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Introduction: Microvascular invasion (MVI) is the main risk factor for overall mortality and recurrence after surgery for hepatocellular carcinoma (HCC).The aim was to train machine-learning models to predict MVI on preoperative CT scan.

Methods: 3-phases CT scans were retrospectively collected among 4 Italian centers. DICOM files were manually segmented to detect the liver and the tumor(s). Radiomics features were extracted from the tumoral, peritumoral and healthy liver areas in each phase. Principal component analysis (PCA) was performed to reduce the dimensions of the dataset. Data were divided between training (70%) and test (30%) sets. Random-Forest (RF), fully connected MLP Artificial neural network (neuralnet) and extreme gradient boosting (XGB) models were fitted to predict MVI. Prediction accuracy was estimated in the test set.

Results: Between 2008 and 2022, 218 preoperative CT scans were collected. At the histological specimen, 72(33.02%) patients had MVI. First and second order radiomics features were extracted, obtaining 672 variables. PCA selected 58 dimensions explaining >95% of the variance.In the test set, the XGB model obtained Accuracy = 68.7% (Sens: 38.1%, Spec: 83.7%, PPV: 53.3% and NPV: 73.4%). The neuralnet showed an Accuracy = 50% (Sens: 52.3%, Spec: 48.8%, PPV: 33.3%, NPV: 67.7%). RF was the best performer (Acc = 96.8%, 95%CI: 0.91-0.99, Sens: 95.2%, Spec: 97.6%, PPV: 95.2% and NPV: 97.6%).

Conclusion: Our model allowed a high prediction accuracy of the presence of MVI at the time of HCC diagnosis. This could lead to change the treatment allocation, the surgical extension and the follow-up strategy for those patients.

Background: While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer.

Materials and methods: MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed.

Results: The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I²:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I²:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I²:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I²:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved.

Conclusion: When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.

Background: The impact of preoperative sarcopenia on postoperative outcomes in gastric cancer remains debated. This study aims to perform an in-depth meta-analysis and comprehensive review of the relationship between preoperative sarcopenia, as assessed by the Skeletal Muscle Mass Index (SMI), and postoperative complications and survival metrics in gastric cancer patients, to offer new insights into this issue.

Methods: We conducted a systematic search of primary studies in databases such as Embase, PubMed, and Web of Science, up to July 2024. Our analysis focused on comparing postoperative readmission and mortality rates, overall and severe complication rates, incidence of specific complications, as well as overall survival (OS) and disease-free survival (DFS) between groups with and without preoperative sarcopenia.

Results: Our review included 42 studies with a total of 11,981 patients. Findings revealed that patients with sarcopenia had significantly higher rates of overall postoperative complications, severe complications, mortality, and readmissions compared to those without sarcopenia (all P < 0.001). A detailed examination showed that sarcopenic patients had notably higher incidences of pulmonary complications, bowel obstruction, and pancreatic fistulas. Additionally, the OS (P < 0.001) and DFS (P = 0.003) rates were considerably lower in the sarcopenia group.

Conclusions: Preoperative sarcopenia is associated with an increased risk of postoperative complications and poorer survival outcomes in gastric cancer patients. Given these associations, it is recommended to incorporate routine screening for sarcopenia using SMI before surgery, where feasible, to enhance patient risk assessment and customize treatment approaches.

Objective: To assess the safety and long-term effectiveness of minimally invasive approach in managing "oldest old" endometrial cancer patients.

Methods: This is a retrospective cohort, multi-institutional study. Consecutive patients, treated between 2000 and 2020, with apparent early-stage endometrial cancer patients, aged ≥85 years. Surgery-related outcomes of robotic-assisted, laparoscopic, and vaginal surgery were compared. Survival was evaluated in patients with at least 3-year follow-up data.

Results: Charts of 82 endometrial cancer patients "oldest old" were retrieved. Intermediate-high and high-risk endometrial cancer patients accounted for 26 (31.7 %) and 17 (20.7 %), respectively. In total, 12 (15 %), 45 (55 %), and 25 (30 %) patients underwent robotic-assisted, laparoscopic, and vaginal surgery, respectively. Looking at surgery-related outcomes, robotic-assisted surgery correlated with a longer operative time (p < 0.001) and longer length of hospital stay (p = 0.002) in comparison to laparoscopic and vaginal approaches. Overall, seven (8.5 %) conversions from the planned approach occurred. The surgical approach did not influence disease-free survival (p = 0.6061) and overall survival (p = 0.4950). Via multivariate analysis, only serosal/adnexal invasion correlated with the risk of death (HR: 3.752, p = 0.038).

