.08; OS not reached vs 39.6 months, p = 0.10].

CONCLUSION

Our work confirms the positive prognostic effect of MSI-H in the curative setting of LAGC, not correlated with pathologic tumor downstaging. Prospective ad-hoc trial and tumor molecular profiling are eagerly needed.

Colorectal cancer, Vitamin D and microbiota: A double-blind Phase II randomized trial (ColoViD) in colorectal cancer patients

BACKGROUND

Several studies suggest a role of gut microbiota in colorectal cancer (CRC) initiation and progression. Vitamin D (vitD) blood levels are also inversely correlated with CRC risk and prognosis. However, these factors' interplay remains unknown.

METHODS

74 CRC patients after standard treatment were randomized to 1-year 2000 IU/day vitD or placebo.  Baseline and post-treatment fecal microbiota for shotgun metagenomics sequencing was collected. Coda-lasso and Principal Component Analysis were used to select and summarize treatment-associated taxa and pathways. Associations between vitD and taxa/pathways were investigated with logistic regression. Mediation analysis was performed to study if treatment-associated taxa mediated the effect of supplementation on 25(OH)D levels. Cox proportional-hazards model was used for disease-free survival (DFS).

RESULTS

60 patients were analyzed. Change in alpha diversity (Shannon: p = 0.77; Simpson: p = 0.63) and post-treatment beta diversity (p = 0.70) were comparable between arms. Post-treatment abundances of 63 taxa and 32 pathways differed between arms. The 63 taxa also mediated the effect of supplementation on 25(OH)D (p = 0.02). There were sex differences in vitD levels, microbiota and pathways. Pathways of essential amino acids' biosynthesis were more abundant in supplemented women. Fusobacterium nucleatum presence at baseline was associated with worse DFS (p = 0.02). Those achieving vitD sufficiency (25(OH)D≥30 ng/ml) had lower post-treatment abundances (p = 0.05). Women were more likely to have F. nucleatum post-treatment (p = 0.02).

CONCLUSIONS

VitD supplementation may contribute shaping the gut microbiota and the microbiota may partially mediate the effect of supplementation on 25(OH)D. The observed sex-specific differences highlight the necessity of including sex/gender as a variable in microbiome studies.

Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement

Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.

Neobladder and ablative pelvic radiotherapy: still a taboo?

The presence of a neobladder constitutes a limitation for the radiation oncologist, as there is no clear evidence about its tolerance to radiotherapy (RT). The limited literature only concerns the conventional postoperative treatment in patients with bladder cancer after cystectomy. Here we report a case of a patient with neobladder who underwent a stereotactic RT for a pelvic recurrence of disease, with response to treatment and no toxicity to the neobladder. This case represents a promising example of the chance to perform RT with ablative intent, using advanced techniques, even on lesions close to the neobladder.

Should we use a patient's port as the preferred intravenous route rather than inserting an additional venous access?

Early in 2021, the Infusion Nursing Society has released the latest version of the Infusion Therapy Standards of Practice. In the last two decades, these Standards have been representing one of the most important evidence-based documents available in the world of venous access. Nevertheless, we were quite concerned reading a recommendation included in chapter 26 (Vascular Access Device Planning: practice recommendation I, C): "Use a patient's port, unless contraindicated (e.g. existing complication) as the preferred IV route in preference to insertion of an additional VAD." Such recommendation is offered not on the basis of evidence, but as experts' opinion ("Committee Consensus"). This Editorial deals with the opinion of GAVeCeLT (The Italian Study Group for Long Term Central Venous Access) that strongly discourage the use of ports for intravenous treatment different from chemotherapy (or from the therapy that specifically required that long term, infrequent access). The rationale for this choice is based on the consideration that the patient's port-if used in a non-specialty ward-would be at high risk of complications, some of them potentially leading to the loss of the device, and that such complications might be particularly difficult to manage in this setting. The continuous or frequent use of a port transforms it into an external device, thus cancelling the main advantage of a totally subcutaneous location, while adding a significant disadvantage (need for repeated percutaneous punctures and risk of extravasation/infiltration due to improper insertion or dislocation of the non-coring needle). One exception is the possible use of port for radio-diagnostic purposes (as long as the port is power injectable). This strategy may be associated with advantages for the patient, and imaging quality improvement, but requires the adoption of specific protocols for prevention of infective and mechanical complications.

WoCoVA consensus on the clinical use of in-line filtration during intravenous infusions: Current evidence and recommendations for future research

The need for filtering intravenous infusions has long been recognized in the field of venous access, though hard scientific evidence about the actual indications for in-line filters has been scarce. In the last few years, several papers and a few clinical studies have raised again this issue, suggesting that the time has come for a proper definition of the type of filtration, of its potential benefit, and of its proper indications in clinical practice. The WoCoVA Foundation, whose goal is to increase the global awareness on the risk of intravenous access and on patients' safety, developed the project of a consensus on intravenous filtration. A panel of experts in different aspects of intravenous infusion was chosen to express the current state of knowledge about filtration and to indicate the direction of future research in this field. The present document reports the final conclusions of the panel.

