Showing papers in "Ejso in 2013"

The Dutch Surgical Colorectal Audit

Abstract: Introduction In 2009, the nationwide Dutch Surgical Colorectal Audit (DSCA) was initiated by the Association of Surgeons of the Netherlands (ASN) to monitor, evaluate and improve colorectal cancer care. The DSCA is currently widely used as a blueprint for the initiation of other audits, coordinated by the Dutch Institute for Clinical Auditing (DICA). This article illustrates key elements of the DSCA and results of three years of auditing. Methods Key elements include: a leading role of the professional association with integration of the audit in the national quality assurance policy; web-based registration by medical specialists; weekly updated online feedback to participants; annual external data verification with other data sources; improvement projects. Results In two years, all Dutch hospitals participated in the audit. Case-ascertainment was 92% in 2010 and 95% in 2011. External data verification by comparison with the Netherlands Cancer Registry (NCR) showed high concordance of data items. Within three years, guideline compliance for diagnostics, preoperative multidisciplinary meetings and standardised reporting increased; complication-, re-intervention and postoperative mortality rates decreased significantly. Discussion The success of the DSCA is the result of effective surgical collaboration. The leading role of the ASN in conducting the audit resulted in full participation of all colorectal surgeons in the Netherlands. By integrating the audit into the ASNs' quality assurance policy, it could be used to set national quality standards. Future challenges include reduction of administrative burden; expansion to a multidisciplinary registration; and addition of financial information and patient reported outcomes to the audit data.

Antitumor effectiveness of electrochemotherapy: A systematic review and meta-analysis

Abstract: Background This systematic review has two purposes: to consolidate the current knowledge about clinical effectiveness of electrochemotherapy, a highly effective local therapy for cutaneous and subcutaneous tumors; and to investigate the differences in effectiveness of electrochemotherapy with respect to tumor type, chemotherapeutic drug, and route of drug administration. Methods All necessary steps for a systematic review were applied: formulation of research question, systematic search of literature, study selection and data extraction using independent screening process, assessment of risk of bias, and statistical data analysis using two-sided common statistical methods and meta-analysis. Studies were eligible for the review if they provided data about effectiveness of single-session electrochemotherapy of cutaneous or subcutaneous tumors in various treatment conditions. Results In total, 44 studies involving 1894 tumors were included in the review. Data analysis confirmed that electrochemotherapy had significantly ( p p p = .028 for OR%). Bleomycin and cisplatin administered intratumorally resulted in equal effectiveness of electrochemotherapy. Electrochemotherapy was more effective in sarcoma than in melanoma or carcinoma tumors. Conclusions The results of this review shed new light on effectiveness of electrochemotherapy and can be used for prediction of tumor response to electrochemotherapy with respect to various treatment conditions and should be taken into account for further refinement of electrochemotherapy protocols.

Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: A French multicentre retrospective cohort study of 566 patients.

Abstract: Background Despite a high response rate to front-line therapy, prognosis of epithelial ovarian carcinoma (EOC) remains poor. Approaches that combine Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with this strategy. Patients and methods A retrospective cohort multicentric study from French centres was performed. All consecutive patients with advanced and recurrent EOC treated with CRS and HIPEC were included. Results The study included 566 patients from 13 centres who underwent 607 procedures between 1991 and 2010. There were 92 patients with advanced EOC (first-line treatment), and 474 patients with recurrent EOC. A complete cytoreductive surgery was performed in 74.9% of patients. Mortality and grades 3 to 4 morbidity rates were 0.8% and 31.3%, respectively. The median overall survivals were 35.4 months and 45.7 months for advanced and recurrent EOC, respectively. There was no significant difference in overall survival between patients with chemosensitive and with chemoresistant recurrence. Peritoneal Cancer Index (PCI) that evaluated disease extent was the strongest independent prognostic factor for overall and disease-free survival in all groups. Conclusion For advanced and recurrent EOC, curative therapeutic approach combining optimal CRS and HIPEC should be considered as it may achieve long-term survival in patients with a severe prognosis disease, even in patients with chemoresistant disease. PCI should be used for patient's selection.

