Annals of Surgical Oncology最新文献

Background: The integration of robotic pancreatectomy into radical resections for advanced gastric cancer (AGC) is a novel and underexplored area, offering potential benefits for both patient outcomes and healthcare systems.^1-10 We report two cases of AGC with pancreatic invasion, managed through robotic pancreatectomy in combination with gastrectomy, enabled by a collaborative effort between upper GI and pancreatic surgeons.

Methods: In the first case, a 75-year-old woman with gastric outlet obstruction due to advanced gastric cancer underwent gastric bypass followed by four cycles of neoadjuvant SOX plus trastuzumab. Robotic pancreaticoduodenectomy was subsequently performed alongside distal gastrectomy with D2 lymphadenectomy, addressing pancreatic head invasion. Postoperative recovery was uneventful, with minimal pain and early resumption of oral intake. She remains disease-free 21 months after treatment.

Results: The second case involved a 66-year-old woman diagnosed with upper gastric cancer with pancreatic body invasion. After achieving a favorable response to four cycles of SOX plus nivolumab, she underwent robotic distal pancreatectomy along with total gastrectomy. Her recovery was smooth, enabling the seamless initiation of adjuvant therapy. She remains recurrence-free 24 months posttreatment.

Conclusions: These cases underscore the advantages of a fully robotic approach, including enhanced surgical precision, faster recovery, and preserved quality of life.^4,10 By enabling pancreatic surgeons to perform complex resections robotically, this strategy encourages upper gastrointestinal surgeons to adopt robotic gastrectomy for advanced cases. Avoiding open conversion reduces the need for additional healthcare resources, underscoring the value of robotic surgery in advancing both patient-centered care and cost-effective cancer management.³.

Background: With the introduction of targeted therapies and the de-escalation of surgical operations, we aimed to describe recent changes in breast cancer treatment.

Patients and methods: The National Cancer Database was queried for patients with clinical stage I-III breast cancer from 2010 to 2023 who underwent surgery. Cochran-Armitage trend tests and the Kaplan-Meier method were used.

Results: We identified 1,769,438 patients; median age was 61 years, with clinical stage I (60.6%), stage II (32.7%), and stage III (6.7%). In total, 74.1% of patients had ER+/HER2-, 13.5% HER2+, and 12.3% ER-/HER2- disease. Most patients (62.7%) underwent breast-conserving surgery (BCS). Mastectomy rates declined from 42.3% in 2010 to 33.3% in 2023 (p < 0.001); within mastectomy, reconstruction rate increased (36.5% to 48.8%) as did contralateral prophylactic mastectomy rates (31.6% to 47.6%), both p < 0.001. Rates of axillary lymph node dissection (ALND) decreased (38.2% to 18.8%, p < 0.001). Omission of axillary surgery among clinical stage I patients increased (4.3% to 12.5%, p < 0.001). Rates of neoadjuvant chemotherapy increased overall and especially among ER-/HER2+ (30.4% to 70.2%, p < 0.001) and ER-/HER2- (25.5% to 64.8%, p < 0.001) subtypes. Use of neoadjuvant endocrine therapy in ER+/HER2- disease increased from 2.8% to 6.0%, p < 0.001. Use of radiation therapy in patients treated with BCS declined (87.8% to 80.1%, p < 0.001). The 10-year overall survival varied by clinical stage group and biologic subtype.

Conclusions: Breast cancer care has evolved, with decreased use of ALND and increased use of reconstruction and of contralateral prophylactic mastectomy in patients undergoing mastectomy. Furthermore, there has been significant increase in neoadjuvant systemic therapy use, especially among HER2+ and ER-/HER2- biologic subtypes.

Background: This study aimed to evaluate the clinical value of robot-assisted surgery combined with the total mesoesophageal excision (TME) for resectable esophageal cancer and to compare its advantages over conventional minimally invasive esophagectomy (MIE) and non-mesoesophageal esophagectomy.