Safe use of Peripherally Inserted Central Catheters for chemotherapy of solid malignancies in adult patients: A 1-year monocentric, prospectively-assessed, unselected cohort of 482 patients

INTRODUCTION

Aim of this study was to analyze the overall complication and failure rates of Peripherally Inserted Central Catheters (PICCs), in a 1-year consecutive unselected cohort of 482 adult patients, affected by non-hematological malignancies undergoing chemotherapy.

METHODS

Adult outpatients (aged 18-75 years), with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, bearing solid tumors and candidates for intravenous chemotherapy were eligible for the study. Exclusion criteria were active infections, coagulopathy (defined as platelet count <50,000/μL and/or prothrombin time more than 18 s), life expectancy <6 months, or inability to give written informed consent. Devices were all implanted in an outpatients' hospital facility, following predefined evidence-based institutional guidelines and protocols by a PICC-dedicated team at the European Institute of Oncology in Milan, Italy, during the 12-month period from January 1 to December 31, 2019.

RESULTS

Five-hundred PICCs were implanted in a cohort of 482 patients during the time interval of this study. Thirty devices were overall removed (6.2%), 23 as a consequence of a complication occurred, and seven inadvertently. The inserted PICCs accounted for a total of 49,718 catheter days in situ, median duration was 85.5 days [interquartile range (IQR): 56-146]. Overall there were 42 (8.7%) complications, corresponding to 0.84 catheter-adverse events (CAE)/1000 PICC-days (95% CI: 0.61-1.14). There were N = 13 (2.7%) thromboses, N = 11 (2.3%) irreversible occlusions, N = 7 (1.5%) accidental removals, N = 5 (1.0%) infections [two Catheter Related Blood Stream Infection (CRBSI) and three exit site/local infection], N = 3 (0.6%) ruptures and N = 3 (0.6%) primary or secondary malpositions.

CONCLUSION

This large prospective study supports the increasing use of PICCs in adult oncology outpatients treated in specialized centers with chemotherapy for non-hematological malignancies. In this clinical setting, PICC failure occurred in 6% only of the inserted devices.

GAVeCeLT-WoCoVA Consensus on subcutaneously anchored securement devices for the securement of venous catheters: Current evidence and recommendations for future research

BACKGROUND

Subcutaneously anchored securement devices (or subcutaneous engineered securement devices) have been introduced recently into the clinical practice, but the number of published studies is still scarce. The Italian Group of Long-Term Central Venous Access Devices (GAVeCeLT)-in collaboration with WoCoVA (World Congress on Vascular Access)-has developed a Consensus about the effectiveness, safety, and cost-effectiveness of such devices.

METHODS

After the definition of a panel of experts, a systematic collection and review of the literature on subcutaneously anchored securement devices was performed. The panel has been divided in two working groups, one focusing on adult patients and the other on children and neonates.

RESULTS

Although the quality of evidence is generally poor, since it is based mainly on non-controlled prospective studies, the panel has concluded that subcutaneously anchored securement devices are overall effective in reducing the risk of dislodgment and they appear to be safe in all categories of patients, being associated only with rare and negligible local adverse effects; cost-effectiveness is demonstrated-or highly likely-in specific populations of patients with long-term venous access and/or at high risk of dislodgment.

CONCLUSION

Subcutaneously anchored securement is a very promising strategy for avoiding dislodgment. Further studies are warranted, in particular for the purpose of defining (a) the best management of the anchoring device so to avoid local problems, (b) the patient populations in which it may be considered highly cost-effective and even mandatory, (c) the possible benefit in terms of reduction of other catheter-related complications such as venous thrombosis and/or infection, and-last but not least-(d) their impact on the workload and stress level of nurses taking care of the devices.

GAVeCeLT-WoCoVA Consensus on subcutaneously anchored securement devices for the securement of venous catheters: Current evidence and recommendations for future research

Background:

Subcutaneously anchored securement devices (or subcutaneous engineered securement devices) have been introduced recently into the clinical practice, but the number of published studies is still scarce. The Italian Group of Long-Term Central Venous Access Devices (GAVeCeLT)—in collaboration with WoCoVA (World Congress on Vascular Access)—has developed a Consensus about the effectiveness, safety, and cost-effectiveness of such devices.

Methods:

After the definition of a panel of experts, a systematic collection and review of the literature on subcutaneously anchored securement devices was performed. The panel has been divided in two working groups, one focusing on adult patients and the other on children and neonates.

Results:

Although the quality of evidence is generally poor, since it is based mainly on non-controlled prospective studies, the panel has concluded that subcutaneously anchored securement devices are overall effective in reducing the risk of dislodgment and they appear to be safe in all categories of patients, being associated only with rare and negligible local adverse effects; cost-effectiveness is demonstrated—or highly likely—in specific populations of patients with long-term venous access and/or at high risk of dislodgment.

Conclusion:

Subcutaneously anchored securement is a very promising strategy for avoiding dislodgment. Further studies are warranted, in particular for the purpose of defining (a) the best management of the anchoring device so to avoid local problems, (b) the patient populations in which it may be considered highly cost-effective and even mandatory, (c) the possible benefit in terms of reduction of other catheter-related complications such as venous thrombosis and/or infection, and—last but not least—(d) their impact on the workload and stress level of nurses taking care of the devices.

