Impact of positive resection margins (R1) on long-term survival of patients with advanced diffuse type gastric cancer

Objective

Gastric cancer (GC) is a leading cause of cancer-related mortality worldwide. Diffuse type GC have a much worse prognosis compared to intestinal type GC. There is an ongoing debate whether microscopic involvement of the proximal margin (R1 resection) influences overall survival (OS) in advanced gastric cancer.

The aim of this study was to assess OS in patients with diffuse gastric cancers and positive lymph node involvement who underwent oncological gastrectomy with R0 and R1 resections.

Methods

All consecutive patients from two tertiary centers operated with curative intent for diffuse gastric cancer between January 2005 and December 2018 were analyzed. Patients with R2 resections or missing data were excluded. Extracted data included demographics, major comorbidities, ASA score, neo-adjuvant treatment, pre- and postoperative staging (TNM 8th edition), postoperative complication with grading according to Clavien classification, survival data and pattern of recurrence. Lymph node involvement was based on pathology.

Kaplan-Meier curves with log-rank test for comparison were used to evaluate survival between groups.

Results

A total of 94 patients with diffuse gastric cancer were included. Two patients were excluded because of R2 resection and missing data regarding pathology, leaving a cohort of 92 patients (48 male, 44 female, median age 62 years). Sixty-four patients were lymph node positive (pN+); 48 patients (75%) with R0 resection and 16 patients (25%) with R1 resection. No difference in terms of preoperative data and intraoperative characteristics was found between R0 and R1 groups. Median OS was better in the R0 group (27 months, 95% CI 17–37) compared to R1 group (7 months, 95% CI 3–11, p<0.001). Similar results were found with disease-free survival (DSF) (25 vs. 6 months, p=0.002).

On multivariable analysis, T stage and resection margin (R status) were independent factors predicting OS (T stage: HR 4.5, p<0.001, R status: HR 4.2, p<0.001) and DFS (T stage: HR 2.9, p=0.004, R status: HR 3.5, p=0.001) in the cohort of patients with lymph node involvement.

Conclusion

The present series confirmed that patients with negative surgical margins have better OS compared to patients with positive margins in case of locally advanced diffuse GC. Therefore, R0 resections should be the goal of oncological gastrectomies.

Third-generation autofluorescence endoscopy for the detection of early neoplasia in Barrett's esophagus: a pilot study

In Barrett's esophagus (BE), second-generation autofluorescence imaging (AFI-II) improves targeted detection of high-grade intra-epithelial neoplasia (HGIN) and early cancer (EC), yet suffers from high false-positive (FP) rates. The newest generation AFI (AFI-III) specifically targets fluorescence in malignant cells and may therefore improve detection of early neoplasia and reduce FP rate. The aim was to compare AFI-III with AFI-II for endoscopic detection of early neoplasia in BE. BE patients with endoscopically inconspicuous neoplasia underwent two diagnostic endoscopies (AFI-II/AFI-III) in a single session. End-points: number of patients and lesions with HGIN/EC detected with AFI-II and AFI-III after white-light endoscopy (WLE) and the value of reinspection of AFI-positive areas with WLE and narrow-band imaging. Forty-five patients were included (38 males, age 65 years). Nineteen patients showed HGIN/EC. AFI-II inspection after WLE increased detection of HGIN/EC from 9 to 15 patients (47 to 79%); AFI-III increased detection from 9 to 17 patients (47 to 89%). WLE plus random biopsies diagnosed 13/19 (68%) HGIN/EC patients. One hundred and four abnormal AFI areas were inspected; 23 (22%) showed HGIN/EC. AFI-II increased detection of HGIN/EC from 10 to 18 lesions (43 to 78%). AFI-III increased detection from 10 to 20 lesions (43-87%). FP rate was 86% for AFI-II and AFI-III. Reinspection with WLE or narrow-band imaging reduced FP rate to 21% and 22%, respectively, but misclassified HGIN/EC lesions as unsuspicious in 54% and 31%, respectively. This first feasibility study on third-generation AFI again showed improved targeted detection of HGIN/EC in BE. However, the results do not suggest AFI-III performs significantly better than conventional AFI-II.

Radiotherapy combined with hyperthermia for primary malignant melanomas of the esophagus

Primary malignant melanoma of the esophagus (PMME) forms about 0.1% of all primary esophageal cancers. Treatment options are very limited for patients unfit for surgery. This is the first report describing the results of external radiotherapy combined with regional hyperthermia for two inoperable PMME patients. Two patients with a T2-3N0M0 PMME were considered unfit for surgery based on age and general condition. External radiotherapy of a total dose of 35 Gy was given in a scheme of seven times 5 Gy, two times per week, and once weekly combined with external and intraluminal hyperthermia (aim 43°C). Toxicity was mild and both patients completed treatment according to protocol. Adequate temperatures at the intraluminal border of the tumor were achieved. In both patients, a complete remission was achieved with complete relief of obstructive symptoms and without signs of locoregional tumor progression until the end of follow-up at 11 and 15 months. External radiation combined with regional hyperthermia could be a good alternative to resection in patients unfit for surgery with a malignant melanoma of the esophagus.

Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review

AIM

This systematic review was performed to answer the question whether hand-assisted laparoscopic surgery (HALS) can preserve the advantages of laparoscopic compared with open surgery in colorectal disease.

METHOD

Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment and data extraction were independently performed by two reviewers. Outcome criteria were operative time, number of trocars used, conversion rate, incision length, blood loss, time to passage of flatus, use of analgesia, postoperative morbidity, in-hospital mortality, length of hospital stay, number of lymph nodes and costs.

RESULTS

Out of 162 publications seven publications were selected for comprehensive review. Three randomized controlled trials (RCT) and four non-RCTs, comprising 571 patients, met the inclusion criteria. Because of heterogeneity, the data could not be pooled. The operative time was significantly longer in HALS in four of the seven studies (addition in median operative time of 13-81 min). The conversion rate varied from 0 to 10%. Two of the four reporting studies demonstrated a significantly shorter time to passage of flatus in HALS (averagely one day in advance). Length of hospital stay was significantly shorter in HALS in four of the seven studies (average gain between 2 and 4 days).

CONCLUSIONS

Hand-assisted laparoscopic surgery has the advantages of laparoscopic surgery over open surgery while reducing some of the disadvantages of laparoscopic surgery (shorter operative time, lower conversion rates). Especially for indications in which an incision to extract the resection specimen is required, HALS provides an excellent treatment option.

Preoperative chemoradiation combined with regional hyperthermia for patients with resectable esophageal cancer

PURPOSE

To analyse the treatment results of neo-adjuvant chemoradiation combined with regional hyperthermia in patients with resectable esophageal cancer.

PATIENTS AND METHODS

Between August 2003 and December 2004, 28 patients entered a phase II study combining chemoradiation over a 4.5-week period with five sessions of regional hyperthermia. Chemotherapy consisted of carboplatin (AUC = 2) and paclitaxel (50 mg/m(2)) and radiotherapy of 41.4 Gy in 1.8 Gy daily fractions. Locoregional hyperthermia was applied using the AMC phased array of four 70 MHz antennas, aiming at a stable tumor temperature of 41 degrees C for one hour. Carboplatin was infused during the hyperthermia session. Esophageal resection was planned at 6-8 weeks after the end of radiotherapy. The majority of the patients had a T3 tumor (86%) and were cN+ (64%). Median follow-up for survivors was 37 months (range 31-46).

RESULTS

Twenty-five patients (89%) completed the planned neo-adjuvant treatment and acute toxicity was generally mild. Twenty-six patients were operated on. A pathologically CR, PRmic, PR and SD were seen in 19%, 27%, 31% and 23% respectively. All patients had a R0 resection. In-field locoregional control during follow up for the operated patients was 100%. Quality of life was good for patients without disease progression. Survival rates at one, two and three years were 79%, 57% and 54% respectively.

CONCLUSION

Neo-adjuvant chemoradiation combined with regional hyperthermia followed by esophageal resection for patients with esophageal cancer resulted in good locoregional control and overall survival.

Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases

OBJECTIVE

The endo-sponge was used in two patients in the treatment of anastomotic leakage following ileo-anal J-pouch reconstruction. Recently, local vacuum sponge treatment has shown to be effective to treat contained anastomotic leakage after low anterior anastomosis in rectal cancer patients.

METHOD

Two patients (male, 18 years; female, 40 years) who underwent restorative proctocolectomy for ulcerative colitis developed localized anastomotic leakage without general peritonitis. This was endoscopically managed by transanal placement of an endo-sponge (B. Braun Medical B.V., Melsungen, Germany) after a diverting ileostomy was performed.

RESULTS

The sponge was frequently replaced until resolution of the sinus was achieved in 35 and 56 days.

CONCLUSION

Vacuum endo-sponge treatment can help anastomotic leakage after ileo-anal pouch surgery.

[Hospital experience and hospital mortality following partial pancreaticoduodenectomy in The Netherlands]

OBJECTIVE

To analyse the effect of hospital experience on mortality after subtotal pancreaticoduodenectomy in the Netherlands.

DESIGN

Retrospective evaluation.

METHOD

Information on hospital mortality and pancreatic resection in 1994 and 1995 in the Netherlands was obtained from the National Medical Register. Subanalysis was carried out of surgical mortality by age and hospital experience.

RESULTS

Approximately 50% of the pancreaticoduodenectomies in the Netherlands were performed in hospitals with limited experience (< 5 procedures per year). Hospital mortality was higher in small-volume hospitals than in hospitals with experience (> 25 procedures per year): in 1994 17.2 and 0% and in 1995 14.6 and 2.9%, respectively (p < 0.05). Mortality was higher in patients older than 70 years compared with patients younger than 55 (p < 0.05).

CONCLUSION

There was a correlation between mortality after pancreaticoduodenectomy and hospital experience. Therefore these procedures should be performed in centres with experience.