Intraperitoneal chemotherapy in advanced gastric cancer. Meta-analysis of randomized trials

Abstract: Introduction An important component of treatment failure in gastric cancer (GC) is cancer dissemination within the peritoneal cavity and nodal metastasis. Intraperitoneal chemotherapy (IPC) is considered to give a fundamental contribute in treating advanced GC. The purpose of the study is to investigate the effects of IPC in patients with advanced GC. Material and methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of IPC + surgery vs. control in patients with advanced GC was performed. Results Twenty prospective RCTs have been included (2145 patients: 1152 into surgery + IPC arm and 993 into control arm). Surgery + IPC improves: 1, 2 and 3-year mortality (OR = 0.31, 0.27, 0.29 respectively), 2 and 3-year mortality in patients with loco-regional nodal metastasis (OR = 0.28, 0.16 respectively), 1 and 2-year mortality rate in patients with serosal infiltration (OR = 0.33, 0.27 respectively). Morbidity rate was increased by surgery + IPC (OR = 1.82). The overall recurrence and the peritoneal recurrence rates were improved by surgery + IPC (OR = 0.46 and 0.47 respectively). There was no statistically significant difference in lymph-nodal recurrence rate. The rate of haematogenous metastasis was improved by surgery + IPC (OR = 0.63). Conclusions 1, 2 and 3-year overall survival is incremented by the IPC. No differences have been found at 5-year in overall survival rate. 2 and 3-year mortality rates in patients with nodal invasion and 1 and 2-year mortality rates in patients with serosal infiltration are improved by the use of IPC. IPC has positive effect on peritoneal recurrence and distant metastasis. Morbidity rate is incremented by IPC. Loco-regional lymph-nodes invasion in patients affected by advanced gastric cancer is not a contraindication to IPC.

Complications of lymphadenectomy for gynecologic cancer.

Abstract: Introduction Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies. Methods Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL. Results We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25–45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5–18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02–0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2–16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL. Conclusion Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

Focusing on desired outcomes of care after colon cancer resections; hospital variations in 'textbook outcome'.

Abstract: Aims We propose a summarizing measure for outcome indicators, representing the proportion of patients for whom all desired short-term outcomes of care (a ‘textbook outcome’) is realized. The aim of this study was to investigate hospital variation in the proportion of patients with a ’textbook outcome’ after colon cancer resections in the Netherlands. Methods Patients who underwent a colon cancer resection in 2010 in the Netherlands were included in the Dutch Surgical Colorectal Audit. A textbook outcome was defined as hospital survival, radical resection, no reintervention, no ostomy, no adverse outcome and a hospital stay Results A total of 5582 patients, treated in 82 hospitals were included. Average textbook outcome was 49% (range 26–71%). Eight hospitals were identified as negative outliers. In these hospitals a ‘textbook outcome’ was realized in 35% vs. 52% in average hospitals ( p Conclusions The textbook outcome, representing the proportion of patients with a perfect hospitalization, gives a simple comprehensive summary of hospital performance, while preventing indicator driven practice. Therewith the ‘textbook outcome’ is meaningful for patients, providers, insurance companies and healthcare inspectorate.

Efficacy of neoadjuvant chemotherapy in patients with FIGO stage IB1 to IIA cervical cancer: an international collaborative meta-analysis.

Abstract: Background The efficacy of neoadjuvant chemotherapy before surgery (NCS) has not been well-established in FIGO stage IB1 to IIA cervical cancer when compared with primary surgical treatment (PST). Thus, we performed a meta-analysis to determine the efficacy of NCS in patients with FIGO stage IB1 to IIA cervical cancer when compared with PST. Methods We searched Pubmed, Embase and the Cochrane Library between January 1987 and September 2010. Since there was a relative lack of relevant randomized controlled trials (RCTs), we included 5 RCTs and 4 observational studies involving 1784 patients among 523 potentially relevant studies. Results NCS was related with lower rates of large tumor size (≥4 cm) (ORs, 0.22 and 0.10; 95% CI, 0.13–0.39 and 0.02–0.37) and lymph node metastasis (ORs, 0.61 and 0.38; 95% CI, 0.37–0.99 and 0.20–0.73) than PST in all studies and RCTs. Furthermore, NCS reduced the need of adjuvant radiotherapy (RT) in all studies (OR, 0.57; 95% CI, 0.33–0.98), and distant metastasis in all studies and RCTs (ORs, 0.61 and 0.61; 95% CI, 0.42–0.89 and 0.38–0.97). However, overall and loco-regional recurrences and progression-free survival were not different between the 2 treatments. On the other hand, NCS was associated with poorer overall survival in observational studies when compared with PST (HR, 1.68; 95% CI, 1.12–2.53). Conclusions Although NCS reduced the need of adjuvant RT by decreasing tumor size and lymph node metastasis, and distant metastasis, it failed to improve survival when compared with PST in patients with FIGO stage IB1 to IIA cervical cancer.