A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

Liver Resection or Resection plus Intraoperative Echo-Guided Ablation in the Treatment of Colorectal Metastases: We are Evaluating Their Effect for Cure

This study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases. Between January 1994 and December 2015, 373 patients underwent surgery for colorectal liver metastases. There were 284 patients who underwent hepatic resection only (Group 1) and 83 hepatic resection plus ablation (Group 2). Group 2 patients had a higher incidence of multiple metastases (100% in Group 2 vs 28.2% in Group 1; P < 0.001) and bilobar involvement (76.5% in Group 2 vs 12.9% in Group 1; P < 0.001) than Group 1 cases. Perioperative mortality was nil in either group, with a higher postoperative complication rate among Group 1 versus Group 2 cases (18 vs 0, respectively). The median follow-up was 90 months (range, 1–180), with a five-year overall survival for Group 1 and Group 2 of 51 per cent and 80 per cent, respectively (P = 0.193). Mean disease-free survival for patients with R0 resection was 55 per cent, 40 per cent, and 37 per cent at one, two, and three years, respectively, and remained steadily higher (at 50%) in those patients treated with resection combined with ablation up to five years (P = 0.069). The only intraoperative ablation failure was for a large lesion (≥5 cm). Our data support the use of intraoperative ablation when complete hepatic resection cannot be achieved.

Liver Resection or Resection Plus Intraoperative Echo-Guided Ablation in the Treatment of Colorectal Metastases: We Are Evaluating Their Effect for Cure

This study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases. Between January 1994 and December 2015, 373 patients underwent surgery for colorectal liver metastases. There were 284 patients who underwent hepatic resection only (Group 1) and 83 hepatic resection plus ablation (Group 2). Group 2 patients had a higher incidence of multiple metastases (100% in Group 2 vs 28.2% in Group 1; P < 0.001) and bilobar involvement (76.5% in Group 2 vs 12.9% in Group 1; P < 0.001) than Group 1 cases. Perioperative mortality was nil in either group, with a higher postoperative complication rate among Group 1 versus Group 2 cases (18 vs 0, respectively). The median follow-up was 90 months (range, 1-180), with a five-year overall survival for Group 1 and Group 2 of 51 per cent and 80 per cent, respectively (P = 0.193). Mean disease-free survival for patients with R₀ resection was 55 per cent, 40 per cent, and 37 per cent at one, two, and three years, respectively, and remained steadily higher (at 50%) in those patients treated with resection combined with ablation up to five years (P = 0.069). The only intraoperative ablation failure was for a large lesion (≥5 cm). Our data support the use of intraoperative ablation when complete hepatic resection cannot be achieved.

Determinants, time trends and dynamic consequences of postoperative hyperglycemia in nondiabetic patients undergoing major elective abdominal surgery: A prospective, longitudinal, observational evaluation

BACKGROUND & AIMS

In retrospective studies an indisputable causal relationship between hyperglycemia and postoperative infections cannot be entirely disclaimed. We aimed investigate whether the time trends of blood glucose levels in the perioperative period could be a determinant of surgery-related infections.

METHODS

Adult patients without diabetes who were candidates for elective major abdominal operation were prospectively enrolled in a longitudinal, observational multicenter study. The blood glucose level was measured every 6 h for 3 days. We calculated the association between blood glucose (BG) levels and the risk of occurrence of surgery-related infections using a joint regression modeling for longitudinal and time-to-event outcomes which accounts for the effect of other risk factors.

RESULTS

Between January 2016 and November 2017, we obtained 6078 BG measures distributed on different time-points in 452 patients. There was a nearly 3-fold increased risk of having hyperglycemia, defined as BG ≥ 125 mg/dL, if the BG level at admission was >100 mg/dL (OR = 2.986, P < 0.001).The hazard of infection for each 10 mg/dL increase of BG levels over time was marginal (HR = 1.065, P = 0.045). The calculated risk of having an infection was 9.6% for BG going from 110 mg/dL during surgery to 84 mg/dL at the end of day 3, 10.5% for BG decreasing from 140 to 114, 11.8% for BG decreasing from 180 to 154 and 24.5% for BG increasing from 80 to 145, 24.7% for BG increasing from 110 to 175, and 25.4% for BG increasing from 140 to 205.

CONCLUSIONS

The time trends of BG - as opposed to the absolute concentration -are major determinants of the risk of postoperative infections.

Genital marginal failures after intensity-modulated radiation therapy (IMRT) in squamous cell anal cancer: no higher risk with IMRT when compared to 3DCRT

Intensity-modulated radiotherapy (IMRT) is considered the preferred option in squamous cell canal cancer (SCAC), delivering high doses to tumor volumes while minimizing dose to surrounding normal tissues. IMRT has steep dose gradients, but the technique is more demanding as deep understanding of target structures is required. To evaluate genital marginal failure in a cohort of patients with non-metastatic SCAC treated either with IMRT or 3DCRT and concurrent chemotherapy, 117 patients with SCAC were evaluated: 64 and 53 patients were treated with IMRT and 3DCRT techniques, respectively. All patients underwent clinical and radiological examination during their follow-up. Tumor response was evaluated with response evaluation criteria in solid tumors v1.1 guideline on regular basis. All patients' data were analyzed, and patients with marginal failure were identified. Concomitant chemotherapy was administered in 97 and 77.4% of patients in the IMRT and 3DCRT groups, respectively. In the IMRT group, the median follow-up was 25 months (range 6-78). Progressive disease was registered in 15.6% of patients; infield recurrence, distant recurrence and both infield recurrence and distant recurrence were identified in 5, 4 and 1 patient, respectively. Two out of 64 patients (3.1%) had marginal failures, localized at vagina/recto-vaginal septum and left perineal region. In the 3DCRT group, the median follow-up was 71.3 months (range 6-194 months). Two out of 53 patients (3.8%) had marginal failures, localized at recto-vaginal septum and perigenital structures. The rate of marginal failures was comparable in IMRT and 3DCRT groups (χ² test p = 0.85). In this series, the use of IMRT for the treatment of SCAC did not increase the rate of marginal failures offering improved dose conformity to the target. Dose constraints should be applied with caution-particularly in females with involvement of the vagina or the vaginal septum.

