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Objective: Metastatic PDAC has a very poor prognosis, and surgery has a limited role. The study aims to evaluate the OS of patients with PDAC and synchronous liver metastasis who undergo surgical therapy (ST) versus non-surgical therapies (NST).

Methods: We performed a random effects meta-analysis. Inclusion criteria were: PDAC histology; studies reporting technically resectable cases with liver metastasis and survival data; absence of extra-hepatic disease. The primary endpoint was to evaluate OS. Results were reported as HR and 95 % CI. We performed a meta-regression analysis to identify factors influencing heterogeneity. We analyzed key covariates in order to predict how changes in these factors affect HR.

Results: Six studies were included. The OS was significantly better in group ST than NST, with HR = 0.41 (95 % CI: 0.32-0.52). Heterogeneity was high (I² = 64.50 %). As the rate of patients who underwent postoperative CT in the ST group decreased, the difference between the two groups decreased (β = -1.28 ± 0.67; p = 0.003), with almost 87.10 % heterogeneity. The adjusted effect based on meta-regression showed an improved OS in ST group only when both pre- and post-operative systemic CT were administrated (HR 0.18, 95 % CI: 0.08-0.40).

Conclusions: In highly selected patients with metastatic PDAC who respond to systemic CT and receive post-operative systemic CT, ST could be associated with improved OS. However, the high heterogeneity and retrospective design of included studies limit the ability to draw definitive conclusions.

Objective: To compare the safety and efficacy of radical prostatectomy with DaVinci robot and Hugo robot.

Methods: The system searches Embase, PubMed, Cochrane library, and Web of Science 4 database. The search time ranges from database creation to June 2024. Stata17 was used for statistical analysis.

Results: A total of 5 studies were conducted, including 816 patients. The results showed that there was no difference in age, preoperative prostate volume, preoperative PSA level, operation time, estimated blood loss, length of stay, overall complications, urinary incontinence, lymph node yield, and positive margin between DaVinci robot and Hugo robot radical prostatectomy. However, the BMI of DaVinci group was larger than that of Hugo (Effect = 0.47, 95%Cl [0.03, 0.91], P < 0.05).

Conclusion: The BMI of the DaVinci group seems to be larger, and Hugo robotic radical prostatectomy seems to be as effective as DaVinci robotic radical prostatectomy. But more well-designed studies are needed to assess the oncology outcomes and cost-effectiveness of both. In addition to this, the accumulation of surgeon experience and the transfer of robotic skills are worthy of further attention.

Background: Lymph node metastasis (LNM) prediction for each LN station is required for tailored surgery for patient safety or improving quality of life in gastric cancer. This retrospective review was performed to develop a prediction program for calculating the probability of LNM according to LN stations in patients with gastric cancer.

Method: Among patients who underwent gastrectomy for primary gastric cancer between 2003 and 2017 at Seoul National University Hospital, 4660 patients up to 2013 were used as the development set, and 2564 patients after 2013 were used as the validation set. Not only the center of tumor but also all locations of stomach by tumor were included in the analysis. A multiple logistic regression analysis was used to develop an LNM prediction program for each LN station in development set. The program was validated using C-statistics and a calibration plot of the validation set.

Results: Multivariate analysis identified tumor depth, gross type, and involved locations as covariates associated with LNM. However, the significant factors differed slightly according to the LN station. The prediction equations were developed for each LN station. In the validation set, the prediction equation exhibited good discriminant C-statistics of over 0.8 for all stations. The calibration plot of the prediction equation predicted the LNM rate, which corresponded closely to the actual rate.

Conclusions: A program was developed to predict LNM at LN stations. Predictive power was confirmed via internal validation. Predicting the LN metastatic rate for each LN station could help in planning more customized surgery.

Introduction: Randomised controlled trials (RCTs) with surgical interventions frequently lack a framework to ensure surgical quality. We aimed to investigate surgical quality assurance (SQA) in oesophagogastric oncology trials and to develop a translatable framework of strategies to overcome challenges in the design and implementation of SQA.

