Surgical Oncology Insight最新文献

Background

An ovarian mass in the setting of colorectal cancer (CRC) can be concerning due to the uncertainty of it being metastatic disease or primary ovarian neoplasm, leading to different referral and treatment options. Our objective was to determine the incidence of ovarian metastasis compared to primary ovarian pathology in women diagnosed with CRC.

Methods

Women aged 18 years or older, diagnosed with CRC in 2014 were included. 806 records were screened for findings of an ovarian mass until 2023. Pathology was determined via resection, biopsy, or imaging with follow-up.

Results

Forty women (5.0 %) had an ovarian mass; 11 at index surgery and 29 on follow-up. Median age at CRC diagnosis was 62.7 years. The incidence of Krukenberg tumour (KT) was 3.2 % accounting for 65 % of ovarian masses. Approximately 20 % presented with synchronous KTs (n = 5) and 53.8 % had synchronous peritoneal carcinomatosis (n = 14). On follow-up, KTs were found in 72.4 % of the patients (n = 21). The Overall Survival (OS) in the KT group was 7.8 % with median survival of 30.4 months. The median time to developing KTs was 20.8 months with 2-year disease-free survival of 19.2 %. Synchronous KT presentation was the only factor associated with worse OS on univariate and multivariate analysis (HR 7.23, 95 % CI 1.57–33.28, P < 0.05).

Conclusion

The risk of developing KT in women with CRC is 3.2 %, of which most (72.4 %) present with metachronous disease within 2 years of CRC diagnosis. Initial evaluation by a gastrointestinal tumor group is warranted.

Synopsis

In this multicenter study involving 806 women diagnosed with colorectal cancer, most ovarian masses that were detected during or following surgery are colorectal metastases and not primary ovarian pathology.

Reoperative parathyroidectomy presents unique challenges and increased risks compared to initial surgeries. A thorough preoperative assessment is crucial, incorporating history, physical exams, laboratory evaluations, imaging studies, operative notes, pathology reports analysis, and postoperative complication reviews. Ectopic parathyroid glands further complicate reoperative procedures, necessitating careful consideration in surgical planning. Radioguided parathyroidectomy offers a safe and successful option for reoperative cases, and is particularly beneficial for detecting ectopic glands.

Purpose

To compare health-related quality of life (HRQL) in primary ovarian cancer (OC) patients with peritoneal metastases (PM) after undergoing upfront cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) as part of a phase 2 trial (NCT-02124421).

Methods

Patients with stage III/IV high-grade serous OC were randomized (1:1) to either CRS/HIPEC with carboplatin followed by 6 cycles of adjuvant systemic chemotherapy (carboplatin/paclitaxel) or CRS followed by 6 cycles of combination intraperitoneal/intravenous chemotherapy (cisplatin/paclitaxel). The trial outcome index (TOI) of the Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaire was used to assess HRQL. The FACT-O was administered at randomization and postoperatively at 6 weeks and 6, 12, and 24 months, or until disease recurrence/death. HRQL was analyzed using a linear mixed model.

Results

Sixteen patients were enrolled in each group. All (32/32) patients completed questionnaires at baseline and 53.1 % (17/32) at 24 months. Reasons for missing scores were similar between groups. Average TOI was similar between treatment arms at each time point. In both arms, mean TOI was below baseline at 6 weeks (p = 0.798) and 6 months (p = 0.821) after CRS, but recovered at 12 months (p = 0.518). No significant differences were found in FACT-O total score or FACT-O individual dimensions over time between groups.

Conclusions

No long-term HRQL impairment was observed when HIPEC was added to CRS in primary OC. Access to CRS/HIPEC as primary treatment of PM in OC should not be solely limited by concerns for patient HRQL.

Synopsis

Health-related quality of life (HRQL) was evaluated in primary ovarian cancer patients participating in a phase 2 trial comparing cytoreductive surgery (CRS)/HIPEC vs CRS + intraperitoneal (IP) chemotherapy. No differences between groups or long-term HRQL impairment were observed.

Introduction

The assessment and management of oligometastatic colorectal cancer has evolved over the last two decades. We aimed to examine trends in the presentation, management and outcomes of patients presenting with liver-only disease, given recent changed standards for baseline imaging, and evolving definitions of resectability. Patients with lung-only disease can provide a contemporaneous control group.

Methods

Prospectively maintained data from the multi-site Treatment of Recurrent and Advanced Colorectal Cancer Registry were reviewed over three consecutive periods; 2009–2013, 2014–2018, and 2019–2023. Survival outcomes were determined by Kaplan-Meier method.

Results

Of 4613 patients with metastatic colorectal cancer, median age was 66 years (interquartile range 56–76), and 2356 (51 %) patients had a single metastatic site. Compared to the earlier periods, patients diagnosed in 2019–2023, were younger, had better ECOG scores and were more likely to have three or more metastatic sites. The proportion of patients with liver-only metastases decreased over the three consecutive periods, from 32.0 % (n = 462), to 27.0 % (n = 498) to 25.9 % (n = 33), p < 0.001, however the proportion of liver-only metastases patients undergoing resection increased from 41.5 to 59.3 %, p < 0.001. The incidence and resection rate of lung-only metastases was unchanged over time.