Treatment of Pneumothorax as a Complication of Long-Term Central Venous Port Placement in Oncology Patients. An Observational Study

Background and Purpose

In percutaneous placement of central venous catheters an inadvertent, direct lesion of the lung parenchyma can occur. This is a cause of iatrogenic pneumothorax, whose incidence is approximately 1 to 4%, largely dependent on the experience of the operator, the site of venipuncture and probably the technique employed. Initial treatment currently ranges from observation alone to formal tube-thoracostomy. In an attempt to define the best initial treatment, if any, we reviewed our personal series and contributions from the literature. As a result we have produced a flow-chart proposing a rational treatment of this frequent complication.

Patients and Methods

One thousand four hundred twenty-one ports were placed in patients at the Department of Surgery of the European Institute of Oncology in Milan through an infraclavicular standardized percutaneous subclavian approach. They were placed during the 60-month period from January 1, 1996 to December 31, 2000 for long-term chemotherapy treatment of solid tumours. Chest upright X-rays were obtained post-operatively in all cases to check the correct position of the catheter tip and the presence of pneumothorax.

Results

Twenty-two patients out of 1421 (1.54%) experienced a radiologically-proven pneumothorax, ranging from 5 to 70% of the affected pleural space. Sixteen patients out of 22 (72.7%) with minor portions of affected pleural space received simple observation. In these patients the most common finding was an uncomplicated tachycardia (more than 100 beats/min); 8 of them did not complain of any symptoms. Six patients (27.2%) underwent an additional procedure (3 tube-thoracostomies and 3 aspirations of the pleural space), claiming symptoms of chest pain and various degrees of dyspnea. Tube thoracostomy was mainly adopted at the beginning of our experience, and in patients with a severe degree of pleural involvement (55 to 70% of the pleural space). Aspiration, instead, was used more recently and in patients with varying degrees of pleural space involved, ranging from 40 to 60%.

Conclusions

Looking at our own series and literature data, patients with iatrogenic pneumothorax following central venous cannulation who do not have a severe underlying pulmonary disease can be reassured, at the time of diagnosis, that surgery is usually unnecessary and tube thoracostomy is rarely needed. Simple aspiration of the pleural air by means of a central venous catheter inserted percutaneously into the pleural space under local anesthesia should be considered, even if the amount of affected pleural space is more than 50%, before opting for a formal tube-thoracostomy using small-bore tubes.

Ultrasound Guided versus Direct Vein Puncture in Central Venous Port Placement

Introduction

This study will report our experience on positioning of totally implanted venous catheter system (port-a-cath) as compared to ultrasound guidance versus blind technique.

Materials and Methods

From July 1996 to November 1999 in the vascular suite of the Europen Institute of Oncology, 427 port-a-cath were implanted in patients with neoplastic disease. All devices were implanted through the subclavian vein. 198 with ultrasound guided puncture and 229 following anatomical landmarks. All patients underwent a close and specific clinical and instrumental follow-up to evaluate possible complications.

Results

Use of Ultrasound (US) in subclavian vein catheterization has reduced the number of puncture attempts, with a better patient complicance, allowing a faster procedure and reducing peri-procedural complications. Ultrasound technique has shown reduction in early complications. In fact in our experience we had no pneumothorax events by using ultrasound guidance, versus 11 events with blind technique. US has shown no reduction in late complications: 3 thrombosis versus 6 thrombosis with US guidance, and 3 fractured and embolized catheter versus 2 cases. Fibrin-cuff percentage was the same in the two groups with only 1 case, as the dislocation of the catheter tip in the jugular vein with 2 cases in both groups. Moreover US let us to avoid the arterial puncture and to perform a more peripheral puncture of the subclavian vein, reducing the risk of “pinch-off” phenomenon and of haematoma, with no cases reported under US guidance versus 1 case respectively in direct vein puncture.

Conclusions

US guided puncture of subclavian vein for the implantation of venous catheter system is faster by reducing procedure time, it is easier for the operator and safer for the patient than blind technique by exposing anatomical structures. Morevover US guidance reduces early complications and limits costs.

Valved Central Venous Catheter Connected to Subcutaneous Port: A Multicenter Phase IV Study Based on a Cohort of 50 Oncology Patients

Purpose

Since technical aspects and clinical features of central venous valved catheters are far from being completely understood, a multinational group of investigators has decided to assess a new distally-valved catheter connected to a port, in the clinical setting of oncology patients undergoing chemotherapy, in an attempt to verify its safety and viability, while also investigating its practical features.