Methods: Seventy-one peer-nominated, international, expert trial stakeholders included surgeons; oncologists; trial managers and trial methodologists. Semi-structured interviews were conducted with expert stakeholders examining challenges to SQA in oncology trials followed by a Delphi process to gain consensus on mitigating strategies. Relevant expert consensus strategies were selected for inclusion within a separate written survey and Delphi process in the active ADDICT RCT.

Results: Expert consensus was reached for 59 strategies to overcome challenges to SQA in oncology trials. 19 of these strategies were selected for inclusion within the ADDICT survey and Delphi process, of which 14 (74 %) gained consensus amongst ADDICT trial stakeholders across two Delphi rounds, indicating their relevance within an active surgical oncology RCT. Prominent mitigating strategies included operative monitoring using photographs and/or videos with a structured objective assessment tool. Summarising the expert Delphi consensus allowed formulation of a framework of strategies to overcome challenges to SQA in oncology trials (SQA-Onc.) CONCLUSION: In this first international expert consensus within this area, agreement was reached for 59 strategies to overcome challenges to implementation of SQA. The proposed SQA-Onc. tool is intended to support SQA measures within future trials. Validating this framework within the next generation of RCTs should be the focus of future research.

Objective: We sought to develop a predictive model to preoperatively identify patients with hepatocellular carcinoma (HCC) at risk of undergoing futile upfront liver resection (LR).

Methods: Patients undergoing curative-intent LR for HCC were identified from a large multi-institutional database. Futile LR was defined by death or disease recurrence within six months postoperatively. Backward logistic regression was performed to identify factors associated with futility. Additionally, binary criteria were established for surgical candidacy, aiming to keep the likelihood of futility below 20 %.

Results: Among 1633 patients with HCC, 264 (16.2 %) underwent futile upfront LR. Tumor burden score (TBS) (coefficient: 0.083, 95%CI: 0.067-0.099), alpha-fetoprotein (AFP) (coefficient: 0.254, 95%CI: 0.195-0.310), and albumin-bilirubin (ALBI) grade 2/3 (coefficient: 0.566, 95%CI: 0.420-0.718) were independently associated with an increased risk of futile LR. The model demonstrated strong discrimination and calibration in both derivation and validation cohorts. Low, intermediate, and high-risk groups were determined based on the risk model, each with an escalating likelihood of futility, worse histological features, and worse survival outcomes. Six distinct conditions based on AFP-adjusted-to-TBS criteria were established, all with a futility likelihood of less than 20 %. Patients fulfilling these criteria had significantly better long-term recurrence-free and overall survival. The futility risk model was made available online for wide clinical applicability: (https://altaf-pawlik-hcc-futilityofsurgery-calculator.streamlit.app/).

Conclusion: A preoperative risk model and AFP-adjusted-to-TBS criteria were developed and validated to predict the likelihood of futile LR among patients with HCC. This pragmatic clinical tool may assist clinicians in preoperative decision-making, helping them avoid futile surgery unlikely to offer long-term benefits.

Background: This study aimed to compare the long-term oncologic outcomes of robot-assisted minimally invasive esophagectomy (RAMIE) with those of conventional open esophagectomy (OE) for esophageal cancer.

Methods: Between January 2006 and December 2021, 1745 consecutive patients underwent esophagectomy for esophageal cancer at Asan Medical Center, Korea. Among them, we retrieved 1133 patients (mean age 63.1 ± 7.8 years, 86 [7.6 %] women, 1100 [97.1 %] squamous cell carcinomas), who were operated by a single surgeon. These patients were categorized into following two groups based on their surgical approaches: RAMIE (n = 497) and OE (n = 636). The RAMIE and OE groups were matched in a 1:1 ratio using propensity scores. Overall survival (OS) and recurrence-free survival (RFS) were compared between the groups.

Results: The median follow-up was 51.8 (24.6-90.2, interquartile) months. Five-year OS (70.7 % vs. 55.0 %, P < 0.01) and RFS (63.3 % vs. 50.1 %, P < 0.01) rates were significantly higher in RAMIE than in OE group. Following propensity-score matching, 886 patients (443 pairs) were successfully matched, demonstrating no significant intergroup differences, including the pathologic stage. The RAMIE group consistently demonstrated enhanced OS (70.4 % vs. 61.8 %, P < 0.01) and RFS (62.8 % vs. 55.8 %, P = 0.04) after five years, even after adjustment. The rate of noncancer mortality was significantly higher in the OE group (P < 0.01), whereas the rate of esophageal cancer-related mortality showed no significant differences between the groups (P = 0.25).

