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The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of COVID-19 pandemic on cancer surgery.A panel session (virtual) was held at the annual Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care to address the impact of COVID-19 on cancer surgery globally. Following the virtual meeting, a questionnaire was sent to all the leaders to gather additional opinions. The input obtained from all the leaders was collated and analyzed to understand how cancer surgeons from across the world adapted in real-time to the impact of COVID-19 pandemic.The surgical oncology leaders noted that the COVID-19 pandemic led to severe disruptions in surgical cancer care across all domains of clinical care, education, and research. Several new changes/protocols associated with increased costs were implemented to deliver safe care. Leaders also noted that preexisting disparities in care were exacerbated, and the pandemic had a detrimental effect on well-being and financial status.The COVID-19 pandemic has led to severe disruptions in surgical cancer care globally. Leaders of the GFCS opined that new strategies need to be implemented to prepare for any future catastrophic events based on the lessons learned from the current events. The GFCS will embark on developing such a roadmap to ensure that surgical cancer care is preserved in the future regardless of any catastrophic global events.

Hypertrophic pyloric stenosis (HPS) is the most important cause of non-bilious vomiting during infancy and it is usually idiopathic. It is very rare in older children and adolescents, in which gastric outlet obstruction (GOO) is more typically secondary to other conditions. Gastrointestinal malformation are frequently associated with Down syndrome and some of them (especially duodenal abnormalities) can be detected quite late. In infants the standard treatment of HPS is represented by a Ramstedt pyloromyotomy, while in adults a distal gastric resection is more indicated and it is usually associated to a Billroth I or II reconstruction. Case report We present an unusual case of a 12-year-old girl with Down syndrome, diagnosed with late-onset HPS. She came to our attention with periodic non-bilious vomiting and growth delay. She underwent multiple imaging examinations, which highlighted the presence of an HPS. Based on patient's age and the thickness of the pyloric muscle, we decided to perform a partial gastrectomy with a Roux-en-y reconstruction. Patient was discharged on the X day. She is now on follow up, gains weight and presents good conditions. Discussion HPS is rare but possible during childhood and adolescence. Diagnosis is usually performed through ultrasounds (US) and upper gastrointestinal radiological series (UGI), but sometimes further examinations are required (abdominal MRI, esophagogastroduodenoscopy). In older children since less invasive techniques are not effective, we have to consider partial gastrectomy. Based on our experience, Roux-en-y reconstruction is a valid option, associated with poor complication and good quality of life.

Introduction: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. Materials and methods: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. Results: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). Conclusions: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Due to an error in production the members of SICE CoDIG (Colon Dx Italian Group) listed in the Acknowledgments were not tagged correctly as authors in the XML of this article. This listing is presented again here:.

BackgroundSeveral associations between microsatellite instability (MSI) and other clinicopathological factors have been reported in gastric cancer, but the results have been ambiguous. This systematic review and meta-analysis investigated the relationship between MSI and overall survival and clinicopathological characteristics of patients with gastric cancer.MethodsA systematic literature search of the PubMed, Cochrane and Ovid databases until 31 January 2016 was performed in accordance with the PRISMA statement. The articles were screened independently according to PICO (population, intervention, comparator, outcome) eligibility criteria. All eligible articles were evaluated independently by two reviewers for risk of bias according to the Quality In Prognosis Study tool.ResultsOverall, 48 studies with a total of 18 612 patients were included. MSI was found in 9·2 per cent of patients (1718 of 18 612), and was associated with female sex (odds ratio (OR) 1·57, 95 per cent c.i. 1·31 to 1·89; P < 0·001), older age (OR 1·58, 2·20 to 1·13; P < 0·001), intestinal Laurén histological type (OR 2·23, 1·94 to 2·57; P < 0·001), mid/lower gastric location (OR 0·38, 0·32 to 0·44; P < 0·001), lack of lymph node metastases (OR 0·70, 0·57 to 0·86, P < 0·001) and TNM stage I–II (OR 1·77, 1·47 to 2·13; P < 0·001). The pooled hazard ratio for overall survival of patients with MSI versus those with non-MSI gastric cancer from 21 studies was 0·69 (95 per cent c.i. 0·56 to 0·86; P < 0·001).ConclusionMSI in gastric cancer was associated with good overall survival, reflected in several favourable clinicopathological tumour characteristics.