Roles of ultrasonography and computed tomography in the surgical management of cervical lymph node metastases in papillary thyroid carcinoma

Abstract: Aims Adequate evaluation and surgical management of cervical lymph node metastasis is very important in papillary thyroid carcinoma (PTC). The aim of this study was to evaluate the impact of preoperative ultrasonography (US) and computed tomography (CT) on the surgical management of cervical lymph node metastases in PTC. Methods Medical records and imaging findings were retrospectively analyzed for 252 patients with PTC who underwent thyroidectomy with neck dissection. Results The sensitivity of both imaging techniques was lower in the central neck (US 23%, CT 41%) than in the lateral neck (US 70%, CT 82%). The specificities of US and CT were 97% and 90% in the central neck, and 84% and 64% in the lateral neck, respectively. Our surgical plans for therapeutic neck dissection were based on imaging findings in 59% of patients who underwent lateral compartment neck dissection and in 32.1% of patients who underwent central compartment neck dissection, respectively. Conclusions The roles of preoperative US and CT in surgical planning for central compartment neck dissection in PTC are limited because of their low sensitivity in the central neck, but US and CT may be useful in cases with non-palpable lateral neck nodes.

Video-assisted thoracoscopic surgery lobectomy versus open lobectomy in patients with clinical stage I non-small cell lung cancer: a meta-analysis.

Abstract: Aims Video-assisted thoracoscopic surgery (VATS) lobectomy for early lung cancer has been shown to be technically feasible. Weather VATS lobectomy has equivalent or better clinical effect compared with open lobectomy for early lung cancer patients remains controversial. The purpose is to assess the value of VATS compared with thoracotomy for stage Ⅰ non-small cell lung cancer (NSCLC) by meta-analysis. Methods We searched databases of EMBASE, PubMed, and ScienceDirect for relevant articles published between January 1990 and January 2013. Eligible studies were randomized controlled trials (RCTs) or comparative studies of VATS lobectomy and open lobectomy for clinical stage Ⅰ NSCLC. Data on operation time, intra-operative blood loss, length of chest tube drainage and hospital stay, complications incidence and 5 year survival rate were meta-analyzed using Review Manager 5.0. Results 20 studies with 3457 clinical stage Ⅰ NSCLC patients were included. There was no difference in operation time between the two groups (P = 0.14), but distinct advantages in terms of intra-operative blood loss, chest drainage time, hospital stay and complication incidence were found in the VATS group (P < 0.01). Moreover, the 5 year survival rate of VATS group was significantly higher than thoracotomy group (OR 1.82, 95% CI, 1.43–2.31, P < 0.01). Conclusion Compared with thoracotomy group, VATS achieved better surgical and oncological outcomes and was a more favorable treatment for stage Ⅰ NSCLC patients.

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion – An extension of the ALPPS approach

Abstract: Background Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new “ALPPS” approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE. Methods A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed. Results The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection. Conclusion Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

Fast-track surgery improves postoperative recovery in patients undergoing partial hepatectomy for primary liver cancer: A prospective randomized controlled trial.

Abstract: Background and aim Fast-track surgery (FTS), combining several techniques with evidence-based adjustments, has shown its effectiveness to accelerate recovery, reduce morbidity and shorten hospital stay in many operations. This randomized controlled study was carried out aiming to compare the short-term outcomes of partial hepatectomy for liver cancer managed with FTS or with conventional surgery (CS). Methods To compare the short-term effects between FTS and CS, a randomized controlled trial was carried out for liver cancer patients undergoing partial hepatectomy from September 2010 to June 2012. Results Patients with liver cancers before receiving partial hepatectomy were randomized into the FTS group ( n = 80) and the CS group ( n = 80). Compared with the CS group, the FTS group had significantly less complications ( P GCQ ) by Kolcaba Line (all P Conclusions FTS was safe and efficacious. It lessened postoperative stress reactions and accelerated recovery for patients undergoing partial hepatectomy for liver cancer.

Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy--systematic review.

Abstract: Purpose There is enormous range in the reported rates of breast reconstruction This study explored reasons for this variation by reviewing the published literature to examine rates of reconstruction, factors associated with uptake, and possible barriers Methods A systematic review of the literature was performed Eligible studies reported rates of breast reconstruction and variables associated with uptake in women undergoing mastectomy for early invasive or in situ breast malignancy Results Twenty-eight eligible studies were included, reporting 159,305 cases of breast reconstruction in 940,678 women In these studies 16·9% of women underwent immediate or delayed reconstruction (range 4·9–81·2%, median 23·3%) Variables associated with reconstruction were: patient/tumour factors (early stage, no adjuvant therapy, young age, white race, private insurance, higher education/income), surgeon/hospital factors and psychological/other factors (including patient choice) Conclusion Rates of breast reconstruction were highly variable Reconstruction appeared to be offered to a minority of women; around half took up the offer The main reasons reported for no reconstruction included patient-related and adjuvant therapy-related factors Clinicians' beliefs about reconstruction may be an important factor Rates of reconstruction could be increased with early discussion of the options when mastectomy is chosen or required

