Combined preoperative endoscopic and laparoscopic ultrasonography for prediction of R0 resection in upper gastrointestinal tract cancer

Pretreatment predictive value of blood neutrophil/lymphocyte ratio in R0 gastric cancer resectability

INTRODUCTION

New parameters complementary to clinical TNM classification are needed, to orient preoperative on the possibility of a R0 gastric cancer resection. We analysed the possible predictive value of blood neutrophil/lymphocytic ratio (N/L) in relation to resectability.

METHODS

Two hundred and fifty-seven gastric cancers consecutively diagnosed and without neoadjuvant treatment were retrospectively studied. Univariate and multivariate analysis of the frequency of R0 cases was performed between groups with a normal N/L ratio (<5) and pathological N/L ratio (≥5). Furthermore, we studied the subgroup of operated patients (n=156) analysing the frequency of R0 resection according to N/L ratio<5 or≥5.

RESULTS

One hundred and fifty-six patients underwent surgical intervention, of which 139 had R0 resections. A high N/L ratio was registered in 46 cases (17.9%). Globally, resectability was higher in patients with a N/L ratio<5: 59.7% vs. N/L ratio≥5: 28.6% (P<.001; OR=3.76; 95% CI=1.78-8.04). The relation between N/L ratio<5 and R0 resection was confirmed in the multivariate (P=.006; OR=3.86; 95% CI=1.46-10.22). In the operated subgroup, the higher frequency of R0 resection achievement is maintained in cases with N/L ratio<5: 91.3% vs. 72.2% (P=.015; OR=4.04; 95% CI=1.23-13.26).

CONCLUSIONS

The presence of a N/L ratio<5 at the diagnosis of a gastric carcinoma is related in a significant and independent way with a higher frequency of R0 tumoral resection, globally. This higher proportion of R0 resection cases in patients with a N/L<5 ratio is confirmed in the subgroup of operated patients.

Esophageal cancer management: preoperative CA19.9 and CEA serum levels may identify occult advanced adenocarcinoma

BACKGROUND

Esophagectomy is contraindicated in case of advanced cancer (i.e., carcinomatosis, distant metastasis, and invasion of other organs). In some cases, preoperative imaging may fail to identify advanced neoplasm and esophagectomy is inappropriately planned. The aim of the study was to identify preoperative biomarkers of occult advanced disease that force surgeons to abort the planned esophagectomy.

METHODS

From 2008 to 2014, 244 consecutive patients were taken to the operative room to have esophagectomy for cancer in our department. All of them had blood test at admission and their preoperative biomarker data were retrieved. Their medical history was collected and the intraoperative findings and outcome were recorded. Non parametric tests, multiple regression analysis, and ROC curves analysis were performed.

RESULTS

In our study group, 14 (5.7 %) patients, scheduled for esophagectomy, were discovered to have occult advanced disease at laparotomy/laparoscopy or at thoracotomy. Six of them had peritoneal carcinomatosis, three had advanced tumor invading other organs, three had small liver metastasis, and two pleural carcinomatosis. In all these cases, esophagectomy was aborted and a feeding jejunostomy was placed. In patients with unresectable esophageal cancer, CA19.9 and CEA serum levels were significantly higher than patients who could have esophagectomy (p < 0.001 and p = 0.003, respectively). CA19.9 and CEA resulted to be accurate biomarkers of occult advanced disease (AUC = 85 %, p < 0.001 and AUC = 73 %, p = 0.002, respectively).

CONCLUSIONS

Preoperative CEA and CA19.9 serum levels should be taken in consideration when evaluating patients candidate to esophagectomy for esophageal cancer to prevent inappropriate laparotomy or thoracotomy. If any doubt arises minimally invasive exploration is warranted.

Current and future intraoperative imaging strategies to increase radical resection rates in pancreatic cancer surgery

Prognosis of patients with pancreatic cancer is poor. Even the small minority that undergoes resection with curative intent has low 5-year survival rates. This may partly be explained by the high number of irradical resections, which results in local recurrence and impaired overall survival. Currently, ultrasonography is used during surgery for resectability assessment and frozen-section analysis is used for assessment of resection margins in order to decrease the number of irradical resections. The introduction of minimal invasive techniques in pancreatic surgery has deprived surgeons from direct tactile information. To improve intraoperative assessment of pancreatic tumor extension, enhanced or novel intraoperative imaging technologies accurately visualizing and delineating cancer cells are necessary. Emerging modalities are intraoperative near-infrared fluorescence imaging and freehand nuclear imaging using tumor-specific targeted contrast agents. In this review, we performed a meta-analysis of the literature on laparoscopic ultrasonography and we summarized and discussed current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery.

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

Surgical management of gastric cancer: review and consideration for total care of the gastric cancer patient

Surgical therapy remains the most effective modality in the treatment of gastric cancer. Staging laparoscopy with laparoscopic ultrasound may increase the accuracy of staging and prevent patients with unresectable gastric cancer from undergoing unnecessary operations. Resection of proximal and distal gastric cancer is best accomplished with an appropriate gastrectomy that ensures adequate resection margins. A D2 lymphadenectomy can be performed safely and facilitates the resection of the minimum 15 lymph nodes required for adequate staging. Adjacent organ resection should be used only in highly selected patients with R0 resection as the goal. Palliative operations offer improved quality of life and symptom relief in patients with metastatic disease. Appreciation of postoperative quality of life after gastric resection facilitates appropriate and effective preoperative counseling. Surgical outcomes may be influenced by hospital volume and rate of adequate lymph node assessment.