Aim: To investigate the outcome and pattern of survivals of rectal cancer patients presenting a complete or nearly complete tumor response after neo-adjuvant treatment. Methods: Young surgeons

Yoon et al reported the first randomized, phase II trial of ramucirumab, an anti-vascular endothelial growth factor receptor-2 monoclonal antibody, as front-line therapy in patients with advanced adenocarcinoma of the esophagus or gastric/gastroesophageal junction [1]. Unfortunately, the addition of ramucirumab to front-line mFOLFOX6 did not improve progression-free survival (PFS) in these patients. We noted from the subgroup analysis of PFS in figure 3A that, although not statistically significant, ramucirumab shows improved efficacy in patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS)=1 compared with ECOG PS 0 (hazard ratio 0.88 and 1 respectively). Based on these findings, we extended this subgroup analysis to all ramucirumab data available from literature.

Gastric gastrointestinal stromal tumors (GISTs) represent a subgroup of GISTs with a better prognosis than those located in other areas. In this retrospective study we performed a molecular characterization of a large series of patients with gastric GISTs in relation to clinical-pathological characteristics and prognosis.DNA was extracted from paraffin-embedded sections from 221 gastric GIST patients submitted to surgery. Exons 9, 11, 13 and 17 of KIT, exons 12 and 18 of PDGFRA and exons 11 and 15 of BRAF were analyzed by direct sequencing. Cox regression analysis adjusted for clinical-pathological factors was performed to evaluate KIT and PDGFRA mutations in relation to the composite endpoint of relapse or death.KIT and PDGFRA mutations were observed in 119 (53.8%) and 56 (25.3%) patients, respectively, whereas 46 (20.8%) patients had wild type (wt) disease. Univariable analyses showed that a high Miettinen risk category and the presence of ulceration and KIT deletions were associated with increased risk of relapse or death (p 0.001; p = 0.0389 and p = 0.002, respectively). After adjusting for Miettinen risk score, KIT deletions remained an independent prognostic factor (HRadj = 2.65, 95% CI [1.15-6.13], p = 0.023). Moreover, KIT deletions in exon 11 codons 557, 558 or 559 were associated with a higher risk of relapse or death than wt tumors (HRadj = 3.29 95% CI [1.64-6.64], p = 0.001).KIT deletions in exon 11, especially those involving codons 557, 558 or 559, were correlated with a more aggressive gastric GIST phenotype and increased risk of relapse or death.

Background Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients. Methods In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy. Results Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, pÂ

Although the mortality for gastric cancer is decreasing in Western Europe and United States, it still remains high in Eastern Europe. This study was aimed at evaluating short- and long-term results of surgical treatment of gastric cancer performed in Latvia Oncology Center.Retrospectively collected data from 461 patients who underwent gastrectomy with curative intent in Latvia Oncology Center from January 2001 to December 2005 were analyzed statistically.An average (range) of 92.2 (81-102) R0-R1 gastrectomies was performed each year. Post-operative complications occurred in 75 patients (16.3%); in-hospital mortality was 3.3%. The overall 5-year survival was 50.8%. In 444 cases (96.3%) there was histopathologic confirmation of R0-resection with a 5-year survival of 52.5% (P0.001). Considering pT category, 5-year survival was 88.6% for pT1 patients, 65% for pT2, 42.3% for pT3 and 27% for pT4 (P0.001). Considering pN category, 5-year survival was 67% for pN0 patients, 30% for pN1 and 29% for pN2-3 (P0.001).Clinico-pathologic characteristics of patients who underwent resection with curative intent are comparable to other Western experiences. Short- as well as long-term results are also similar if not for pN+ patients where no difference between pN1 and pN2 cases was observed.

