Annals of Surgical Oncology最新文献

Background: Minimally invasive anatomical hepatectomy is performed worldwide.¹ During liver transection, the hepatic vein guided approach (HVGA) is often utilized.² However, when tumors invade major vessels, extended anatomical hepatectomy may be indicated, making the HVGA unsuitable. At our institution, the Glissonean-guided approach (GGA) has been adopted for laparoscopic extended posterior sectionectomy. This technique is conceptually similar to systematic extended right posterior sectionectomy, previously described in open surgery.³ This study presents the surgical procedure and perioperative outcomes of the GGA for this procedure.

Patients and methods: In total, 19 patients underwent laparoscopic extended posterior sectionectomy. Among them, 11 patients were treated using the HVGA, while 8 were treated using the GGA. The perioperative outcomes were compared between the two groups.

Results: No severe complications (Clavien-Dindo grade ≥ III) or in-hospital mortality occurred. Liver transection time was significantly shorter in the GGA group (p = 0.037), and blood loss was reduced (p = 0.033). The right hepatic vein (RHV) was divided in all cases. No significant differences were observed in IWATE criteria, postoperative hospital stay, or R0 resection rate, although the GGA group tended to have a higher R0 rate.

Conclusions: In laparoscopic extended posterior sectionectomy, the GGA demonstrated favorable perioperative outcomes, with a significantly reduced liver transection time in comparison with HVGA. The GGA also tended to be associated with higher R0 resection rates, although the difference was not statistically significant. The GGA may be a valuable alternative technique for cases in which the HVGA is not feasible owing to tumor location and vascular invasion.

Background: The prognostic role of lymphadenectomy during esophagectomy for esophageal cancer in complete responders to neoadjuvant therapy is uncertain. This study aimed to help clarify this question.

Patients and methods: This was a bi-national population-based cohort study in Sweden (2006-2024) and Finland (2006-2019). The main cohort included 515 patients with esophageal cancer who underwent esophagectomy after complete or near-complete tumor response without lymph node metastasis following neoadjuvant therapy. A secondary cohort included 669 patients with similar tumor response, regardless of nodal status. Data came from medical records and national health data registers. Associations between lymphadenectomy (categorized in quartiles) and 5-year mortality were assessed using multivariable Cox regression, yielding hazard ratios (HR) with 95% confidence intervals (CI), adjusted for age, sex, country, comorbidity, type of neoadjuvant therapy, calendar year, tumor histology, hospital volume, tumor location, tumor response, and T stage.

Results: In the main cohort, comparing the highest quartile of lymphadenectomy (≥ 27 nodes) with the lowest (0-11 nodes) indicated decreased 5-year all-cause mortality (HR 0.54, 95% CI 0.34-0.88). Stratified analyses suggested no significant association for complete responders (HR 0.68, 95% CI 0.39-1.16), but for near-complete responders (HR 0.32, 95% CI 0.14-0.72). The associations disappeared when assessing stage purification bias in the secondary cohort (n = 669), with the corresponding HRs of 0.91 (95% CI 0.63-1.32) for all responders, 1.01 (95% CI 0.61-1.66) for complete responders, and 0.79 (95% CI 0.47-1.33) for near-complete responders. Results were similar for 5-year disease-specific mortality.

Conclusions: After considering stage purification bias, more extensive lymphadenectomy did not improve the long-term survival among patients with complete or near-complete tumor response after neoadjuvant therapy.

Background: Robotic surgery is becoming an increasingly popular option for breast cancer surgery. However, studies comparing the characteristics of single-port robotic-assisted nipple-sparing mastectomy (SP RA-NSM) and conventional nipple-sparing mastectomy (CNSM) are limited. This study aimed to compare the outcomes of SP RA-NSM and CNSM.

Methods: This study conducted a comparative cross-analysis using propensity score-matching between patients who underwent CNSM (n = 148) and those who underwent SP RA-NSM (n = 148). The initial cohort included 1,512 patients with unilateral breast cancer between October 2020 and April 2024 at Asan Medical Center in Seoul, Republic of Korea (1,208 CNSM patients and 304 SP RA-NSM patients). Propensity score-matching was performed in a 1:1 ratio using age, body mass index, tumor size, and specimen weight as covariates.