Methods

Our project was structured as a phase IV multicenter study. Hospitalized adults (ages 18–80 years) who had solid tumors and were candidate for intravenous chemotherapy met the criteria to enter the study. One single type of port was used (made of titanium, plastic and silicone) connected to a silicone, distally valved catheter (as manufactured by B. Braun Aesculap). A case report form was provided for each treated case; all relevant data regarding implantation and follow-up were entered into the form, mailed to a coordinating center (G. Chevillon, B. Braun Medical, France) and stored in a software database for statistical analysis.

Results

50 patients (from 6 participating centers) were included in this study. No major complications occurred at insertion. The most frequent clinical problem during follow-up was inability to draw blood samples (9% during the first chemotherapy cycle; 8% after the second cycle); blood obtained from the device was defined “unsuitable for hematology test” in 9% of the cases at first chemotherapy cycle and in 23% of the cases after the second cycle. No catheter obstruction occurred.

Conclusion

The distally valved catheter port tested in this study was reliable, safe and practical for long-term treatment of an oncology patients’ population undergoing chemotherapy. As most other reports and clinical trials dealing with other types of distally valved catheters pointed out, inability to draw viable blood samples (so called withdrawal occlusion) is a major concern in their clinical use. Mechanisms underlying this technical problem are still unclear.

Hereditary diffuse gastric cancer in two families: A case report

Hereditary diffuse gastric cancer (HDGC) is associated with E-cadherin 1 (CDH1) germline mutations. In the present study, two unusual HDGC cases are described. Case 1 was a female with no family history of gastric cancer who developed Hodgkin's lymphoma at 19 years of age, and DGC at 32 years of age. Due to her young age (32 years), the patient was examined for CDH1 abnormalities and a deleterious mutation was identified. Her father and younger sister were identified to be carriers of the mutation. Case 2 was a 36-year-old female diagnosed with lobular breast cancer (LBC); her mother had LBC, and her grandmother had LBC and DGC. The molecular test was wild-type for breast cancer susceptibility genes 1 and 2; however, a large deletion in CDH1 was identified. At prophylactic gastrectomy, early DGC was identified. Early onset of DGC and LBC justifies testing for CDH1. A better knowledge of tumor natural history in carrier subjects is important to aid genetic counseling, in order to assess the surveillance time required prior to carrying out prophylactic surgery.

Impact of home enteral nutrition in malnourished patients with upper gastrointestinal cancer: A multicentre randomised clinical trial

BACKGROUND

Weight loss is frequent in patients with gastrointestinal (GI) cancer. Nutritional status deteriorates throughout anti-cancer treatment, mostly after major surgery, increasing complications, reducing tolerance and worsening the final prognosis. Enteral nutrition is safe and effective in malnourished patients undergoing major GI surgery. Randomised trials aimed at investigating the effects of home enteral nutrition (HEN) in post-surgical patients with GI cancer are lacking. This study compares HEN and counselling in limiting weight loss during oncologic treatment.

PATIENTS AND METHODS

Patients with upper GI cancer and candidate to major surgery were included in the protocol when the nutritional risk screening (NRS 2002) score was ≥3. All patients were supported with enteral nutrition through a jejunostomy after surgery and randomly assigned to continue enteral nutrition or receiving nutritional counselling after discharge. Nutritional and performance status, quality of life (QoL) and tolerance to cancer treatment have been evaluated at 2 and 6 months after discharge.

RESULTS

Seventy-nine patients were randomised; 38 continued enteral nutrition at home and 41 patients received nutritional counselling only. After 2 months, patients on HEN maintained their mean body weight, while patients in the nutritional counselling group showed a weight loss of 3.6 kg. Patients supported on HEN had a higher chance to complete chemotherapy as planned (48% versus 34%). QoL was not worsened by HEN. No complications were reported.

CONCLUSIONS

HEN is a simple and feasible treatment to support malnourished patients with upper GI cancer after major surgery and during chemotherapy in order to limit further weight loss.

Sclerosing angiomatoid nodular transformation of the spleen during pregnancy: Diagnostic challenges and clinical management

We report the first case of sclerosing angiomatoid nodular transformation (SANT) of the spleen diagnosed during pregnancy, discussing differential diagnosis, immunohistochemical profile and treatment. A G2P1 37-year-old woman presented during the 19th week of gestation because of pruritus at lower limbs. To exclude cholestasis, an abdominal ultrasound and whole body magnetic resonance were performed and a single solid lesion with intrinsic vascularization was identified. Therefore, at 22 weeks gestation, after normal fetal assessment, the patient was referred for a splenectomy. No further treatment was suggested and the patient gave birth at 42 weeks gestation with a spontaneous delivery. Distinguishing SANT from other vascular neoplasms of the spleen during pregnancy is a difficult task. Surgical excision should be performed to exclude malignancy and to resolve symptoms, if present.

Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis

BACKGROUND

In recent decades there has been an increasing trend toward sphincter-preserving procedures for the treatment of low rectal cancer. Robotic surgery is considered to be particularly beneficial when operating in the deep pelvis, where laparoscopy presents technical limitations. The aim of this study was to prospectively evaluate the functional outcomes in patients affected by rectal cancer after robotic total intersphincteric resection (ISR) with hand-sewn coloanal anastomosis.