Conclusions: RAMIE could be a safer option for patients compared with conventional open esophagectomy with favorable long-term outcomes related to noncancer mortality.

Background: ¹⁸F-FDG PET-CT-based host metabolic (PETMet) profiling of non-tumor tissue is a novel approach to incorporate the patient-specific response to cancer into clinical algorithms.

Materials and methods: A prospectively maintained institutional database of gastroesophageal cancer patients was queried for pretreatment PET-CTs, demographics, and clinicopathologic variables. ¹⁸F-FDG PET avidity was measured in 9 non-tumor tissue types (liver, spleen, 4 muscles, 3 fat locations). Logistic and Cox regression were used to model pathologic response (PR) and overall survival (OS) respectively. Classification and regression tree (CART) and random forest modeling were employed to create decision trees and identify PETMet features associated with outcome.

Results: Two-hundred and one patients with distal gastroesophageal (48 %) or gastric (52 %) adenocarcinoma were included. PET-CT-derived scores were independently associated with PR after adjusting for clinical variables. CART and Random Forest methods identified critical split points of non-tumor tissue ¹⁸F-FDG avidity that can classify patients and predict PR. PET-CT risk groups created from decision trees predicted PR significantly better than the clinical model (p < 0.001). Specifically, an elevated erector spinae-to-gluteal fat ¹⁸F-FDG avidity ratio (≥2.7) combined with low ¹⁸F-FDG avidity in the spleen (<2.9) and rectus femoris (<0.52) predict PR. No advantage of PET-CT risk groups was seen for predicting OS (p = 0.155).

Conclusions: Pretreatment host PETMet features may be useful for predicting PR after neoadjuvant therapy in gastroesophageal cancer. Unsupervised decision trees indicate that low ¹⁸F-FDG avidity in visceral fat, subcutaneous fat, and muscle result in the most favorable PR, suggesting that systemic hypermetabolism adversely impacts prognosis.

Background: Centrally located hepatocellular carcinoma (HCC) is a subtype HCC with special location adjoined hepatic portals. It is difficult to be radically resected with sufficient surgical margin. We discussed whether neoadjuvant therapy could increase surgical margin and reduce recurrence.

Methods: From January 2018 to September 2023, 106 centrally located HCC patients who underwent radical liver resection were retrospectively included. Neoadjuvant therapy included transarterial chemoembolization (TACE) with programmed death 1 (PD-1) inhibitors plus tyrosine kinase inhibitor (TKI). Surgical margin and long-term outcomes were compared between patients with and without neoadjuvant therapy.

Results: 40 patients underwent neoadjuvant therapy and 66 patients underwent surgery alone. In neoadjuvant therapy group, 3 (7.5 %) patients achieved progression disease, 9 (22.5 %) patients achieved stable disease, 13 (32.5 %) achieved partial response and 15 (37.5 %) achieved complete response based on the mRECIST criterion. Ultimately, 36 patients (90 %) underwent subsequent surgical resection in the neoadjuvant therapy group. The neoadjuvant therapy had the advantages of declining alpha fetoprotein level (5.9 ng/mL vs 50.1 ng/mL, P = 0.001), microvascular invasion rate (MVI) (12.5 % vs 30.3 %, P = 0.036), reducing tumor size to 5.1 ± 2.1 cm from 6.2 ± 2.2 cm (P = 0.021), and increasing more patients with surgical margin>1 cm (30.0 % vs 7.6 %, P = 0.002). The neoadjuvant therapy group reduced tumor recurrence and prolonged overall survival. Multivariate analysis found that neoadjuvant therapy was an independent protective factor for overall survival and recurrence free survival.

Conclusions: Neoadjuvant therapy showed advantage of reducing tumor burden and increasing surgical margin for centrally located HCC, resulting in longer overall survival and recurrence free survival.