Methods: The study retrospectively analyzed data from 159 patients who underwent McKeown esophagectomy at 2 provincial tertiary hospitals (January 2019-March 2025). The patients were stratified into 4 groups based on surgical approach, including robot-assisted total mesoesophageal esophagectomy (RATME, n = 38), robot-assisted conventional minimally invasive esophagectomy (RAMIE, n = 37), video-assisted thoracoscopic total mesoesophageal esophagectomy (VATME, n = 42), and video-assisted minimally invasive esophagectomy (VAMIE, n = 42). The analysis compared baseline characteristics, perioperative data, and survival outcomes among groups.

Results: The RATME group had a significantly longer operative time than the other groups (P < 0.01). However, it demonstrated significant reductions in intraoperative blood loss and thoracic drainage volume within the first 48 h postoperatively (P < 0.05), together with a shorter postoperative hospital stay. Compared with the non-mesoesophageal group, the mesoesophageal group had significantly more harvested lymph nodes (P < 0.05) and a lower overall incidence of postoperative complications (P < 0.05). No statistically significant differences were observed in overall survival (OS) or disease-free survival (DFS) among the 4 groups. The incidence of recurrence and death events was lower in the RATME group.

Conclusion: Robot-assisted total mesoesophageal esophagectomy (RATME) could be a safe technique. Integrating mesoesophagus theory with robotic surgery achieved superior perioperative outcomes, including reduced intraoperative bleeding, increased lymph nodes dissected, lower complication rates, and accelerated recovery, and it may bring about a better long-term outcome.

Background: Because of the rapid uptake of robot-assisted radical prostatectomy (RARP), educational programs or established methods based on the skill level and mental stress of surgeons have yet to be established. This study aimed to measure physiologic stress as heart rate (HR) changes and heart rate variations (HRVs) in surgeons wearing a device during RARP.

Patients and methods: We collected device data for 30 consecutive cases from surgeon A, relatively inexperienced in RARP, and surgeon B, experienced in over 200 cases. As a wearable device, we used Fitbit Charge 2 (Fitbit Inc., San Francisco, CA, USA). Surgical outcomes included estimated blood loss volume and robotic console time; HR changes and HRVs in each surgeon were measured. The standard deviation of NN intervals (SDNN) for HRV was calculated and cumulative sum (CUSUM) control charts used to quantitatively evaluate surgeons' learning curves.

Results: For surgeon A, as case numbers increased, console time was significantly reduced; maximum and average HRs were also significantly decreased. However, a trend was not observed for surgeon B. The SDNN, as a biomarker of mental stress in surgeon B, was significantly better compared with surgeon A. For surgeon A, according to an analysis using CUSUM methods, and average and maximum HRs, learning curves with regard to console time and estimated blood loss volume were similar.

Conclusions: By using a wearable device, mental stress, as represented by the HRV, could be easily estimated and visualized as a surgical outcome. This affected surgeons' learning curves, including for console time and estimated blood loss volumes.

Background: Findings have linked GNAS-activating mutations, frequent in appendiceal adenocarcinoma (AA), with improved overall survival but poor response to chemotherapy. The authors hypothesized that GNAS-activating mutations are associated with differential outcomes in AA treated with chemotherapy.

Methods: Patients seen at the authors' center between 2013 and 2023 who received systemic chemotherapy for metastatic/recurrent AA were identified. The primary outcome was disease event-free survival (EFS), defined as time from start of chemotherapy (5-fluorouracil/capecitabine based) to earliest disease event, including death, clinical/radiographic recurrence, or progression. Study outcomes were assessed using Kaplan-Meier estimations and Cox proportional hazards regression.