Aim The purpose of this prospective observational study was to analyze the role of Mib-1 immunostaining as a proliferation index in breast cancer. Correlations between Mib-1 expression and clinico-pathological characteristics as well as its prognostic value have been studied in a series of 432 node negative breast cancers. Methods Mib-1 expression was evaluated by immunohistochemistry. Tumor sections from highly cellular invasive areas of cancer were stained by monoclonal antibody Mib-1 (Dako) and cells whose nuclei stained positive were counted in 10 randomly chosen HPFs and expressed as percentages of all epithelial cells. A minimum of 400 cells were counted. Correlation between Mib-1 staining and clinico-pathological factors was investigated by means of univariate and multivariate analyses. The prognostic impact on actuarial disease free (DFS) and overall survival (OS) was evaluated by univariate analysis using the log-rank test and by multivariate analysis using Cox regression model. Results Tumors were considered as positive for Mib-1 expression when more than 15% of cells counted were stained. Mib-1 positivity was found in 190/432 cases and resulted in being significantly related to tumor grade, tumor size and absence of estrogen receptors at multivariate analysis. With a median follow-up of 66 months, Mib-1 positivity resulted in being the only independent predictor of OS (RR 2.92), and an independent predictor of DFS (RR 2.01) together with absence of estrogen receptors (RR 2.15). Conclusions Mib-1 index of proliferative activity correlates well to other established prognostic factors of breast cancer. Mib-1 index may improve the tailoring of adjuvant therapy in early breast cancer, and our experience adds evidence to its effectiveness as prognostic factor. Efforts to reach uniformity in the methodology and in the scoring system should be done to warrant a standardized procedure and make Mib-1 determination definitively reliable in the current clinical practice.

Duodenal gastrointestinal tumors represent an extremely rare subset of stromal tumors arising from interstitial cells of Cajal. In the last 30 years the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity, in association with developments in endoscopy, imaging technology, and immunohistochemistry has resulted in novel diagnostic and treatment approaches. This is a comprehensive review of the current data of the literature on the various aspects of the diagnosis and treatment of these tumors. The duodenum is the less commonly involved site for these tumors in the digestive tract. Endoscopy and computed tomography can usually establish the diagnosis, confirmed by immunohistochemical staining and occasionally molecular genetic analysis. Endoscopic ultrasound with fine needle aspiration has been recently found to be the gold diagnostic standard with high sensitivity and specificity rates, diagnosing GIST in up to 80% of patients. Due to the complex anatomy of the pancreatico-duodenal region optimal therapeutic strategy of duodenal GISTs are challenging. Nevertheless surgical resection with microscopically clear resection margins seems to be the only potentially curative treatment for non-metastatic primary GISTs of the duodenum. Imatinib mesylate plays a key role in the management of GISTs both as neoadjuvant therapy and in patients with recurrent and metastatic disease. Meanwhile, the advances in the comprehension of the pathophysiology and natural history of this previously misunderstood clinical entity as well as the treatment of these tumors may render feasible, in the near future, the advent of newer and more effective treatment options.

Study objective: Biopsy-proven esophageal high grade dysplasia and/ or cancer, until a few years ago, was normally staged with CT and referred for esophagectomy, a procedure with high morbility and mortality rates. Recent evidence has suggested how EMR could be a more accurate grading tool for esophageal lesions and can be also employed as a definitive treatment option for a considerable amount of these patients. The aim of this study is to analyze our experience on the role of EMR as a diagnostic tool and to evaluate the long term outcome of the procedure when performed as a therapeutic treatment. Material and methods: We retrospectively reviewed data on 80 consecutive patients that underwent EMR for biopsy proven HGD (n 1⁄4 30), SCC (n 1⁄4 33) or EAC (n 1⁄4 17) at our Department. Complications that developed during the procedure, changes in histologic diagnosis, rate of submucosal invasion and additional treatments were recorded. Rates of metachronous lesions and recurrences at the EMR site throughout the follow-up and their treatment were recorded as well. Main results: EMR histology resulted in altered grading or staging in 42.5% patients (17.65% upstaging, 82.35% downstaging). Moreover, downstaging occurred in 30% patients with cancer and upstaging in 20% patients with HGD. Complications during the procedure occurred in 8.75% patients (5 hemorrhages that were treated with hemostatic forceps and 2 perforations that required surgery). Submucosal invasion was revealed in 37.14% patients with EMR-proven cancer. Of these 23.07% were referred to surgery, the others were treated conservatively due to comorbidities that contraindicated surgery or patient refusal. During the follow up of patients without submucosal invading cancer (58 patients, mean follow-up duration 40.22 months, SD 39.13) metachronous lesions developed in 6 patients (10.34%) and recurrences in 4 (6.90%). Of these, 4 were referred to surgery, 3 underwent an additional EMR session and 3 received other treatments due to inoperability. Conclusion: EMR histology changes the diagnosis in 42.5% patients and can also be used as an effective and safe treatment option, thus it reduces dramatically the need for esophagectomy. It should be employed regularly in the diagnostic work-up and as a treatment option for patients with esophageal lesions.