METHODS AND PROCEDURES

From March 2008 to October 2012, 23 consecutive patients affected by distal rectal adenocarcinoma underwent robotic ISR. Operative, clinical, pathological and functional data regarding continence or presence of a low anterior resection syndrome (LARS) were prospectively collected in a database.

RESULTS

Twenty-three consecutive patients were included in the study: 8 men and 15 women. The mean age was 60.2 years (range 28-73). Eighteen (78.3%) had neoadjuvant radiochemotherapy. Conversion rate was nil. The mean operative time was 296.01 min and the mean postoperative hospital stay was 7.43 ± 1.73 days. According to Kirwan's incontinence score, good fecal continence was shown in 85.7% of patients (Grade 1 and 2) and none required a colostomy (Grade 4). Concerning LARS score, the results were as follows: 57.1% patients had no LARS; 19% minor LARS and 23.8% major LARS.

CONCLUSIONS

Robotic total ISR for low rectal cancer is an acceptable alternative to traditional procedures. Extensive discussion with the patient about the risk of poor functional outcomes or LARS syndrome is mandatory when considering an ISR for treatment of low rectal cancer.

Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition three-dimensional vision, it translates the surgeon’s hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors’ centre.

Surgical management of duodenal stump fistula after elective gastrectomy for malignancy: an Italian retrospective multicenter study

BACKGROUND

Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome.

METHODS

We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics.

RESULTS

The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7-10.6, P < 0.001). The indication for first DSF surgery was intra-abdominal sepsis; the failure rate was over 30%, associated with the appearance of fistulas of neighboring organs, bleeding, and the need for reoperations. The mortality rate was 28% and was related to the presence of vascular disease (P = 0.04), more than one reoperation (P = 0.05), sepsis (P < 0.001), and renal failure (P < 0.001). Fifty-four patients recovered after a median of 39 days (interquartile range 22-68 days); the need to perform more reoperations (P < 0.01) and the presence of an abdominal abscess (P < 0.01) led to an increase in healing time.

CONCLUSIONS

Surgery for DSF has a poor prognosis. Our data will help to identify patients at risk of death, but unfortunately could not establish the best surgical procedure applicable to all cases of DSF.

Inactivity of imatinib in gastrointestinal stromal tumors (GISTs) harboring a KIT activation-loop domain mutation (exon 17 mutation pN822K)

The development of gastrointestinal stromal tumors (GISTs) is largely driven by mutations in the KIT and PDGFRα genes. Imatinib mesylate is an oral small molecular tyrosine kinase inhibitor that mainly targets abl, c-KIT, and PDGFRα. Imatinib achieves disease control in approximately 70%–85% of patients with advanced GIST, and the median progression-free survival is 20–24 months. The efficacy of imatinib correlates with tumor kinase mutational status (exon 11 mutations mainly), and some mutations are known to be responsible for primary and secondary imatinib resistance. Beyond these, there are many other mutations that are considered rare and are associated with unknown clinical behavior. In the literature, there are poor and inconsistent data about the inhibitor sensitivity of mutations occurring in the activation-loop domain encoded by exon 17. In this article, we focus on a case of a patient suffering from GIST, harboring an extremely rare KIT activation-loop domain mutation (exon 17 mutation pN822K) treated with imatinib. A review of the literature is also presented.

E-cadherin germline mutation carriers: clinical management and genetic implications

Hereditary diffuse gastric cancer is an autosomic dominant syndrome associated with E-cadherin protein (CDH1) gene germline mutations. Clinical criteria for genetic screening were revised in 2010 by the International Gastric Cancer Linkage Consortium at the Cambridge meeting. About 40 % of families fulfilling clinical criteria for this inherited disease present deleterious CDH1 germline mutations. Lobular breast cancer is a neoplastic condition associated with hereditary diffuse gastric cancer syndrome. E-cadherin constitutional mutations have been described in both settings, in gastric and breast cancers. The management of CDH1 asymptomatic mutation carriers requires a multidisciplinary approach; the only life-saving procedure is the prophylactic total gastrectomy after thorough genetic counselling. Several prophylactic gastrectomies have been performed to date; conversely, no prophylactic mastectomies have been described in CDH1 mutant carriers. However, the recent discovery of novel germline alterations in pedigree clustering only for lobular breast cancer opens up a new debate in the management of these individuals. In this critical review, we describe the clinical management of CDH1 germline mutant carriers providing specific recommendations for genetic counselling, clinical criteria, surveillance and/ or prophylactic surgery.

The Impact of pelvimetry on anastomotic leakage in a consecutive series of open, laparoscopic and robotic low anterior resections with total mesorectal excision for rectal cancer

BACKGROUND/AIMS

Recently, pelvic anatomy has been taken into consideration and related to surgical outcome indicators after low anterior resection (LAR). Several pelvimetric parameters have been matched with conversion rate, postoperative complications and duration of surgery in laparoscopic series, and with the quality of specimen and pathologic outcomes in further open surgical series.

METHODOLOGY

In 97 consecutive patients submitted to sphincter-saving LAR with total mesorectal excision (TME) five pelvic dimensions were measured by abdominal computed tomography scan: anteroposterior and transverse diameters in the pelvic inlet (IAP and ITRA), anteroposterior and transverse diameters in the pelvic outlet (OAP and OTRA), and the pelvic depth. The endpoint evaluated was anastomotic leakage (AL) rate.