Combined pretherapeutic endoscopic and laparoscopic ultrasonography may predict survival of patients with upper gastrointestinal tract cancer

BACKGROUND

The combination of endoscopic and laparoscopic ultrasonography (EUS-LUS) is accurate for resectability assessment of patients with upper gastrointestinal cancer (UGIC). But neither the ability of EUS/LUS to predict long-term prognosis nor the potential impact on patient survival using this selection strategy has been investigated. This prospective, single-center study evaluated whether pretherapeutic EUS-LUS stratification related to the prognosis in UGIC patients and whether patient selection by this strategy provided a prognostic outcome comparable with survival data from the literature.

METHODS

Each patient had a pretherapeutic tumor node metastasis (TNM) stage and a resectability assessment assigned based on EUS-LUS findings. Survival curves were constructed and compared for each of the EUS-LUS TNM stage and resectability groups at the end of the observation period. Finally, the R0 resection rate, median, and 5-year survival rates were compared with the literature.

RESULTS

This study enrolled 936 consecutive patients with esophageal (n = 256), gastric (n = 273), or pancreatic (n = 407) cancer. A statistically significant survival difference (p < 0.01) between the different TNM stages and resectability groups predicted by EUS-LUS was observed regardless of the cancer type. The poor prognosis for the patients with irresectable or disseminated UGIC was accurately predicted by EUS and LUS. The R0 resection rate as well as the median and 5-year survival rates were comparable with data from the literature.

CONCLUSION

The pretherapeutic EUS-LUS patient stratification related significantly to the final prognosis for UGIC patients. An EUS-LUS-based patient selection strategy seemed to provide a prognostic outcome similar to data from computed tomography (CT)-based populations.

Ecoendoscopia na avaliação pré-operatória do estádio em doentes com câncer gástrico: correlação com os achados cirúrgicos e/ou histopatológicos

RACIONAL: O câncer gástrico é a maior causa de morte por câncer no Brasil. Na avaliação do prognóstico e no planejamento da terapêutica, é importante determinar o estádio e classificá-lo em TNM. OBJETIVO: Estudar os resultados da ecoendoscopia na determinação pré-operatória das categorias T e N. MÉTODOS: Foram examinados prospectivamente e de forma consecutiva 30 pacientes com adenocarcinoma gástrico no período de 1 ano. Utilizou-se o aparelho Olympus GIF-UM-20. Após seu posicionamento na terceira porção duodenal, estudaram-se as estações linfonodais 16, 13, 12, 6, 5, 4, 3, 8, 7, 9, 10, 11, 1 e 2, usando a freqüência de 7,5 MHz. Os resultados T e N foram comparados com os achados cirúrgicos e/ou histopatológicos. Nos casos irressecáveis, a correlação foi feita com os achados macroscópicos. Para a análise estatística utilizou-se o teste de correlação coeficiente kappa. RESULTADOS: Foram realizadas 16 gastrectomias totais, 7 subtotais, 5 laparotomias exploradoras e 2 videolaparoscopias. Para a categoria T a ecoendoscopia acertou em 25/30 casos (83,3%). Todos os restantes 16,7% foram superestimados. A precisão variou de 90% a 96,7%, de acordo com as subdivisões T1 a T4. Para a categoria N, a ecoendoscopia foi correta em 23/30 casos (76,7%), sendo 16,6% subestimados e 6,7% superestimados. A precisão variou de 76,7% a 90%, de acordo com as subdivisões N0 a N2. CONCLUSÃO: Houve nítida correlação entre a ecoendoscopia pré-operatória e os achados cirúrgicos e/ou histopatológicos em pacientes com adenocarcinoma gástrico.

Staging laparoscopy for advanced gastric cancer: is it also useful for the group which has an aggressive surgical strategy?

BACKGROUND

Staging laparoscopy has been shown to be useful for increasing the accuracy of preoperative staging. However, controversy still exists regarding patient selection and subsequent treatment. The aim of this study was to determine the role of staging laparoscopy for a group that has a policy to perform aggressive surgery for advanced gastric cancer.

METHODS

Twenty-four patients with clinical T3 or T4 gastric cancer expected to undergo curative resection, based on conventional preoperative diagnostic methods underwent staging laparoscopy. We examined the accuracy and the impact of staging laparoscopy on the further treatment options.

RESULTS

The mean running time for the staging laparoscopy was 40.7 min (range: 25-75 min), and one complication was noted (4.2%). In regard to the tumor depth, 11 of 24 (45.8%) cases had a discrepancy after staging laparoscopy. In addition, 15 of 24 patients (62.5%) were found to have unsuspected peritoneal metastases, and 8 patients (33.3%) were excluded from laparotomy. The remaining 16 patients (66.7%), including 9 patients with localized peritoneal metastases (P1), underwent resection. The diagnostic accuracy for T factor was 81.3% in 16 laparotomy cases and overall accuracy of P factor was 91.7%.

CONCLUSIONS

Staging laparoscopy had a significant impact on decisions regarding the treatment plan in patients with advanced gastric cancer for a group that has an aggressive treatment strategy.