Background: Abdominal malignant tumors sometimes involve the inferior vena cava (IVC).1-4 In such cases, radical resection, including IVC resection and reconstruction, is a critical component of curative treatment.3,4 Although patch repair or synthetic tube grafts are used for IVC reconstruction, synthetic grafts may carry risks of infection and thrombosis.5-7 Although tubularized bovine pericardium grafts have shown favorable outcomes, the technical details are not well documented.1,8-11 CASE PRESENTATION: IVC patch reconstruction using bovine pericardial grafts was performed in three cases. In one, the patch extended over more than two-thirds of the circumference, and the reconstruction was carried out in an irregular shape to preserve the branch of the left renal vein. By using a tubularized bovine pericardium graft, a smooth shape enabled easier reconstruction of the branches. A 33-year-old woman presented with an initially unresectable large leiomyosarcoma invading the IVC and hepatic veins. After chemotherapy shrank the tumor, surgical resection, including right nephrectomy, partial hepatectomy, and IVC resection, was performed. A 14 cm tube graft was created in the operating room using bovine pericardium, and this was anastomosed to the IVC. Elevated left renal vein pressure indicated side-to-end anastomosis. Postoperative computed tomography confirmed graft patency, and the patient was discharged uneventfully on postoperative day 10.
Conclusions: We present the technical details of IVC resection and reconstruction using a tubularized bovine pericardium graft, along with left renal vein reconstruction.
Background: Men are often diagnosed with node-positive breast cancer and treated with mastectomy because of a lack of screening and an unfavorable tumor-to-breast ratio. The AMAROS trial showed no difference in outcomes between axillary lymph node dissection (ALND) and axillary radiation in women with cT1-2N0 breast cancer with positive sentinel lymph nodes (+SLNs). Axillary management in men remains unstandardized, so we assessed current trends and outcomes.
Methods: Males with cT1-2N0M0 breast cancer undergoing mastectomy with one to two +SLNs were identified from the National Cancer Database (2018-2021). Patients were stratified by axillary management. Postmastectomy radiotherapy (PMRT) included chest wall and axillary fields. Management strategies and overall survival were analyzed.
Results: Among 445 patients, 25% had no further axillary treatment, 22% underwent ALND, 29% PMRT, and 24% ALND+PMRT. Patients with two +SLNs more often underwent ALND+PMRT (43% vs. 19%, p < 0.001). The use of PMRT rose over time (23-36%), whereas ALND alone declined (27-12%). Additional positive nodes were found in 31% of ALND cases, with no difference between ALND and ALND+PMRT. Performance of ALND delayed PMRT (194 vs. 133 days from diagnosis, p < 0.001). On multivariable analysis, two +SLNs predicted ALND+PMRT (odds ratio 2.5, p = 0.006). Older age (p < 0.001) and two +SLNs (p = 0.03) were linked to worse overall survival, whereas axillary management was not (p = 0.23).
Conclusion: Although axillary strategies are proven safe and effective in women, their extrapolation to men is inconsistent. Half of men undergoing mastectomy are undertreated or overtreated, underscoring the need for multidisciplinary consensus and prospective male-specific data to guide care and reduce morbidity.
Background: Radiographically occult peritoneal carcinomatosis (PC) is a major concern in gastric cancer; hence staging laparoscopy (SL) is recommended prior to initiating treatment, particularly neoadjuvant systemic therapy (NST). However, compliance may vary and could result in understaging. We sought to evaluate the utilization of SL in patients with gastric cancer referred to academic institutions.
Patients and methods: This is a multi-institution retrospective study of patients with a diagnosis of gastric/gastroesophageal junction (GEJ) Siewert 3 adenocarcinoma who received treatment between 2010 and 2022. Demographics, tumor characteristics, treatment, and recurrence data were collected. Descriptive statistics and multivariate analysis were performed.