Results: Both groups had a median age of 46 years at diagnosis and pathologic stages of disease ranging from 0 to II. During surgery, SP RA-NSM resulted in less blood loss than CNSM (0-10 ml [74.3% vs 29.7%], 11-100 ml [25.0% vs 70.3%]; p < 0.001). Postoperative complications were significantly less frequent in the SP RA-NSM group (p = 0.046), and nipple ischemia was absent (0.0% vs 2.7%; p = 0.044). Skin necrosis was slightly higher in CNSM (3.4%) than in SP RA-NSM (0.7%) (p = 0.099). Seroma was less frequent in SP RA-NSM (8.1%) than in CNSM (12.2%), although the difference was not significant (p = 0.248).

Conclusion: The SP RA-NSM procedure is a safer and more favorable surgical approach that could serve as a significant alternative to CNSM.

Background: Portal hypertension restricts the available therapeutic choices for hepatocellular carcinoma (HCC), adversely impacting patients' prognosis. Established guidelines regarding the treatment of patients with clinically significant portal hypertension (CSPH) are still a matter of debate. This study aimed to evaluate the therapeutic outcomes and identify the optimal treatment strategy for such a population.

Materials and methods: The Kaplan-Meier method was utilized for survival analyses. The inverse probability of treatment weighting and multivariate Cox regression models were implemented to adjust for confounding covariates. The relationships between prognostic index and observation end points were evaluated using restricted cubic spline curves.

Results: Of the enrolled 3013 patients with HCC with CSPH, 342 (11.4%), 1056 (35.0%) and 1615 (53.6%) underwent ablation, liver resection (LR), and transarterial chemoembolization (TACE), respectively. The preliminary analysis indicated that a substantial level of heterogeneity existed within the entire population, while LR possessed the acceptable short-term safety and rendered a potential trend toward a survival benefit over interventional treatments after adjustment for confounding covariates. After we classified the patients on the basis of tumor burden, the distinct advantages of LR over interventional treatments concerning overall survival and disease-free survival were confirmed, and these advantages were coincident among all subset analyses and personalized treatment allocation analyses.

Conclusions: Both surgical and interventional treatments could offer survival benefits for patients with HCC with CSPH, while LR provided a notable survival advantage in comparison to interventional therapies, even in patients classified as having intermediate or advanced-stage HCC. LR should be prioritized if it is amenable rather than contraindicated.

Background: Accurate characterization of the breast cancer-related lymphedema (BCLR) population is essential to understand its pathophysiology and develop predictive models for identifying at-risk patients and implementing tailored preventive microsurgical strategies. Key factors influencing BCRL severity and progression remain unclear. This study characterizes patients with BCRL seeking microsurgical treatment and evaluates the impact of oncological treatment intensity on lymphedema severity and progression.

Methods: This cohort study was conducted at an outpatient tertiary lymphedema clinic between 2017 and 2023. BCRL severity was assessed at intake by a lymphedema-specialized plastic surgeon using International Society of Lymphology staging and indocyanine green lymphography with near-infrared fluorescence imaging (ICG-NIFI). Data were collected during scheduled medical evaluations and analyzed retrospectively. Exploratory analysis investigated associations between oncological treatment intensity and BCRL severity and progression.

Results: A total of 163 consecutive female patients with BCRL were included. Lymphedema severity varied significantly, with no consistent link between severity and time since onset. A significant association was found between axillary lymph node dissection (ALND) and ICG-NIFI stages (p<0.001). However, no significant associations were found between oncological treatment intensity-surgery, radiotherapy, systemic treatment-and BCRL severity and progression. Analyses further revealed associations between lymphedema severity, body mass index, postmenopausal status, and clinical course.