The Indocyanine Green Method Is Equivalent to the (99m) Tc-Labeled Radiotracer Method for Identifying the Sentinel Node in Breast Cancer: A Concordance and Validation Study

Abstract: We assessed concordance between the indocyanine green (ICG) method and 99mTc-radiotracer method to identify the sentinel node (SN). One hundred thirty-four women with clinically node-negative early breast cancer received preoperative injection of 99mTc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for detection of SNs. The 134 patients provided 246 SNs, detected by one or both methods. The two methods were concordant for 230/246 (93.5 %) SNs and discordant for 16 (6.5 %) SNs. The ICG method detected 99.6 % of all SNs. Fluorescent lymphangiography with ICG allows an easy identification of axillary SNs, at a frequency not inferior to that of the radiotracer method and can be used alone to reliably identify SNs.

Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis.

Abstract: Background The clinical risk factors of delayed gastric emptying (DGE) in patients after pancreaticoduodenectomy (PD) remains controversial. Herein, we conducted a systematic review to quantify the associations between clinical risk factors and DGE in patients after conventional PD or pylorus preserving pancreaticoduodenectomy (PPPD). Methods A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2012 was performed. Cohort, case–control studies, and randomized controlled trials that examined clinical risk factors of DGE were included. Results Eighteen studies met final inclusion criteria (total n = 3579). From the pooled analyses, preoperative diabetes (OR 1.49, 95% CI, 1.03–2.17), pancreatic fistulas (OR 2.66, 95% CI, 1.65–4.28), and postoperative complications (OR 4.71, 95% CI, 2.61–8.50) were significantly associated with increased risk of DGE; while patients with preoperative biliary drainage (OR 0.68, 95% CI, 0.48–0.97) and antecolic reconstruction (OR 0.17, 95% CI, 0.07–0.41) had decreased risk of DGE development. Gender, malignant pathology, preoperative jaundice, intra-operative transfusion, PD vs. PPPD and early enteral feeding were not significantly associated with DGE development (all P > 0.05). Conclusions Our findings demonstrate that preoperative diabetes, pancreatic fistulas, and postoperative complications were clinical risk factors predictive for DGE. Antecolic reconstruction and preoperative biliary drainage result in a reduction in DGE. Knowledge of these risk factors may assist in identification and appropriate referral of patients at risk of DGE.

Preoperative predictors of microvascular invasion in multinodular hepatocellular carcinoma

Abstract: Background The preoperative predictors of microvascular invasion (MVI) in multinodular hepatocellular carcinoma (HCC) are currently unclear Methods We retrospectively analyzed 266 patients who underwent potentially curative resection of multinodular HCC MVI was diagnosed on pathological examination in 64 patients Preoperative risk factors for MVI were identified and survival curves were analyzed Results Patients with MVI had significantly lower overall and recurrence-free survival rates than those without MVI (overall survival, 1 year: 86% vs 71%, 3 years: 58% vs 16%; recurrence-free survival, 1 year: 69% vs 12%; 3 years: 48% vs 12%; both P 400 μg/L (odds ratio [OR] = 3732, P = 0016), serum gamma-glutamyltransferase (GGT) level >130 U/L (OR = 19779, P 8 cm (OR = 5545, P = 0010), and tumor number >3 (OR = 11566, P = 0007) were independent predictors of MVI A scoring system was constructed, and the MVI rate was significantly higher in patients with a score of ≥3 than those with a score of <3 (641% vs 109%, P < 0001) Overall and recurrence-free survival rates were significantly lower in patients with a score of ≥3 (both P < 0001) Conclusions Serum AFP level >400 μg/L, serum GGT level >130 U/L, total tumor diameter >8 cm, and tumor number >3 were preoperative predictors of MVI in patients with multinodular HCC In patients with a high risk of MVI and well-preserved liver function, anatomic resection may be worth considering

Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound

Abstract: Background In patients with breast cancer, grey-scale ultrasound often fails to identify lymph node (LN) metastases. We aimed to validate the technique of contrast-enhanced ultrasound (CEUS) as a test to identify sentinel lymph node (SLN) metastases and reduce the numbers of patients requiring a completion axillary node clearance (ANC). Methods 371 patients with breast cancer and a normal axillary ultrasound were recruited. Patients received periareolar intra-dermal injection of microbubble contrast agent. Breast lymphatics were visualised by CEUS and followed to identify and biopsy axillary SLN. Patients then underwent standard tumour excision and either SLN excision (benign biopsy) or axillary clearance (malignant biopsy) with subsequent histopathological analysis. Results The technique failed in 46 patients, 6 patients had indeterminate biopsy results and 24 patients were excluded. In 295 patients with a conclusive SLN biopsy, the sensitivity of the technique was 61% and specificity 100%. Given a benign SLN biopsy result, the post-test probability that a patient had SLN metastases was 8%. 35 patients were found to have SLN metastases and had a primary ANC (29 macrometastases and 6 micrometastases/ITC). There were 22 false negative results (10 macrometastases and 12 micrometastases). Macrometastases in core biopsy specimens correlated with LN macrometastases on surgical excision. Conclusion Pre-operative biopsy of SLN reduced the numbers of patients requiring completion ANC. Despite the low sensitivity, only 22 patients (8%) with a benign SLN biopsy were subsequently found to have LN metastases. Without the confirmation of macrometastases on core biopsy specimens, patients with micrometastases/ITC may be inadvertently selected for primary ANC.

Preservation of the internal genital organs during radical cystectomy in selected women with bladder cancer: a report on 15 cases with long term follow-up.

Abstract: Purpose To prospectively present the technique, functional and oncological outcome of internal genitalia sparing cystectomy for bladder cancer in 15 selected women. Patients and methods Between January 1995 and December 2010, 305 women underwent orthotopic neobladder after radical cystectomy. Of these, 15 cases with a mean age of 42 years underwent genitalia sparing. Inclusion criteria included stage (T2b N0 Mo or less, as assessed preoperatively, unifocal tumors away from the trigone, sexually active young women and internal genitalia free of tumor. Cystectomy with preservation of the uterus, vagina and ovaries and Hautmann neobladder were performed. Oncological, functional, urodynamic and sexual outcome using Female Sexual Function Index (FSFI) were evaluated. Results Definitive histopathology showed advanced stage not recognized preoperatively in 2 patients, who developed local recurrence and bony metastasis after 3–4 months. A third patient developed bony metastasis after 15 months. No recurrence developed in the retained genital organs. The remaining 12 patients remained free of disease with a mean follow-up of 70 months. Among women eligible for functional evaluation, daytime and nighttime continence were achieved in 13/13 (100%) and 12/13 (92)%, respectively. Chronic urinary retention was not noted. The urodynamic parameters were comparable to those in other patients without genital preservation. Sexual function (FSFI) was better in these patients than in others without genital preservation. Conclusions Genital sparing cystectomy for bladder cancer is feasible in selected women. It provides a good functional outcome, better sexual function and the potential for fertility preservation. So far, the oncological outcome is favorable.

Pancreatectomy for adenocarcinoma in elderly patients: postoperative outcomes and long term results: a study of the French Surgical Association.

Abstract: Aim To determine the benefit of surgery for resectable pancreatic adenocarcinomas (PAs) in elderly patients. Methods From 2004 to 2009, 932 patients with resectable PAs underwent pancreatectomies without neoadjuvant treatment in 37 institutions. The patients were divided into three groups according to age: n = 580); 70–79 years (70s group, n = 288), and ≥80 years (80s group; n = 64). Preoperative, intraoperative, postoperative, and histological data were recorded to assess the postoperative course and survival. Results Preoperative or intraoperative characteristics, and the histological findings were comparable in the three groups. Postoperative mortality and morbidity rates did not differ in the three groups. Adjuvant therapies were more frequently used in younger patients than in elderly patients ( p p = 0.16). The median survival of the control, 70s, and 80s groups was 24 months, 35.3 months, and 30 months, respectively. Four independent prognostic indicators were identified by multivariate analysis: venous invasion (hazard ratio (HR) = 2.12), arterial invasion (HR = 2.96), positive lymph nodes (HR = 2.25), and adjuvant treatment (HR = 0.65). Conclusions Fit elderly patients with resectable PAs should not be excluded from surgical resection of PA solely because of their real age. Moreover, elderly patients seem to obtain similar advantages from pancreatectomies than younger patients.

Clinical-pathologic features, long term-outcome and surgical treatment in a large series of patients with invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC).

Abstract: Purpose of the study A retrospective analysis on 1407 patients with invasive ductal carcinoma (IDC) and 243 invasive lobular carcinoma (ILC) was performed in order to compare the histological features, the immunohistochemical characteristics, the surgical treatment and the clinical outcome in the two groups. Results ILC seems to be more likely multifocal, estrogen receptor positive, HER-2 negative and to have a lower proliferative index compared to IDC. ILC, when treated with conservative surgery, required more frequently re-excision and/or mastectomy because of positive resection margins. No difference was observed in terms of 5-year disease free survival and local relapse free survival between the two groups, in the whole series and in the subgroup of patients treated with breast-conserving treatment. Conclusion ILC can be safely treated with conservative surgery but a more accurate preoperative evaluation of tumor size and multifocality could be advocated, in order to reduce the re-excision rate.