Results: A total of 280 patients with gastric/GEJ cancer were identified, of which 75 (26.8%) had clinical stage IV disease and were excluded. Of the remaining 205 patients, 74 (36.1%) underwent upfront surgery and 131 (63.1%) underwent NST. Only 39 (29.8%) patients in the NST group underwent SL, of whom 15(38.4%) were found to have peritoneal metastases; 12 (80%) had gross PC and 3 (20%) had positive cytology. Among patients who underwent surgical resection after NST (n = 77), 26 (33.7%) experienced disease recurrence with a median time to recurrence of 11.6 months. The peritoneum (n = 10/26, 38.5%) was the most common site of recurrence.
Conclusions: Compliance with SL prior to NST is poor (29.8%), and in the group that underwent SL, 38% of patients were upstaged due to presence of peritoneal metastases. These findings are significant, as the management and prognosis of peritoneal metastases are drastically different. Various factors could lead to poor compliance with SL, hence better compliance and alternate approaches to reliably detect PC are needed.
Background: In patients with colorectal cancer and peritoneal metastases (CRC-PM), the completeness of cytoreductive surgery (CRS) is crucial. However, a history of moderate (Prior Surgical Score, PSS-2) or extensive (PSS-3) abdominal surgery may compromise the exploration, increasing the risk of undetected CRC-PM. This retrospective monocentric study investigated the value of preoperative peritoneal magnetic resonance imaging (MRI) in identifying potentially occult lesions in patients with PSS-2/3 CRC-PM scheduled for CRS.
Patients and methods: Consecutive patients with pathologically confirmed CRC-PM and PSS-2/3, selected for radical treatment, were included. All underwent preoperative peritoneal MRI ≤ 7 days before CRS, between January 2015 and December 2020. MRI, surgical, and pathological reports were reviewed focusing on seven anatomical sites of interest (perihepatic, pelvic, retroperitoneum, abdominal wall, anastomosis, inguinal canal, and cardiophrenic space).
Results: Overall, 248 patients were included; 242 (97.6%) underwent complete CRS (CC-0). Among them, 212 (85.5%) were PSS-2 and 36 (14.5%) PSS-3. The sensitivity, specificity, and accuracy of MRI in detecting lesions were, respectively, 65%, 91%, and 82% (perihepatic region); 53%, 81%, and 63% (pelvis); 41%, 91%, and 69% (retroperitoneum); 46%, 91%, and 79% (abdominal wall); and 44%, 98%, and 74% (anastomotic sites). In the inguinal canal and cardiophrenic space, preoperative MRI led to ten resections in ten patients, with neoplastic cells detected in eight cases (80%).
Conclusions: Preoperative peritoneal MRI demonstrated good specificity and a promising negative predictive value (NPV) but modest sensitivity in detecting lesions across seven anatomically challenging regions. Further studies are warranted to better define its added value over standard preoperative imaging protocols.
Introduction: Combined criteria have been used in many facets of urologic surgical care in the management of urological cancer. We aimed to validate the prognostic ability of a pentafecta related to the outcomes of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).
Patients and methods: Data were obtained from the Clinical Research Office of the Endourology Society Urothelial Carcinomas of the Upper Tract (CROES-UTUC) registry, a prospective multinational database. Non-metastatic UTUC patients treated with RNU were included. We adopted a pentafecta criteria of (1) negative surgical margin; (2) en bloc resection of the bladder cuff; (3) absence of major complications; (4) template-based lymph node dissection performed per European Association of Urology guidelines; and (5) absence of recurrence (urothelial and/or distant recurrence) within 12 months. Outcomes were pentafecta achievement rates and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meier survival analyses with log-rank were performed on survival outcomes. Multivariate Cox regression was performed to identify confounders, and logistic regression was performed to identify factors that confounded the pentafecta achievement rate.