Conclusions: All three minimally invasive approaches are safe and effective methods for managing endometrial cancer in the oldest old population. Chronological age, per se, should not be considered a contraindication for receiving minimally invasive surgery.

Objective: Pulmonary pleomorphic carcinoma is a relatively rare and aggressive subtype of non-small cell lung cancer (NSCLC), with a poor prognosis and early recurrence, and is resistant to conventional therapies. This study investigated the efficacy of immune checkpoint inhibitors (ICIs) in improving the survival outcomes of patients with pulmonary pleomorphic carcinoma with postoperative recurrence.

Methods: We conducted a retrospective analysis of 71 patients with pulmonary pleomorphic carcinoma who underwent pulmonary resection at Tokyo Medical University Hospital between 2008 and 2022. Clinicopathological data, programmed cell death ligand 1 (PD-L1) expression, and postoperative recurrence treatment outcomes were reviewed.

Results: Among the 71 patients with pulmonary pleomorphic carcinoma, the 5-year overall survival (OS) rate was 48.6 %, and high PD-L1 expression (28-8 clone) was observed in 87 %. The median recurrence-free survival (RFS) was 19.4 months, and postoperative recurrence occurred in 38 patients (54 %). Treatment after recurrence was administered to 24 patients (63 %), and immunotherapy was administered to 10 patients (26 %). In patients treated with ICI, the overall response rate (ORR) was significantly higher (50 %) compared to those treated without ICI (7 %). The median survival time after relapse was notably longer in the ICI-treated group (83.9 months), compared to the non-ICI group (10.1 months).

Conclusion: ICIs significantly improve survival outcomes in patients with recurrent pulmonary pleomorphic carcinoma, particularly in those with high PD-L1 expression. Early postoperative recurrence and rapid progression have been observed, making therapeutic intervention challenging. Close follow-up is crucial, and ICIs become a pivotal treatment option for managing this highly aggressive cancer.

Background: In line with the trend towards minimally invasive, patient-tailored treatment, a selected group of patients with an in-breast tumour recurrence (IBTR) is treated by repeat breast-conserving treatment (BCT). To select eligible patients for repeat BCT, a reliable pre-operative work-up is essential. This study reports on the role of ¹⁸F-FDG PET/CT in detecting synchronous regional and distant metastases in patients with IBTR.

Patients and methods: A nation-wide data query was sent out to all Dutch hospitals offering breast cancer treatment. Breast cancer surgeons from 34 hospitals participated, filling electronic case report forms (eCRFs) on 549 patients treated for IBTR from 2016 to 2017.

Results: Of the 549 included patients, 297 were screened using ¹⁸F-FDG PET/CT for the presence of distant metastases. Forty of them (13.5 %) presented with synchronous distant metastatic disease. In 168 clinically node-negative patients who underwent ¹⁸F-FDG PET/CT, a suspect regional lymph node was found in 18 (10.7 %). Final pathology of these lymph nodes yielded a positive lymph node in 12 patients (7.1 %). Positive predictive value (PPV) of ¹⁸F-FDG PET/CT in clinically node-negative patients was 66.7 % and negative predictive value (NPV) was 85.3 %.

Conclusion: The clinically relevant percentage of synchronous distant metastatic disease justifies the use of ¹⁸F-FDG PET/CT in the workup of patients with an IBTR. Furthermore, ¹⁸F-FDG PET/CT can assist in detecting regional axillary lymph node metastases, but requires histopathological confirmation given the moderate PPV, before clinical decisions can be made.

Background: Population ageing and cancer burden are important global public health problems that pose unprecedented threats to health systems worldwide. Frailty is a common health problem among elderly patients with cancer. In recent years, the use of prehabilitation to improve frailty has received widespread attention. Few studies have addressed the specific physiologic effects of prehabilitation on patients undergoing surgery.

