Annals of Surgical Oncology最新文献

Background: In hepato-pancreato-biliary (HPB) surgery, precise anatomic understanding is essential.1.Ann Hepatobiliary Pancreat Surg. 23:145-154;2.J Hepatobiliary Pancreat Sci. 30:851-862; In Japan, advanced HPB board certification requires preoperative schema drawing.3.J Hepatobiliary Pancreat Sci. 24:252-261 Although three-dimensional (3D) imaging improves preoperative recognition,4.Ann Gastroenterol Surg. 6:190-196;5.Ann Surg Oncol. 32:3539-3543;6.Ann Surg Oncol. 31:6567-6568; no widely adopted system exists for real-time intraoperative navigation.7.Ann Surg. 271:e4-e7;8.Int J Comput Assist Radiol Surg. 20:117-129;9.Gastroenterol Res Pract. 2021:9621323; At the authors' institution, schematic diagrams have been used, but they are time-consuming and limited in detail. To overcome these limitations, the authors developed a simple, low-cost intraoperative 3D navigation method using free computer-aided design (CAD) applications.

Methods: The authors analyzed 32 HPB cases managed between January and August 2025. Computed tomography (CT) data were reconstructed into 3D images using REVORAS (Ziosoft Inc., Tokyo, Japan). Based on these images, schematic diagrams were created with Procreate (Savage Interactive Pty Ltd., Australia), and CAD models were generated with Fusion 360 (Autodesk Inc., San Francisco, CA, USA) and Shapr3D (Shapr3D Zrt., Budapest, Hungary). The creation times were measured and compared.

Results: Surgical approaches included open (n = 14), robotic (n = 16), and laparoscopic (n = 2) procedures comprising pancreatic (n = 18), hepatic (n = 13), and sarcoma (n = 1) resection. Both schematic diagrams and CAD models were created in all cases. The median creation time was significantly shorter for CAD models (7 min 25 s) than for diagrams (19 min 48 s) (p < 0.01). The CAD models enabled real-time anatomic sharing via tablets with TilePro integration in the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA).

Conclusions: Intraoperative CAD-based navigation is simple, cost-effective, and time-efficient, with strong potential for widespread adoption and educational value in HPB surgery.

Background: Although cytoreductive surgery (CRS) and hyperthermic intrathoracic chemoperfusion (HITHOC) are used to treat primary pleural malignancies, their role in managing pleural metastases from pseudomyxoma peritonei (PMP) remains underexplored. This study evaluated the role of CRS/HITHOC on outcomes of PMP with pleural involvement.

Patients and methods: We conducted a single-institution, retrospective analysis of patients with PMP who underwent CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) between 2008 and 2022. Perioperative and oncologic outcomes between patients with metachronous or synchronous pleural metastases were compared between those treated with and without CRS/HITHOC.

Results: A total of 814 patients with PMP underwent CRS/HIPEC during the study period. In total, 64 patients (7.9%) developed pleural metastases (8 synchronous and 56 metachronous), with a median pleural recurrence interval of 15.6 months (interquartile range (IQR) = 6.8-26.6 months). Of these, 20 patients received CRS/HITHOC as part of multimodal management. There was no significant difference in median age between groups (52 versus 56 years; p = 0.602), though the CRS/HITHOC group trended toward fewer preceding recurrences at other sites (35.0% versus 43.2%; p = 0.593). All 20 patients undergoing HITHOC had pleurectomy and decortication; there was no 30-day mortality. The HITHOC group demonstrated a trend toward improved OS after pleural recurrence (58.5 versus 16.4 months; p = 0.063) and had a longer survival from the time of initial HIPEC (106.0 versus 42.9 months; p = 0.015) in this cohort.

Conclusions: Incorporating HITHOC into the management of PMP with pleural involvement was associated with improved survival and may represent an effective strategy for both the treatment and palliation of pleural metastases in PMP.

Background: Cytoreductive hepatectomy has repeatedly been reported to improve prognosis in pancreatic neuroendocrine tumor liver metastasis (PNETLM). However, whether primary tumor resection impacts prognosis in asymptomatic synchronously metastasized pancreatic neuroendocrine tumors (PNETs) remains elusive. We aimed to evaluate the prognostic impact of primary tumor resection in patients undergoing cytoreductive hepatectomy for PNETLM.