The prognostic factors for advanced gastric carcinoma without serosal invasion (pT2 AGC) are not clear. In terms of prognosis, pT2 AGC is considered intermediate between early gastric cancer (EGC) and gastric carcinoma with serosal invasion.From January 1985 to December 2000, 182 patients with pT2 AGC underwent curative gastric resection in our Department. Prognostic factors were evaluated by univariate and multivariate analyses.Univariate analysis demonstrated that gender, tumour location, lymph node involvement, Borrmann type, number of lymph nodes involved, venous infiltration and extent of lymphadenectomy were significantly related to the prognosis. Multivariate analysis revealed that extent of lymph node metastasis (N1 vs N0 relative risk (RR) of recurrences=3.96, p0.05; N2 vs N0 RR=6.55, p0.05), and extent of lymphadenectomy (D1 vs D2 RR=3.2, p0.01) were independent prognostic factors. In a subset of patients in which venous infiltration was analysed, this factor was also significant (RR=3.9, p0.05).Our study shows that lymph node involvement and venous infiltration are important prognostic factors for pT2 AGC and, as such, adjuvant chemotherapy could be useful in this group of patients. An extensive lymph node dissection, minimum D2, should always be performed in order to reduce the risk of recurrence.

The test and treat strategy for Helicobacter pylori infection has raised some concern since young gastric cancer patients may have no alarm symptoms. In this study the frequency of alarm symptoms was assessed in a series of young gastric cancer patients, as well as the impact of absence of alarm symptoms on delay in diagnosis and stage of gastric cancer at diagnosis and survival.A retrospective study was carried out on 92 gastric cancer patientsor = 45 years of age identified from databases in four hospitals between January 1985 and December 2001. Characteristics analysed included duration and features of dyspeptic symptoms, presence of alarm symptoms, time interval from the onset of symptoms to diagnosis, pTNM stage and survival.Of the 92 patients, 54 (58.7%) presented uncomplicated dyspepsia and 38 (41.3%) alarm symptoms. In those with uncomplicated dyspepsia, epigastric pain was the most common complaint (64.1%) followed by vomiting (30.4%), heartburn and nausea. Weight loss was the most common alarm symptom (30.4%), followed by anorexia (10.9%), dysphagia or anaemia (7.6%). The mean delay from first symptoms to final diagnosis was 16.8 +/- 13.9 weeks in patients with alarm symptoms and 29.3 +/- 39.9 weeks in patients without alarm symptoms (P:ns). Patients without alarm symptoms showed significantly less aggressive gastric cancer compared to patients with alarm symptoms in relation to TNM stage and survival (cumulative 5-year survival rate: 76% versus 49% P: 0.01). The survival rate, at 5 years, of patients without alarm symptoms, and with a history of dyspepsia of more than 24 weeks, was higher than that in patients with early diagnosis (93.4% versus 66.5%: P: 0.05).A large proportion of young gastric cancer patients present without alarm symptoms. Despite the delay in diagnosis, these patients have a better outcome than those with alarm symptoms. Thus the delay in diagnosis of patients without alarm symptoms does not affect survival.

Gastric carcinoma (GC) is an important cause of death and is associated with infection by Helicobacter pylori (H. pylori) strains expressing CagA, an oncoprotein encoded by the cagA gene (for a comprehensive discussion of H. pylori infection, see Ref. [1]). Recent studies have shown that CagA can be injected into the colonized mucocytes through a conjugative apparatus encoded by cag genes upstream cagA. Once inside the cell, CagA undergoes phosphorylation by host cell kinases. Phosphorylated CagA is capable of altering the cell morphology and disturbing host-signaling pathways, which ultimately may lead to the development of GC. The fragment of the cagA gene encoding the carboxylterminal end of CagA is polymorphic, as it presents numerous genomic repetitions that contain the tyrosine EPIYA motif, a 5-amino acid sequence (Glu–Pro–Ile–Tyr– Ala), which is the site where CagA undergoes phosphorylation. In 1998, Yamaoka et al. [2] observed that strains with a high number of genomic repetitions in the cagA variable region were isolated more frequently from patients with GC. They classified the cagA structural types in A, B, C and D types, on the basis of the amplicon sizes obtained with primers spanning the entire cagA variable region. Types B and D have similar sizes and can be differentiated by sequencing the amplicons. Later on, the dissection of the cagA 30 repeat region of numerous H. pylori strains indicated that the occurrence of gastric mucosa atrophy, a lesion considered a pre-cancerous condition, was more likely when patients were infected by strains possessing a high number of repeats, i.e. strains with type C cagA gene [3]. In the scientific literature, there are only few reports about the possible association between clinical features and the CagA structural variability. In the present study, we investigated on the possible relationship existing between the polymorphism of the cagA 30 variable region and the occurrence of GC. We also determined the CagA mass expressed by different strains to ascertain whether the CagA size corresponded to the length of the amplicons. Forty H. pylori strains were isolated from resected gastric mucosa of patients with GC and 46 strains from gastric biopsies of patients with chronic gastritis only (CGO). Strains were identified by the Gram stain and oxidase, catalase and urease tests and stored at -80 C until the characterisation of the cagA polymorphism was performed. The cagA structural types were determined by polymerase chain reaction (PCR) using the following primers spanning the cagA variable region [2]; the different sizes of the amplicons obtained range from 642 to 834 bp