Treatment and prevention of peritoneal carcinomatosis from gastric cancer by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Overview and rationale

Abstract: Peritoneal carcinomatosis (PC) from gastric cancer is a condition with a very bleak prognosis. Most authors consider it to be a terminal disease and recommend palliative therapy only. Multimodal therapeutic approaches to PC have emerged in the last decades, combining cytoreductive surgery (CRS) and peritonectomy procedures with perioperative intraperitoneal chemotherapy (IPEC), including hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC). We reviewed the pertinent literature concerning the HIPEC modality both for the treatment of established PC and the prevention of peritoneal recurrence after potentially curative gastric cancer (GC) surgery. Basically, the two procedures relate to different aspects of GC and they are not comparable, since the latter has been used as an adjuvant when PC is still not macroscopically evident and the former has been exclusively used in advanced gastric cancer stages with peritoneal dissemination. Data supporting beneficial effects once gastric PC is already manifest is scarce and limited to few centres with specific experience in this field. Conversely, with regards to the peritoneal perfusion for preventing PC in high risk gastric cancer patients, there are phase III trials and meta-analysis which support beneficial effects resulting from the HIPEC procedure. To offer a baseline guide, we summarized the actual status and general outcome obtained by this multimodal technique, in association or not with CRS as treatment of advanced GC.

Acellular dermal matrix (ADM) assisted breast reconstruction procedures: Joint guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons

Abstract: Tissue expansion with delayed insertion of a definitive prosthesis is the most common form of immediate breast reconstruction performed in the United Kingdom However, achieving total muscle coverage of the implant and natural ptosis is a key technical challenge The use of acellular dermal matrices (ADM) to supplement the pectoralis major muscle at the lower and lateral aspects of the breast has been widely adopted in the UK, potentially allowing for a single stage procedure There is however little published data on the clinical and quality criteria for its use, and no long term follow-up The guidelines have been jointly produced by the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons and their aims are: to inform those wishing to undertake ADM assisted breast reconstruction and, to identify clinical standards and quality indicators for audit purposes The guidelines are based on expert opinion of a multi-disciplinary working group, who are experienced in the technique, and a review of the published data

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort.

Abstract: Introduction Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. Materials and methods A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. Results Results and limitations: 467 patients were enrolled. Median age was 70 years (range 35–89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa ( p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002–1.007 per minute; p = 0.0001). Conclusions In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

Modular hemipelvic endoprosthesis reconstruction--experience in 100 patients with mid-term follow-up results.

Abstract: Introduction Pelvic endoprostheses are becoming more commonly used in recent years. In 2007, we reported the early results of modular hemipelvic endoprosthesis. In order to provide longer follow-up results, we conducted the current study. Objective To explore overall survival, local recurrence rate, metastasis rate, function score and survivorship of the prosthesis and related complications. Methods We retrospectively reviewed one hundred consecutive patients who received reconstruction with modular hemipelvic endoprostheses from June 2001 to March 2010. The living patients were followed for an average of 52.9 (range, 24–103) months. There were 85 primary tumors and 15 isolated metastases. Results At the time of last follow-up, fifty-eight patients were alive with no evidence of disease and thirty-six patients died of disease. Twenty patients experienced a local recurrence and twenty-eight patients developed distant metastasis. Patients with wide surgical margins had a significantly lower local recurrence rate than those with inadequate margins ( p = 0.03). The mean MSTS (Musculoskeletal Tumor Society) 93 score was 57.2% (range, 16.7–86.7%). The mean Karnofsky Performance Score (KPS) was 64.4 (range, 30–90). Postoperative complications occurred in 45% of the patients. Wound healing disturbance (18%) and deep infection (15%) were the most predominant. Less frequent complications included dislocation, which occurred in nine patients and mechanical complications including 5 breakages and 2 aseptic loosening. Conclusion The modular hemipelvic endoprosthesis can provide a versatile reconstruction option for a variety of pelvic defects with an acceptable rate of complication. Wide margins whenever possible should be the goal for these complex patients.