Patients and methods: This retrospective single-center study analyzed patients who underwent hepatectomy for pancreatic PNETLM between January 2000 and December 2020. Patients were categorized according to surgical approaches: cytoreductive hepatectomy without primary tumor resection at any time (non-PTR), cytoreductive hepatectomy and pancreaticoduodenectomy (PD), or cytoreductive hepatectomy and distal pancreatectomy (DP). Surgical outcomes and risk factors for overall survival (OS) were assessed.

Results: A total of 118 patients with asymptomatic PNETs and synchronous liver metastases were analyzed. The median OS was 10 years (95% CI: 6.5-12), with no significant differences across surgical approach regarding primary tumor resection (non-PTR: 10 years; PD: 8 years; DP: 9.5 years; p = 0.589). Survival rates at 5 years were 66.7% in non-PTR, 62.3% in PD, and 65.8% in DP respectively. PFS was similar between groups (p = 0.301). Extrahepatic disease and liver lesion count were significant predictors of progression-free survival in univariate analysis (p < 0.050), while resection of the primary tumor had no significant impact (p = 0.749) CONCLUSIONS: PNET primary tumor resection was not associated with improved long-term outcomes in PNETLM patients after cytoreductive hepatectomy. This should spark interest if refraining from primary resection might be an option in selected patients considering the risks associated with pancreatic surgery.

Background: Advanced pancreatic ductal adenocarcinoma (PDAC) often infiltrates or obstructs the superior mesenteric vein (SMV)/portal vein, leading to collateral vein (CV) formation. Although CVs are hypothesized to affect surgical outcomes, data regarding their clinical significance remain limited. This study aimed to evaluate the impact of CV formation on short-term outcomes in patients with PDAC who underwent portomesenteric venous resection (PVR).

Methods: We retrospectively analyzed PDAC cases undergoing PVR at our institution between 2010 and 2023. CVs were identified using preoperative computed tomography, and patients were categorized based on the presence or absence of CVs. Short-term outcomes were assessed prospectively. A subgroup analysis was performed to evaluate the clinical relevance of proximal versus distal SMV involvement.

Results: Among 403 patients with PDAC undergoing PVR, 27 (6.7%) had CVs. The CV group exhibited significantly longer operative times (median: 618 vs. 517 minutes, p < 0.0001) and greater blood loss (median: 1500 vs. 590 mL, p < 0.0001). Postoperative complications (Clavien-Dindo classification ≥IIIa) were more frequent in the CV group (33.3% vs. 10.1%, p = 0.002). Multivariate analysis identified CV formation as the strongest predictor of blood loss ≥1000 mL (odds ratio: 6.63 [95% confidence interval 2.70-17.3], p < 0.0001). As expected, distal SMV involvement correlated with longer operative times but did not impact other outcomes.

Conclusions: CV formation, a characteristic feature of advanced PDAC, was strongly associated with increased surgical difficulty and postoperative complications, highlighting the need for tailored strategies to optimize outcomes in PDAC cases undergoing PVR.

Background: Prior evidence indicate that differences in treatment settings between patients with colorectal cancer (CRC) from high-poverty areas (HPA, ≥ 20% residents living under poverty level) and low-poverty areas (LPA) might have contributed to disparities in their health outcomes. We sought to determine whether certain hospitals predominantly provided surgical care for patients with CRC from HPAs and examine associated patient outcomes.

Patients and methods: We identified patients undergoing surgery for nonmetastatic CRC diagnosed during 1/1/2009-12/31/2019 from SEER-Medicare. We defined poverty-area-serving (PAS) hospitals as hospitals with ≥ 50% patients from HPAs. We compared in-hospital adverse events, 30 day readmission, and long-term mortality between patients from HPAs and LPAs treated at PAS and non-PAS hospitals using logistic and Cox regression.

Results: Our cohort included 81,992 patients with CRC (median age = 78 years, 53.8% female, 15.9% in HPAs) treated by 991 hospitals. The 180 (18.2%) PAS hospitals treated 64.2% of patients from HPAs versus 2.6% from LPAs. Compared with patients from LPAs treated at non-PAS hospitals, patients from HPAs treated at PAS hospitals had more frequent in-hospital adverse events (OR[95%CI] = 1.17[1.07-1.29]), 30-day readmission (OR[95%CI] = 1.33[1.20-1.47]), worse all-cause (HR[95%CI] = 1.16[1.10-1.22]), and cancer-specific mortality (HR[95%CI] = 1.23[1.15-1.32]).