Conclusion

The increasing number of metastatic sites and reduced number of patients with liver-only metastases is potentially explained by the increased use of FDG-PET imaging at baseline. The increased proportion of patients with liver-only disease undergoing resection may be explained by advancement in surgical techniques, improvements in systemic therapies and the evolving definition of resectable disease.

Synopsis

The pattern and treatment of metastatic colorectal cancer has evolved over the last two decades. This study examines the trends in presentation management and outcomes of patients with metastatic colorectal cancer using a multi-site database.

Synopsis

Sebaceous carcinoma of the breast is a rare breast neoplasm with a small number of published cases. We report an updated systematic review of these cases to provide insight into the patient demographics, clinical presentation, and patient outcomes.

Background

The use of Irreversible Electroporation (IRE) in borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) is increasing. However, its potential impact on survival has been debated. We hypothesized that addition of IRE to the conventional multimodal therapy would be associated with improved overall survival (OS) in BR/LA PDAC patients.

Methods

Among patients received neoadjuvant chemotherapy, we identified PDAC patients with BR/LA disease who underwent resection alone, resection+IRE, IRE alone, and no resection but would have been eligible for IRE. Kaplan-Meier method with Peto-Peto modified log-rank test and Cox proportional hazard were used in survival analyses.

Results

102 patients were included in the cohort – 40 resection-only (18 % LA), 13 resection+IRE (46 % LA), 14 IRE-only (93 % LA), and 35 unresected (77 % LA). Median age was 65. IRE patients had a median follow-up of 22 months [95 %CI:14–28], while for non-IRE patients it was 17 months [95 %CI:12–26]. Median age and proportion without comorbidities did not significantly differ across groups. Median OS was 30 months [95 %CI:30-NR] among patients who underwent resection+IRE, 27 months [95 %CI:23–48] for resection-only, 28 months [95 %CI:16-NR] for IRE-only, and 14 months [95 %CI:10–20] for unresected patients. In multivariable analyses, resection (HR:0.26 [95 %CI:0.13–0.54], P < 0.001), neoadjuvant chemoradiation (HR:0.50 [95 %CI:0.28–0.88], P = 0.017), and IRE (HR:0.49 [95 %CI:0.26–0.94], P = 0.03) were independently associated with decreased risk of mortality.

Conclusions

IRE may enhance survival in BR/LA PDAC patients who receive conventional multimodal therapy. Prospective studies are needed to confirm the potential benefits of IRE as an adjunct during pancreatic resection after multimodal neoadjuvant therapy for BR/LA PDAC.

Synopsis

Irreversible electroporation can be a valuable adjunct to the current multimodal therapy for treating borderline resectable and locally advanced pancreatic cancer.

Background

Sentinel node biopsy is a standard component of staging for patients with melanoma. Lymphoscintigraphy with technetium99 (^99mTc) is highly reliable but not patient centered, requiring a separate visit to radiology and often a painful injection. We assessed intra-operative real-time fluorescence lymphangiography as an alternative to ^99mTc for sentinel node localization in patients with extremity melanoma.

Methods

A multi-center single arm prospective trial was conducted for patients with extremity melanoma. All subjects had lymphoscintigraphy with ^99mTc prior to surgery and a dermal injection of indocyanine green in the operating room. The surgeon was blinded to the lymphoscintigraphy results and used real-time fluorescence imaging to localize the sentinel nodes. Success rate and operative times were recorded.

Results

Four surgeons enrolled 35 subjects with melanoma of the upper or lower extremity, excluding hands and feet, who met criteria for sentinel node biopsy based on NCCN guidelines. Each surgeon enrolled at least 8 subjects. The overall success rate for the first sentinel node was 83 % (29/35). The success rate varied between the axilla and groin, and between first, second and third sentinel nodes. The average time to identify the first sentinel node was 14 min, with no consistent improvement over time. There were no complications related to the ICG.

Conclusions

The success rate of sentinel node localization with indocyanine green and fluorescence imaging is high, but not high enough to use this method alone. ICG can safely replace blue dye. The learning curve for this technique is likely more than 8 patients.

Synopsis

ICG and fluorescence imaging may aid in sentinel node localization but should not replace lymphoscintigraphy with ^99mTc. ICG with fluorescence imaging can safely replace blue dye. The learning curve for this technique is at least 8 patients.

Introduction

The impact of a positive resection margin (RM+) in appendiceal cancer (AC) remains unclear, with small studies suggesting it does not worsen survival in low-grade subtypes. We aimed to evaluate RM+ rates, its risk factors, and survival outcomes across different AC histologies.

Methods

We conducted a multicenter retrospective cohort study using the National Cancer Database (2004–2019) and including stage I-III AC cases. Surgical and survival outcomes were compared between RM+ and RM- groups, with logistic regression analyzing the association of RM+ and its predictors. Subgroup analysis was performed for low/high tumor grade (LG/HG), mucinous/non-mucinous pathology (MAC/NMAC), and signet ring cell carcinoma (SRC).