Conclusion: This study provides a comprehensive profile of patients with BCRL seeking microsurgical treatment, revealing variable lymphedema progression patterns. Oncological treatment intensity did not appear to influence BCRL severity or progression, suggesting that these may depend more on biological predisposition. These findings enhance BCRL understanding and highlight the importance of precise patient characterization, laying the foundation for targeted, individually tailored preventive microsurgical interventions.

Background: Data to inform surgical management of the axilla after neoadjuvant endocrine therapy (NET) are limited. Here we report nodal status, surgical procedure, and outcomes among patients enrolled between 2016 and 2020 in the Palbociclib and Endocrine therapy for LObular breast cancer Preoperative Study (NCT02764541).

Methods: Women with hormone receptor-positive, HER2-negative tumors > 1.5 cm, any cN, were randomized 2:1 to NET ± palbociclib for 24 weeks. Axillary surgery (sentinel lymph node biopsy [SLNB] ± axillary dissection [ALND]) and nodal evaluation (H&E ± IHC) were not specified in the protocol. Pathologic node-positive (ypN+) rates, local-regional recurrence-free interval (LRRFI), and breast cancer-specific survival (BCSS), compared by univariate Cox proportional hazards, were prespecified exploratory endpoints.

Results: A total of 188 patients were analyzed (128 treated with NET + palbociclib, 60 NET), median age 56.5 years (interquartile range [IQR] 50-66). 82 (43.6%) had lobular histology, 99 (52.7%) were cN0, 84 (44.7%) cN+, and 5 (2.6%) cN unknown. Of cN+ patients with known ypN, nodal pathologic complete response rates were 10.9% (6/55) after NET + palbociclib and 13.6% (3/22) after NET. Among 108 ypN+ patients, 26 (24.1%) underwent SLNB, 82 (75.9%) ALND, and 99 (91.7%) radiation. At 4.65 years (IQR 3.66-5.56) median follow-up, 3-year LRRFI for ypN+ patients treated with SLNB only was 96% (88.6%, 100%) and ALND was 97.4% (93.9%, 100.0%), p = 0.6; 3-year BCSS for SLNB was 96.0% (88.6%, 100.0%) and ALND was 100.0% (100%, 100%), p = 0.9.

Conclusions: The addition of palbociclib to NET did not impact pathologic nodal outcomes. Among those with ypN+ disease, neither LRRFI nor BCSS appears to be impacted by performance of ALND.

Trial registration: clinicaltrials.gov, NCT02764541.

Background: Currently, patients with biopsy-proven axillary disease undergoing neoadjuvant chemotherapy (NAC) must undergo completion axillary lymph node dissection (cALND) if there is residual disease in the sentinel lymph nodes (SLN). In the era of axillary de-escalation, our objectives were to evaluate the frequency of involved non-SLN during cALND and whether clinical, radiologic, and pathologic characteristics can predict non-SLN involvement.

Methods: This was a multicenter, retrospective cohort study of patients with biopsy proven node-positive breast cancer between 2012 and 2024, who had residual nodal metastases (ypN+) post NAC and underwent cALND following SLN biopsy (SLNB) or targeted axillary lymph node dissection (TAD). Patients were grouped by the presence or absence of positive non-SLN at cALND (cALND+ vs. cALND-). Descriptive statistics were used to compare demographic, radiologic and pathologic data between groups. Univariate and multivariate analyses were used to identify predictors of cALND+.

Results: Overall, 122 ypN+ patients were included in the study; 57 (46.7%) had cALND+. Predictors of cALND+ on multivariate analysis included the number of abnormal lymph nodes on pretreatment axillary ultrasound (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.5-10, p = 0.006), SLN extracapsular extension on final pathology (OR 2.6, 95% CI 1.08-6.5, p = 0.036), lymphovascular invasion (OR 2.47, 95% CI 1.05-6.02, p = 0.041) and SLN ratio (positive SLNs/total SLNs excised) > 0.5 (OR 4.33, 95% CI 1.88-10.4, p < 0.001).

Conclusions: This study proposes factors that predict cALND+ in initially node-positive patients who undergo NAC and have ypN+ disease on SLNB/TAD and identifies patients who should potentially be selected for cALND versus those who maybe be spared.