Lack of survival advantage among re-resected elderly glioblastoma patients: a SEER-Medicare study

BACKGROUND

The survival benefit of re-resection for glioblastoma (GBM) remains controversial, owing to the immortal time bias inadequately considered in many studies where re-resection was treated as a fixed, rather than a time-dependent factor. Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we assessed treatment patterns for older adults and evaluated the association between re-resection and overall survival (OS), accounting for the timing of re-resection.

METHODS

This retrospective cohort study included elderly patients (age ≥66) in the SEER-Medicare linked database diagnosed with GBM between 2006 and 2015 who underwent initial resection. Time-dependent Cox regression was used to assess the association between re-resection and OS, controlling for age, gender, race, poverty level, geographic region, marital status, comorbidities, receipt of radiation + temozolomide, and surgical complications.

RESULTS

Our analysis included 3604 patients with median age 74 (range: 66-96); 54% were men and 94% were white. After initial resection, 44% received radiation + temozolomide and these patients had a lower hazard of death (hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.26-0.31, P < .001). In total, 9.5% (n = 343) underwent re-resection. In multivariable analyses, no survival benefit was seen for patients who underwent re-resection (HR: 1.12, 95% CI: 0.99-1.27, P = .07).

CONCLUSIONS

Re-resection rates were low among elderly GBM patients, and no survival advantage was observed for patients who underwent re-resection. However, patients who received standard of care at initial diagnosis had a lower risk of death. Older adults benefit from receiving radiation + temozolomide after initial resection, and future studies should assess the relationship between re-resection and OS taking the time of re-resection into account.

Surgical management of recurrent intrahepatic cholangiocarcinoma: predictors, adjuvant chemotherapy, and surgical therapy for recurrence: A multi-institutional study by the Kyushu Study Group of Liver Surgery

Objectives of the present study were to identify predictors of the recurrence of intrahepatic cholangiocarcinoma (ICC), and to evaluate the survival benefit of adjuvant chemotherapy and surgical treatment for ICC recurrence. A multi‐institutional retrospective study was carried out in 356 patients with ICC who underwent curative surgery at one of 14 institutions belonging to the Kyushu Study Group of Liver Surgery. A total of 214 patients (60%) had recurrence. Predictors of ICC recurrence were as follows: positive for pathological intrahepatic metastasis (im), positive for lymph node metastasis (n), positive for pathological lymphatic infiltration (ly), pathological bile duct invasion (b), and tumor size ≥4.4 cm. Adjuvant chemotherapy was given to 120 patients (34%) and, in the patients with im or tumor size ≥4.4 cm, adjuvant chemotherapy showed a survival benefit. Only 37 patients (17%) underwent surgical treatment for ICC recurrence. The surgical treatment resulted in a good 5‐year survival rate (44%), which is similar to the rate obtained by the first operation for primary ICC. Prognosis of patients with primary im after the second operation was significantly worse (5‐year survival 18%) compared to patients without primary im. Primary im+ should be considered a contraindication for surgical treatment for ICC recurrence.

Review of 103 Cases of Laparoscopic Repeat Liver Resection for Recurrent Hepatocellular Carcinoma

INTRODUCTION

Laparoscopic repeat liver resection (LRLR) has been shown in small retrospective studies to be a safe and effective treatment for recurrent hepatocellular carcinoma (rHCC) in selected patients. The aim of this study was to perform a systematic review of the current literature to determine the safety, feasibility, and oncologic integrity of LRLR for rHCC.

METHODS

A computerized search of the PubMed database was performed for all English language studies evaluating LRLR for HCC from January 1, 2005 to March 31, 2016.

RESULTS

Ten studies reporting on 103 patients were included in this review. 30/51 (58.5%) patients had liver cirrhosis. In 66/95 (69.5%) patients, the index surgery was an open resection and this was a major hepatectomy in 8/49 (16.3%) patients. In 17/72 (23.6%) patients, LRLR was performed for tumors in the posterosuperior segments and in 21/60 (35%) for ipsilateral HCC recurrence. The median tumor size of rHCC ranged from 17-40 mm and 8/69 (11.6%) LRLR were for multifocal rHCC. In 100/103 (97%) patients LRLR was attempted via pure laparoscopy and 2 (1.9%) required open conversion. Median operation time of LRLR ranged from 73-343 minutes and the median blood loss ranged from 50 to 297 mL. The reported postoperative morbidity was 24/97 (24.7%) and there was no postoperative mortality. The median postoperative length of stay ranged from 3.5 to 11 days. Three studies compared the outcomes of LRLR versus open resection for rHCC and all three demonstrated a significant decrease in blood loss in favor of LRLR.

CONCLUSION

In highly selected patients; LRLR for rHCC is feasible and safe. LRLR can be performed for patients with previous open LR, previous major hepatectomy, two previous LR, multiple tumors, liver cirrhosis, ipsilateral HCC recurrence, and cancers located in the difficult posterosuperior segments. Comparative studies have demonstrated that LRLR is superior to open repeat liver resection in terms of perioperative outcomes such as decreased blood loss and length of stay.

Repeat liver resection after a hepatic or extended hepatic trisectionectomy for colorectal liver metastasis

OBJECTIVE

A right and left hepatic trisectionectomy and an extended trisectionectomy are the largest liver resections performed for malignancy. This report analyses a series of 23 patients who had at least one repeat resection after a hepatic trisectionectomy for colorectal liver metastasis (CRLM).

METHODS

A retrospective analysis of a single-centre prospective liver resection database from May 1996 to April 2009 was used for patient identification. Full notes, radiology and patient reviews were analysed for a variety of factors with respect to survival.

RESULTS

Twenty-three patients underwent up to 3 repeat hepatic resections after 20 right and 3 left hepatic trisectionectomies. In 18 patients the initial surgery was an extended trisectionectomy. Overall 1-, 3- and 5-year survival rates after a repeat resection were 100%, 46% and 32%, respectively. No factors predictive for survival were identified.

CONCLUSION

A repeat resection after a hepatic trisectionectomy for CRLM can offer extended survival and should be considered where appropriate.