Results: Overall, 1049 cases were analyzed, and pentafecta was achieved in 504 patients (48.0%). Baseline characteristics were comparable between those who achieved pentafecta versus those who did not. Pentafecta achievement was associated with OS advantage (hazard ratio [HR] 0.586, p = 0.024) and RFS advantage (HR 0.291, p = 0.001). Multivariate Cox regression analysis identified that only pentafecta achievement and advanced T stage were independent predictors of RFS and OS. A ureteric location (compared with pelvicalyceal tumor) (odds ratio [OR] 0.424, p = 0.002), multifocality (OR 0.191, p < 0.001) and open RNU (OR 0.661, p = 0.010) were predictors of pentafecta non-achievement.
Conclusion: We validated a pentafecta that gauged surgical quality for RNU. Quality-of-care metrics should be promoted to unify surgical outcomes in UTUC management.
Background: Occult malignancy (OM) identified in contralateral prophylactic mastectomy (CPM) presents a challenge for axillary management.
Methods: This meta-analysis identified retrospective studies using PubMed, Embase, and Cochrane Reviews with the keywords OM and CPM. In this study, OM was defined as invasive disease only. To determine the proportion of OM and node positivity rates, MedCalc software was used.
Results: The 27 studies in this meta-analysis included 5728 patients who underwent CPM, with OM identified in 87 patients. The pooled incidence of OM was 1.55%. Of the 73 patients with axillary staging details available, 41 patients with OM (56%) underwent surgical axillary staging. Of these 41 patients, 8 had a positive sentinel lymph node (SLN) (20%), and 4 of the 8 patients had subsequent axillary lymph node dissection (ALND) with no additional positive lymph nodes identified. For 64 of the 87 patients with OM, T category was available. Of these 64 patients, 62 (97%) had pT1 and 2 (3%) had pT2 carcinoma. Histologic subtype was available for 52 OMs. Of these, 39 (75%) were ductal, 8 (15%) were lobular, and 5 (10%) were other. Biomarkers were available for 33 OMs, of which 21 (64%) were luminal A, 3 (9%) were luminal B, 3 (9%) were luminal human epidermal growth factor receptor 2 (HER2), and 6 (18%) were triple-negative.
Conclusions: Occult malignancy in CPM is uncommon (1.55%), and when it occurs, it is predominantly pT1, luminal A, or invasive ductal carcinoma. Occult malignancy with SLN metastasis occurs in only 0.1% of CPMs, and when present, SLN metastasis is low volume (≤2 nodes). This supports the current guideline recommendations against routine SLN surgery at the time of CPM.
Background: Age related changes in the tumor microenvironment (TME) may contribute to cancer progression in older adults. Changes in gene expression with age were analyzed to identify differences in cytokine activity and the extracellular matrix (ECM) in papillary thyroid cancer (PTC).
Patients and methods: RNA sequencing data of PTC samples were obtained from The Cancer Genome Atlas (TCGA) and divided into four groups: G1 (22-55 years), G2 (55-64 years), G3 (65-74 years), and G4 (≥ 75 years). Disease stages were defined as local (T1-3N0M0), nodal (T1-3N1abM0), and advanced (T4NXM0-1). Differentially expressed genes (DEGs) identified from DESeq2 RNA-seq analysis were subjected to gene set enrichment analysis (GSEA) and ingenuity pathway analysis (IPA).
Results: Overall, 476 PTC samples were retrieved: G1 (n = 329), G2 (n = 71), G3 (n = 49), and G4 (n = 27). Advanced disease occurred more frequently in older patients (2% in G1 versus 10% in G4, p < 0.0001). Comparing G1 versus G2, G1 versus G3, and G1 versus G4 identified 179, 153, and 254 DEGs, respectively (padj < 0.01). GSEA identified 23 ECM-associated DEGs and 11 cytokine receptor binding-associated DEGs that showed increasing transcription from G1 to G4. A subgroup analysis performed on only patients with conventional PTC found a larger number of DEGs from G1 to G4 than in the overall cohort (85% versus 73%, respectively).
Conclusions: Expression of genes associated with the ECM and cytokine receptor binding changed significantly with advanced age, suggesting that age related changes in the TME may contribute to cancer progression.
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