Diffusion-weighted magnetic resonance for prediction of response after neoadjuvant chemoradiation therapy for locally advanced rectal cancer: Preliminary results of a monoinstitutional prospective study

Abstract: Purpose To evaluate diffusion-weighted imaging (DWI) for assessment of treatment response in locally advanced rectal cancer (LARC) 8 weeks after neoadjuvant chemoradiotherapy (CRT). Methods and materials A total of 28 patients with LARC underwent magnetic resonance imaging (MRI) prior to and 8 weeks after CRT. Tumor volume (TV) was calculated on T2-weighted MRI scans as well as the apparent diffusion coefficient (ADC) was calculated using Echo-planar DWI-sequences. All data were correlated to surgical results and histopathologic tumor regression grade (TRG), according to Mandard's classification. Post-treatment difference ADC (%ΔADC) and TV (%ΔTV) changes at 8 weeks were compared complete response (CR; TRG1) and non-complete response tumors (non-CR; TRG2–5). Results The mean % ADC increase of CR group was significantly higher compared to non-CR group (77.2 ± 54.63% vs. 36.0 ± 29.44%; p = 0.05). Conversely, the mean % TV reduction did not significantly differ in CR group from non-CR group (73.7% vs. 63.77%; p = 0.21). Accordingly, the diagnostic accuracy of the mean % ADC increase to discriminate CR from non-CR group was significantly higher than that of the mean % TV reduction (0.913 vs. 0.658; p = 0.022). No correlation was found between mean % TV reduction and TRG (rho = 0.22; p = 0.3037), whereas a negative correlation between mean % ADC increase and TRG was recorded ( r = −0.69; p = 0.006). Conclusion The mean % ADC increase appears to be a reliable tool to differentiate CR from non-CR after CRT in patients with LARC.

Liver metastases from breast cancer: Surgical resection or not? A case-matched control study in highly selected patients

Abstract: Aim To determine whether, in a highly selected patient population, medical treatment combined with surgical resection of liver metastases from breast cancer is associated with improved survival compared with medical treatment alone. Patients and methods Between 1988 and 2007, 100 liver resections for metastatic breast cancer were performed at Institut Curie, 51 of which met the criteria for inclusion in this case-control study. With the exception of bone metastases, patients with other distant metastasis sites were excluded. Surgery was only performed in patients with stable disease or disease responding to medical treatment evaluated by imaging evaluation. Surgical cases were individually matched with 51 patients receiving medical treatment only. All patients had 4 or fewer resectable liver metastases. The study group was matched with the control group for age, year of breast cancer diagnosis, time to metastasis, TNM stage, hormone receptor status and breast cancer tumour pathology. Results Univariate analysis confirmed a survival advantage for patients lacking bone metastases and axillary lymphadenopathy at the time of breast cancer diagnosis and for surgically treated patients. Multivariate analysis indicated that surgery and the absence of bone metastases were associated with a better prognosis. A multivariate Cox model adapted for paired data showed a RR = 3.04 (CI: 1.87–4.92) ( p Conclusion Surgical resection of liver metastases from primary breast cancer appears to provide a survival benefit for highly selected patients.

Prognostic value of the IASLC/ATS/ERS classification in stage I lung adenocarcinoma patients—Based on a hospital study in China

Abstract: Aims We investigated the relationship between predominant subtype, according to the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Lung Adenocarcinoma Classification, and prognosis in stage I lung adenocarcinoma in Zhejiang Cancer Hospital. Methods Two hundred and sixty-one patients with stage I lung adenocarcinoma, operated in Zhejiang Cancer Hospital, were identified between 2000 and 2010. Survival curves were plotted using the Kaplan–Meier method. The Cox proportional hazard model was used for multivariate analysis. Results None of the cases were adenocarcinoma in situ and six were minimally invasive adenocarcinomas. Two hundred and fifty-five cases were invasive adenocarcinoma. Of those, 80, 76, 42, 34, 19, and 4 were papillary predominant, acinar predominant, micropapillary predominant, solid predominant, lepidic predominant subtypes, and variants of invasive adenocarcinoma, respectively. Patients with micropapillary and solid predominant tumors had a significantly worse disease-free survival as compared to those with other subtypes predominant tumors ( p p = 0.002 and 0.015). Conclusion The predominant subtype in the primary tumor was associated with prognosis in resected stage I lung adenocarcinoma.