Methods: Frail elderly patients (aged at least 65 years) who underwent elective primary surgery for gastric cancer between September 2022 and October 2023 were included in this single-centre prospective cohort study and were categorized into multimodal prehabilitation or ERAS standard care groups. Prehabilitation, including physical and respiratory training, nutritional support and psychosocial treatment, was provided at least two weeks before gastrectomy. The primary outcome was functional status. Secondary outcomes included changes in indices of lipid metabolism, oxidative stress and chronic inflammation.

Results: Over a 13-month period, 137 participants were assessed for eligibility, and 110 patients (prehabilitation 55, ERAS 55) were analysed. Compared with the baseline, patients in the prehabilitation group exhibited increased physical capacity before the operation (mean 6-min walk test change +28 m; P < 0.001). After prehabilitation intervention, inflammation-related indicators (NLR, PLR, SII and CRP) improved, and proinflammatory cytokine production (IL-5, IL-6, IL-1β, IL-10 and TNF-α) decreased. After surgery, the increase in IL-6 was reduced in the prehabilitation group (P = 0.036). Moreover, prehabilitation was associated with alleviating oxidative stress as determined by the levels of MDA (P = 0.005).

Conclusion: Multimodal prehabilitation can play a beneficial role in improving functional abilities by reducing chronic inflammation, improving lipid metabolism, and attenuating oxidative stress.

Background: Fluorescence-guided lymphadenectomy (FLND) using indocyanine green (ICG) has emerged as a promising technique to enhance the accuracy of lymphadenectomy in rectal cancer surgery. Effective lymphadenectomy is crucial for improving prognosis in patients with advanced rectal cancer, but it remains technically challenging and controversial.

Methods: This prospective nonrandomized controlled study was conducted involving 129 patients underwent laparoscopic surgery, and 64 patients assisted by FLND. Patients received submucosal ICG injections before surgery to facilitate FLND. Lymph nodes were categorized as station 251, station 252, or station 253 based on their anatomical locations. The effectiveness of FLND was evaluated by comparing the number of harvested and metastatic lymph nodes between the FLND and control groups.

Results: The FLND group demonstrated a significantly higher median number of harvested station 253 lymph nodes compared to the control group (2.0 vs. 1.0, P = 0.007). The FLND cohort had a shorter postoperative hospital stay (6 days vs. 8 days, P < 0.001) and similar rates of postoperative complications compared to the control cohort. The study found no significant differences in the median number of harvested station 251 (10.0 vs. 11.0, P = 0.872) and station 252 (6.0 vs. 5.0, P = 0.369) lymph nodes between the groups. Univariate and multivariate analyses indicated that FLND significantly increased the harvested lymph node count.

Conclusion: Radical surgery assisted by FLND significantly improves the accuracy and yield of lymphadenectomy in mid-low rectal cancer, enhancing surgical outcomes and patient prognosis. Future advancements in fluorescence imaging and related technologies hold promise for further improving the clinical effectiveness of this technique.

Neoadjuvant chemotherapy is suggested in locally advanced colon cancer. Data on improved long-term oncological outcomes are lacking, which hampers the implementation in clinical practice. This systematic review provides an overview of the benefits and drawbacks of neoadjuvant chemotherapy in patients with locally advanced colon cancer. A systematic literature search was performed using Embase (OVID), MEDLINE (OvidSP), and the Cochrane Library. Studies reporting on the efficacy of neoadjuvant chemotherapy in patients with operable, locally advanced colon cancer without metastases at the time of diagnosis were considered eligible for inclusion. An overview of short- and long-term outcomes of neoadjuvant chemotherapy is provided based on available literature. Additionally, proportional meta-analyses were performed using MedCalc Statistical Software version 19.2.6. A total of 17 unique studies were included in this review, 3 randomised controlled trials and 14 prospective single-arm or retrospective studies. The maximum reported dropout before surgery was 7.8 % in the neoadjuvant chemotherapy group. A histopathological complete response after neoadjuvant chemotherapy was observed in 0-4.8 % of the patients. The occurrence of anastomotic leaks was less than 8 % for both patients treated with neoadjuvant chemotherapy and patients treated with upfront surgery. Neoadjuvant chemotherapy is a safe alternative for adjuvant chemotherapy based on the dropout rate before surgery and the peri-operative morbidity and peri-operative mortality. Robust long-term survival outcomes are lacking and serious concerns regarding the risk of overtreatment have been expressed. Hence, neoadjuvant chemotherapy might be considered in a select group of patients with locally advanced colon cancer.