Results

Among 6800 patients identified, 737 (10.8 %) had RM+, while 6063 (89.2 %) had RM-. RM+ rates varied across AC histologies: 10.9 % in LG-MAC, 17.0 % in HG-MAC, 7.8 % in LG-NMAC, 13.9 % in HG-NMAC, and 17.9 % in SRC. RM+ correlated with significantly worse survival in LG-MAC (HR 1.67), HG-MAC (HR 1.83), LG-NMAC (HR 2.04), and SRC (HR 2.37) but not in HG-NMAC after adjusting to other factors. Predictors of RM+ included pT stage, preoperative chemotherapy in LG tumors and pT stage and positive lymph nodes in HG tumors whereas more extensive resection was associated with RM- in both LG and HG.

Conclusion

RM+ worsens survival in most AC subtypes, highlighting the importance of achieving negative margins. Extensive resection, like right hemicolectomy, can improve RM- rate, but factors such as pT stage, lymph node status, and preoperative chemotherapy also affect RM+. Surgeons should prioritize achieving RM- in all AC histologies.

Background

Acral lentiginous melanoma holds the worst prognosis of all cutaneous melanomas. We aim to further detail the incidence of upstaging in plantar melanoma (PM) as well as identify factors associated with upstaging.

Methods

A retrospective analysis of medical records was performed of patients who underwent surgical intervention for non-metastatic primary PM at a single NCI-designated Comprehensive Cancer Center (January 2011-August 2023). The primary outcome was rate of upstaging, defined as an increase in the T-stage on final surgical pathology compared to biopsy. Clinical and pathologic staging were determined by the AJCC 8th edition. Statistical analysis included Pearson’s Chi-squared test, Fisher’s exact test, Wilcoxon rank sum test, and Kruskal-Wallis rank sum test.

Results

Forty-nine patients were identified, with an average age of 65 years (51 % male). Majority self-identified as Caucasian (55 %). Initial biopsy techniques were shave (49 %), punch (34 %) and excisional (17 %). Twenty-four patients (50 %) demonstrated upstaging. Seventy-seven percent (n = 10) of patients with clinical Tis were upstaged. Eight patients required reoperation due to upstaging, with 6 having melanoma in situ on biopsy. On multivariable logistic regression, patients with clinical Tis-T1 were more likely to be upstaged compared to T2-T3 (OR 8.75, p < 0.041). Type of biopsy, lesion size < 15 mm and positive deep margins on biopsy were not associated with risk of upstaging.

Conclusions

Our findings suggest a high incidence of upstaging of PM with no identifiable factors associated with upstaging. Patients with clinical Tis or T1 PM should undergo resection with wider margins and be strongly considered for sentinel lymph node biopsy at time of index operation.

Synopsis

In this large cohort of patients with non-metastatic primary plantar melanoma, half of the cohort was upstaged following resection. The risk was higher in patients diagnosed with Tis or T1 on biopsy compared to T2-T3. Biopsy type, lesion size < 15 mm and positive deep biopsy margins were not associated with upstaging. More radical treatment of plantar melanomas may be warranted.

Background

Although outcomes of treatment for colorectal cancer liver metastases (CRLM) have improved with multidisciplinary treatment, recurrence rates after resection of liver metastases are still high. Although surgical margin (SM) is considered irrelevant in the case of R0 resection, its effectiveness is still unclear. In this study, we investigated the prognostic association of SM in CRLM according to RAS status.

Methods

Of 220 patients who had undergone initial hepatic resection for CRLM at our hospital between January 2000 and February 2020, finally, 164 remained in the study cohort. SMs (mms) were measured by macroscopic and microscopic examinations. Associations between SM, presence or absence of RAS mutations, and prognosis were analyzed using multivariate analysis with the Cox proportional hazards model.

Results

Of the 164 patients, 68 (41 %) had RAS mutations. The RAS mutation group had significantly poorer disease-free survival (DFS) (P < 0.001) and over-all survival (OS) (P < 0.001). In the RAS wild group, SM status was not significantly associated with OS or DFS, whereas in the RAS mutation group, SM< 2 mm was significantly associated with worse DFS (P = 0.014). Multivariate analysis showed that SM< 2 mm was an independent predictor of poor DFS in the RAS mutation group (HR 21.3, 95 % CI: 2.25–201.3, P = 0.008).

Conclusions

RAS mutation status is an independent predictor of poor prognosis after hepatectomy for CRLM. Especially in patients with RAS mutations, SM < 2 mm is associated with significantly worse post-hepatectomy DFS, suggesting achieving a wide SM (≥2 mm) is indicated in patients with RAS mutations

Synopsis

RAS mutation is an independent predictor of poor prognosis after hepatectomy for CRLM. Especially in patients with RAS mutations, SM < 2 mm is associated with significantly worse post-hepatectomy DFS, suggesting achieving a wide SM (≥2 mm) is indicated.