Hepatic resection for synchronous hepatic metastasis from gastric cancer

Abstract: Background The role of surgical resection for synchronous hepatic metastases arising from gastric adenocarcinoma has not been established. This study was designed to explore the clinicopathologic features and surgical results of these patients. Methods Twenty-five (4.8%) of 526 patients diagnosed with synchronous hepatic metastatic gastric cancer received hepatectomy and gastrectomy at the same time; 2 cases underwent repeat hepatectomy after intrahepatic recurrence. Clinicopathologic parameters of the hepatic metastases and the surgical results for all 25 patients were analysed. Results The 1-, 3-, and 5-year overall survival (OS) and recurrence-free survival (RFS) rates after resection were 96.0%, 70.4%, and 29.4%, respectively, and 56.0%, 22.3%, and 11.1%, respectively. Five patients survived for more than 5 years after surgery, and no mortality has occurred within 30 days after resection. Univariate analysis revealed that patients with multiple hepatic metastases suffered poorer OS (P = 0.026) and RFS (P = 0.035) than those with solitary hepatic metastasis. Postoperative adjuvant chemotherapy was a significant indicator of a favourable OS (P = 0.022). Number of metastatic lesions remained significant in the multivariate analysis of OS and RFS (P = 0.039, P = 0.049, respectively). None of variables of the primary lesion was a significant prognostic factor for those patients. Conclusions Gastric cancer patients with a solitary synchronous liver metastasis may be good candidates for hepatic resection. Postoperative adjuvant chemotherapy may provide a benefit by aiding in OS.

Quality of life of older rectal cancer patients is not impaired by a permanent stoma

Abstract: Background The current study was undertaken to investigate the impact of a stoma on the HRQL with a special focus on age. Materials and methods Using the Eindhoven Cancer Registry, rectal cancer patients diagnosed between 1998 and 2007 in 4 hospitals were identified. All patients underwent TME surgery. Survivors were approached to complete the SF-36 and EORTC QLQ-C38 questionnaires. HRQL scores of the four groups, stratified by stoma status (stoma/no stoma) and age at operation ( Results Median follow-up of 143 patients was 3.4 years. Elderly had significantly worse physical function ( p = 0.0003) compared to younger patients. Elderly ( p = 0.005) and patients without a stoma ( p = 0.009) had worse sexual functioning compared to younger patients and patients with a stoma. Older males showed more sexual dysfunction ( p = 0.01) when compared to younger males. In comparison with the normative population, elderly with a stoma had worse physical function ( p p p p Conclusions Older patients with a stoma have comparable HRQL to older patients without a stoma or the normative population, indicating the feasibility of a permanent stoma for elderly patients with a low situated rectal carcinoma. The negative impact of treatment on sexual functioning as found in the current study calls for further attention to alleviate this problem in sexually active patients.

Carcinoma of the gallbladder: patterns of presentation, prognostic factors and survival rate. An 11-year single centre experience.

Abstract: Background This report examines the patterns of presentation, prognostic factors and survival rate of all patients with gallbladder cancer (GBC) evaluated at our tertiary academic hospital over an 11-year period. Methods A retrospective review of a prospectively collected database of all patients with GBC presenting between January 1998 and December 2008 was performed. Results 102 GBC-patients were included: 69 women and 33 men (median age: 65,5 years). Forty-five patients presented with incidental gallbladder cancer (IGC) and 57 with nonincidental cancer (NIGC). Curative surgery rate was 84.4% for IGC and 29.8% for NIGC ( p p Conclusions Majority of patients with a potentially curable disease had IGC. Almost 80% of patients with NIGC presented with unresectable disease. For patients who underwent resection with curative intent, actuarial 5-year survival was 63.2%. Liver involvement was the only independent prognostic factor. All patients with IGC and a pT2 or more advanced T stage should undergo a second radical resection.

Microwave ablation with or without resection for colorectal liver metastases

Abstract: Background: Ablation with or without resection for colorectal liver metastases has been suggested as a potential method of improving survival if complete surgical resection is not possible. This study assessed the safety and efficacy of surgical microwave ablation (MWA) with or without resection for colorectal liver metastases. Methods: A retrospective case series was reviewed. Data was extracted for all patients treated with open MWAwith or without resection for colorectal liver metastases. Endpoints included postoperative 30-day morbidity and mortality, local treatment failure, disease free survival and overall survival. Results: A total of 43 patients with technically irresectable disease were treated with MWA; 28 underwent combined MWA and resection, whilst 15 underwent MWA as the sole treatment modality. Overall post-operative morbidity was 35%, 30-day postoperative mortality 2%. At a median follow-up of 15 months, local treatment failure was observed in 4% of ablated lesions. 3-year OS was 36% for MWA group, compared to 45% for the combined ablate/resect group with 3-year DFS of 32% and 8% respectively. Conclusion: Microwave ablation with or without resection is a safe and effective method of achieving local disease control. Ablation with or without resection is associated with good long-term outcomes, and may be a suitable treatment option for small non-resectable colorectal liver metastases. 2013 Elsevier Ltd. All rights reserved.