RESULTS

There were 51 open, 12 laparoscopic and 34 robotic LARs. The sum of IAP OAP and OTRA (Pelvic Index) significantly predicted AL showing that starting from the cut-point of 290 mm down to a PI of 278 mm the odds-ratio of having an AL increased from 2.63 (95% CI: 1.10,5.47) to 5.07 (95% CI: 1.35,8.02).

CONCLUSIONS

The sum of the 3 pelvic dimensions which we termed “Pelvic Index” was associated to AL following sphinctersaving LAR. This may be considered in planning the surgical strategy for rectal cancer patients.

Cost effectiveness of different central venous approaches for port placement and use in adult oncology patients: evidence from a randomized three-arm trial

BACKGROUND

No randomized trials have so far investigated the cost effectiveness of different methods for implantation and use of central venous ports in oncology patients.

PATIENTS AND METHODS

Overall, 403 patients eligible for receiving intravenous chemotherapy for solid tumours were randomly assigned to implantation of a single type of port, either through a percutaneous landmark access to the internal jugular vein, an ultrasound (US)-guided access to the subclavian vein, or a surgical cut-down access through the cephalic vein at the deltoid-pectoralis groove. Insertion and maintenance costs were estimated by obtaining the charges for an average implant and use, while the costs of the management of complications were analytically assessed. The total cost was defined as the purchase cost plus the insertion cost plus the maintenance cost plus the cost of treatment of the complications, if any.

RESULTS

A total of 401 patients were evaluable-132 with the internal jugular vein, 136 with the subclavian vein and 133 with the cephalic vein access. No differences were found for the rate of early complications. The US-guided subclavian insertion site had significantly lower failures. Infections occurred in 1, 3, and 3 patients (internal jugular, subclavian, and cephalic access, respectively; p = 0.464), whereas venous thrombosis was observed in 15, 8, and 11 patients, respectively (p = 0.272). Mean cost for purchase, implantation, diagnosis and treatment of complications in each patient was <euro>2,167.85 for subclavian US-guided, <euro>2,335.87 for cephalic, and <euro>2,384.10 for internal jugular access, respectively (p = 0.0001).

CONCLUSION

US real-time guidance to the subclavian vein resulted in the most cost-effective method of central venous port placement and use.

Laparoscopic and robotic total mesorectal excision in the treatment of rectal cancer. Brief review and personal remarks

The current standard treatment for rectal cancer is based on a multimodality approach with preoperative radiochemotherapy in advanced cases and complete surgical removal through total mesorectal excision (TME). The most frequent surgical approach is traditional open surgery, as laparoscopic TME requires high technical skill, a long learning curve, and is not widespread, still being confined to centers with great experience in minimally invasive techniques. Nevertheless, in several studies, the laparoscopic approach, when compared to open surgery, has shown some better short-term clinical outcomes and at least comparable oncologic results. Robotic surgery for the treatment of rectal cancer is an emerging technique, which could overcome some of the technical difficulties posed by standard laparoscopy, but evidence from the literature regarding its oncologic safety and clinical outcomes is still lacking. This brief review analyses the current status of minimally invasive surgery for rectal cancer therapy, focusing on oncologic safety and the new robotic approach.

Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes

BACKGROUND

Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce.

METHODS

The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared.

RESULTS

There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024).

CONCLUSION

RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.

The role of the robotic technique in minimally invasive surgery in rectal cancer

Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors’ centre.

ERCC1 predicts outcome in patients with gastric cancer treated with adjuvant cisplatin-based chemotherapy

BACKGROUND

Adjuvant chemotherapy is gaining an increasing role in resectable gastric cancer. Customizing chemotherapy on the basis of chemosensitivity may improve outcome, and putative predictive molecular markers have been mostly evaluated in Asian patients. We profiled key DNA and damage signaling factors and correlated them with outcome, in a European cohort.

METHODS

Formalin-fixed tumor samples obtained from surgical specimens of patients treated with adjuvant cisplatin-based chemotherapy for gastric cancer were analyzed. Immunohistochemistry (IHC) was performed to analyze excision repair cross-complementing gene 1 (ERCC1) and thymidylate synthase (TS) expression, and p53 mutations were detected with direct sequencing.

RESULTS

Among the 68 patient recruited, the median age was 69 (range 30-74), and UICC stage was III in 44 patients (65 %). With a median follow-up of 40.5 months, disease-free and overall survival were 18.0 (95 % CI 13.4-22.76) and 56 months (95 % CI 44.87-67.13), respectively. ERCC1 score was 0 in 14 out 67 (21 %) cases, 1 in 19 (28 %), 2 in 20 (30 %) and 3 in 14 cases (21 %). Longer overall survival (p = 0.04) was found in patients categorized as ERCC1 negative by IHC according to median score. TS score was 0 in 16 out 67 (24 %) cases, 1 in 27 (40 %), 2 in 16 (24 %) and 3 in 8 cases (12 %). Mutations of p53 were found in 21 out 66 (32 %) cases. Neither TS nor p53 were found to correlate with outcome.

CONCLUSION

Excision repair cross-complementing gene 1 by IHC might predict patients more likely to benefit from adjuvant cisplatin-based chemotherapy in curatively resected gastric cancer. In patients exhibiting ERCC1 positive tumors, alternative regimens should be evaluated.