Background: Duodenal stump fistula (DSF) is a severe complication of gastrectomy. Although nonsurgical therapy is preferred, surgery is still mandatory in one third of DSF patients. The aim of this article is to analyze the surgical management of DSF and factors related to its outcome. Methods: We performed a retrospective multicenter study using data from January 1990 to November 2011 in 16 Italian surgery centers. We collected 8,268 elective gastrectomies for malignancies, 7,987 by the laparotomic and 281 by the laparoscopic approach. Two hundred five patients developed a DSF, 75 of whom underwent surgery for DSF. We analyzed mortality and DSF healing time as well as the impact of clinical, oncological, and surgical characteristics. Results: The laparoscopic approach increased the risk of DSF development (odds ratio 5.6, 95% confidence interval 2.7–10.6, P&nbsp

The aims of this retrospective study were to determine the factors predictive of morbidity and mortality, and to evaluate the probability of long-term survival in octogenarians with carcinomas of the gastrointestinal tract.Out of a total of 194 patients, aged 80 years or over, with histologically diagnosed carcinoma of the stomach or colon-rectum, observed between 1987 and 1995, 167 underwent surgery and were included in this study. The relationship between a series of clinico-pathological variables and morbidity/mortality rates was investigated by univariate and multivariate analysis. Complete follow-up data were available in 161 patients.Fifty-nine patients (35.3%) experienced complications and 14 (8.4%) died during hospitalization. Statistical analysis identified hypoalbuminaemia (P0.01, relative risk (RR)=2.92) and hypercreatininaemia (P0.05, RR=3.59) as independent predictors of post-operative complications. Hypercreatininaemia (P0.05, RR=5.22) and non-curative surgery (P0. 05, RR=3.99) significantly affected operative mortality. Crude 5-year survival rate, including operative mortality after curative surgery, was 41% in gastric cancer and 39% in colorectal cancer patients.These results indicate that surgery for gastrointestinal carcinomas yields an acceptable operative risk in octogenarians, and provides good long-term results if oncological radicality can be obtained. Pre-operative evaluation of tumour stage and patient's general condition is useful to identify subgroups of patients at high risk of surgical complications and mortality.

Introduction Hereditary diffuse gastric cancer is an autosomal inherited syndrome associated with the E-cadherin germline mutations. Different types of CDH1 germline mutations have been reported; the missense alterations are rarely identified when compared with truncating mutations. The identification of missense mutation represents a clinical burden, since its pathogenicity is still under genetic and clinical studies. The aim of this critical review was to discuss E-cadherin germline missense mutations in diffuse gastric cancer. Materials and methods In this paper, we reviewed the literature data about the CDH1 germline missense mutations identified in early-onset and hereditary diffuse gastric tumours. The roles of clinical surveillance and prophylactic gastrectomy were discussed. Mutations reported in breast lobular cancer were excluded. Results We identified a total of 31 CDH1 germline missense mutations with different pathogenic impact on E-cadherin function (pathogenic vs. neutral). The majority of these alterations were localized at the extracellular domain of the CDH1 gene. These mutations affected indifferently hereditary and sporadic diffuse gastric carcinomas. Conclusion In this critical review, we reported all missense mutations identified to date and discussed about the E-cadherin missense mutation function, clinical management for asymptomatic mutation carriers and the roles of prophylactic total gastrectomy and endoscopic surveillance.