Results: The study included 48 patients. In 18 (37.5 %) of the 48 patients, GNAS-activating mutations were seen. Patients with GNAS mutations were more likely to have lower grades of disease (p = 0.003), with lower proportions of lymphovascular invasion (p = 0.005) and perineural invasion (p = 0.03), but a higher median peritoneal carcinomatosis index (p = 0.03). In the multivariable analysis, GNAS mutations (10.7 months [95 % confidence interval {CI}, 7.1-19.2] vs 20.3 months [95 % CI, 18.6-29.4; adjusted HR {aHR}, 3.75; 95 % CI, 1.84-7.63] p < 0.001) and metachronous metastases (aHR, 5.14; 95 % CI, 2.08-12.69; p < 0.001) were associated with worse EFS. Both CC0-1 resection (aHR, 0.12; 95 % CI, 0.05-0.28; p < 0.001) and CC2-3 resection (aHR, 0.28; 95 % CI, 0.10-0.81; p = 0.02) were associated with prolonged EFS. There was no significant difference in the OS from the date of metastases diagnosis between the GNAS^mt and GNAS^wt patients (HR, 0.68; 95 % CI, 0.31-1.47; p = 0.33).

Conclusions: With systemic chemotherapy, GNAS-mutated metastatic/recurrent AAs have worse EFS despite less frequent high-risk features. Routine somatic mutation-testing of patients with AA should be considered for prognostication and possibly therapeutic decision-making.

Background: Patients undergo mastectomy in both ambulatory surgery centers (ASCs) and inpatient settings. Guidelines for site selection are poorly defined. Older adults, particularly those with frailty, are at increased risk of adverse outcomes postoperatively. Transfer to an acute hospital is a unique adverse event suggesting potentially inappropriate ASC care.

Methods: The authors used logistic regression modeling to describe the association of frailty with site of care and transfer, and modeled expected costs associated with ambulatory mastectomy for robust and prefrail or frail patients.

Results: In ASCs, 85.3% of all patients and 51.3% of prefrail or frail patients underwent mastectomy. Frailty or prefrailty was associated with increased odds of inpatient care (odds ratio [OR], 5.856; p < 0.001). Odds of transfer were higher among prefrail and frail patients (OR, 2.640; p < 0.05), but rates remained low (< 0.4%). Rates of transfer needed to negate cost-savings from ambulatory procedures are more than 100 times the current rate (38%; standard error, 4.7%). If all prefrail and frail patients received care at ASCs, expected cost savings would be $8404 per patient.

Conclusions: Despite slightly higher rates of transfer, clinicians should consider treating frail and prefrail older adults in ASCs given possible economic benefits.

Background: As the relationship between oral microbiota and treatment efficacy in esophageal cancer remains unexplored, we aimed to clarify it using metagenomic analysis.

Patients and methods: Of the 140 consecutive patients with esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy with R0 resection at Hiroshima University Hospital between April 2020 and May 2024, 74 who received neoadjuvant therapy were included in this study. 16S rRNA gene from oral tongue coating samples was amplified using polymerase chain reaction and subjected to next-generation sequencing. The oral microbiome data were analyzed using QIIME2 and linear discriminant analysis effect size, and the relationship between the oral microbiota and treatment efficacy and prognosis was assessed.

Results: Alpha diversity of the oral microbiota was significantly correlated with the pathological response. Univariate and multivariate analyses showed that the alpha diversity of the oral microbiome (high versus low) was a significant predictor of a good pathological response. Patients with high alpha diversity had significantly improved recurrence-free survival and overall survival compared with those with low alpha diversity. Furthermore, eight bacterial groups (Lactobacillales, Peptostreptococcales-Tissierellales, Bifidobacteriaceae, Erysipelotrichaceae, Lactobacillaceae, Anaerovoracaceae, Staphylococcaceae, and Aerococcaceae) were significantly more abundant in individuals who responded well to neoadjuvant therapy and two bacterial groups (Streptococcaceae and Corynebacteriaceae) were significantly more abundant in poor responders.

Conclusions: Our results demonstrate a correlation between the oral microbiome and ESCC treatment efficacy, suggesting that it is a significant prognostic factor. Our findings may also help predict the efficacy of esophageal cancer treatment.