Factors predicting worse prognosis in patients affected by pT3 N0 colon cancer: long-term results of a monocentric series of 137 radically resected patients in a 5-year period

BACKGROUND AND PURPOSE

For patients with Stage II colon cancer, the use of adjuvant chemotherapy remains controversial. The purpose of this study was to identify clinical and/or pathological findings related to a worse prognosis in this category of patients.

PATIENTS AND METHODS

We retrospectively analyzed the data of consecutive patients, extracted by an institutional Tumour Registry, admitted to an affiliated University Hospital in Milan (European Institute of Oncology) for adenocarcinoma of the colon (all sites), between 2000 and 2005, and having a final pT3 N0 pathology staging after curative surgery. Adjuvant chemotherapy was decided as a result of a medical decision within a multidisciplinary Tumor Board.

RESULTS

Data of 137 patients were obtained, with a median follow-up of 77 months (range 6-131). Patients who received chemotherapy were younger than patients who did not. Nine patients out of 137 (6.5 %) died as a consequence of colon cancer recurrence; four of them had received adjuvant chemotherapy. Only histological grade III and mucinous histotype were found to impact on cumulative incidence of colon-related events (p 0.03 and 0.02, respectively); no impact was found on cumulative incidence of colonic neoplasm recurrence-related deaths (p 0.74 and 0.74, respectively). Number of analyzed LNs (lymph nodes) emerged as a factor possibly affecting the cumulative incidence of colon-related events (p 0.09) as well as the cumulative incidence of colonic neoplasm recurrence-related deaths (p 0.10). The risk of events was inversely proportional to the number of dissected LNs, even over 20 up to about 25 LNs. Never-smokers exhibited a lower incidence of colon-related events, although the difference was not statistically significant (p 0.09). All other analyzed variables did not show any impact on survival rate, including age, gender, ASA score, BMI, site of colonic neoplasm, multifocality, perivascular invasion, and use of adjuvant chemotherapy.

CONCLUSIONS

Histology grading G3 and mucinous histotype were predictors of worse outcome. Efforts to improve LN evaluation should result in clinically significant improvements in outcome, and also the quality of care for patients with radically resected stage II colon cancer.

The nutritional risk in oncology: a study of 1,453 cancer outpatients

PURPOSE

There is little information about the nutritional status of cancer outpatients because the practice of nutritional screening is rarely performed. This study aims to define the pattern of scores of nutritional risk in 1,453 outpatients and factors associated with a high nutrition risk score, to facilitate the identification of such patients by the oncologists.

METHODS

We prospectively screened the nutritional status of cancer outpatients according to the NRS-2002 score which combines indicators of malnutrition and of severity of the disease (1-3 points, respectively). A score ≥ 3 indicates "nutritional risk". The association of the nutritional scores with some patient/tumour/therapy-related variables was investigated through univariable and multivariable linear regression models.

RESULTS

Thirty-two percent of outpatients were at nutritional risk. Primary tumour site, Eastern Cooperative Oncology Group score and presence of anorexia or fatigue were significantly associated with the nutrition risk score. Depending on the combination of these variables, it was possible to estimate different probabilities of nutritional risk.

CONCLUSIONS

The frequency of a relevant nutritional risk was higher than expected considering the favourably selected population. The nutritional risk was associated with common clinical variables which are usually recorded in the charts and could easily alert the oncologist on the need of a further nutritional assessment or a nutritional support.

Catheter rupture and distal embolisation: a rare complication of central venous ports

Central venous access devices placed through a percutaneous subclavian approach may be compressed by neighbouring bony structures, leading to biomaterial fatigue, catheter fracture at the compression site, and possible embolisation of distal fragment into the central veins. The aim of this paper is to review the experience of the authors, including more than 1300 subclavian port placements, carried out during a five-year period, discussing possible causes and therapeutic options of this rare complication. Nine patients out of 1320 (0.68%) experienced this complication during the five-year period of this study. Two patients only showed a retrospective radiologic evidence of the 'pinch-off sign' (e.g. initial compression of the catheter at the costo-clavicular junction). No patients had symptoms from the embolised catheter fragment; the most frequent symptom (8 out of 9 cases) was a painful swelling around the port area during infusion, related to the extravasation of medications or fluids into the subcutaneous tissue. The site of embolised segment varied from azygos vein to right pulmonary artery; however, these findings did not affect the outcome, and all the embolised fragments were successfully retrieved through a transfemoral approach using a radiologic interventional technique. No fatality occurred. The catheter fracture and embolisation of the distal fragment are a well-known complication of subclavian central venous long-term cannulation, whose estimated overall incidence is 0.5-1%. Diagnosis is usually based on the radiologic appearance of the catheter compression (so called 'pinch-off sign'), which is far from being constant; a clinical suspicion can derive from intermittent malfunction, which claims differential diagnosis with the pres-ence of a fibrin sleeve around the tip of the catheter. Once diagnosed, the treatment is always an interventional radiologic approach, which has a very high success rate. When it fails, the possibility to leave the fragment embolised in the central veins, heart or pulmonary arteries, should be considered, being the thoracotomy and open catheter retraction questionable, at present time, in patients who have no symptoms and limited life-expectancy.