Conclusions: A group of PAS hospitals treated a significant proportion of patients with CRC from HPAs and few from LPAs and was associated with worse short- and long-term patient outcomes. These findings highlight the presence and negative impact of healthcare segregation by area-level poverty and systemic inequities faced by individuals from HPAs. Multilevel resources are needed to address quality of care and other healthcare-associated needs for individuals from disadvantaged areas.

Background: We compared systematic endobronchial ultrasound-guided transbronchial needle aspiration (S-EBUS-TBNA) [sampling every lymph node (LN) > 5 mm regardless of its appearance on positron emission tomography/computed tomography (PET/CT)] with targeted (T) EBUS-TBNA (sampling only abnormal LNs on PET/CT) for mediastinal staging of locally advanced non-small cell lung cancer (NSCLC).

Patients and methods: Patients with NSCLC with N2 involvement on PET/CT who underwent S-EBUS-TBNA were retrospectively included. For T-EBUS-TBNA, the results of the samplings of abnormal PET/CT LNs during S-EBUS-TBNA were considered. The percentage of cases where S-EBUS-TBNA diagnosed a larger extent of mediastinal disease compared with T-EBUS-TBNA (upstaging from N2a to N2b/N3 and upstaging from N2b to N3) was estimated.

Results: A total of 89 patients were included: 61 had N2a and 28 had N2b on PET/CT. Of the 61 with N2a S-EBUS-TBNA diagnosed N3 disease in 2 cases, N2b in 4, N2a in 43, and N0/1 in 12. These 12 patients underwent video-assisted mediastinoscopy (VAM) that showed N2a involvement in 3 and N0/1 in 9. Of the 28 with N2b, S-EBUS-TBNA proved N3 disease in 2 cases, N2b in 10 cases, N2a in 7, and N0/1 in 9. These nine patients underwent confirmatory VAM that showed N2a in two and N0/1 in 7. S-EBUS-TBNA diagnosed a larger extent of mediastinal disease compared with T-EBUS-TBNA staging in 9% of cases: 4 patients with N3 disease that had N2 on PET/CT and four with N2b that had N2a on PET/CT.

Conclusions: In patients with NSCLC, S-EBUS-TBNA diagnoses a larger extent of mediastinal disease compared with T-EBUS-TBNA.

Background: After breast-conserving surgery (BCS) for early-stage breast cancer, re-excision rates for positive or close margins remain high, although most re-excisions show no residual disease. This study aimed to identify clinicopathologic factors associated with residual disease to guide re-excision decisions.

Methods: The study evaluated women with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent BCS and re-excision for positive or close margins from 2018 to 2024 at the Saint John's Cancer Institute. The association between clinical-pathologic variables and residual disease was evaluated by multivariable logistic regression.

Results: Of 932 patients treated with BCS, 184 (19.7 %) underwent re-excision for positive or close margins. Residual disease was found in 54 (29 %) patients, most commonly DCIS (n = 36, 66.7 %). In the multivariable analysis, residual disease was associated with three or more positive margins (odds ratio [OR], 9.87; 95 % confidence interval [CI], 3.23-30.17), DCIS at the margin (OR, 7.4; 95 % CI, 1.56-35.16), PR negativity (OR, 4.06; 95 % CI, 1.26-13.12), and mammographic microcalcifications (OR, 3.0; 95 % CI, 1.17-7.69). Conversely, reduced risk was associated with age ≥60 years (OR, 0.07; 95 % CI, 0.01-0.46), invasive carcinoma with extensive intraductal component (EIC: OR, 0.15; 95 % CI, 0.03-0.66), and pure DCIS (OR, 0.14; 95 % CI, 0.03-0.63).

Conclusions: Residual disease was found in fewer than one third of re-excision specimens. Factors reflecting margin burden and tumor biology, especially the number of positive margins, DCIS involvement of margin, and PR-negativity, were associated with residual malignancy, whereas EIC and older age were associated with a lower likelihood of residual disease. These findings support a risk-adapted, individualized approach to re-excision after BCS to minimize unnecessary surgery.