Search

Evidence on the optimal extent of lymph node dissection for left-sided pancreatic ductal adenocarcinoma (PDAC) is scarce. The aim of the current study was to compare the long-term outcomes of patients who underwent D1 distal pancreatectomy (DP) with D2 DP for left-sided PDAC.Patients undergoing DP for left-sided PDAC at the four institutions affiliated to The Jikei University were enrolled in this study. Patients were divided into D1 and D2 groups. Patients' clinical characteristics, overall survival (OS), and relapse-free survival (RFS) were compared between the two groups before and after propensity-score matched (PSM) analysis.Of 145 patients with left-sided PDAC, 55 patients underwent D1 DP and 90 underwent D2 DP, of whom 38 matched pairs were included in the PSM analytic cohort. In the unmatched cohort, no significant difference was found between the D1 and D2 groups for both OS (median 2.51 vs. 3.07 years; p=0.709) and RFS (median 1.47 vs. 1.27 years; p=0.565). After PSM, OS (median 2.37 vs. 3.56 years; p=0.407) and RFS (median 1.35 vs. 1.11 years; p=0.542) were not significantly different between the two groups. In a comparison of regional and systemic recurrence sites, no significant difference was observed between the two groups (p=0.500).The long-term survival of D1 DP for left-sided PDAC was not inferior to D2 DP. In an era in which the importance of multidisciplinary treatment for PDAC has been documented, unnecessary extended surgery should be avoided.

Introduction The aim of this study is to investigate the relationship between preoperative serum transferrin level and long-term outcomes in patients with colorectal liver metastases after hepatic resection. Methods We retrospectively investigated 72 patients who underwent hepatic resection for colorectal liver metastases and explored the relationship between serum transferrin level and long-term outcomes. Results In multivariate analysis, H3 (odds ratio 3.43, 95% confidence interval 1.11–10.89 and P = 0.03) was an independent and significant predictor of the disease-free survival, and a transferrin level ≥ 190 mg/dl (odds ratio 0.20, 95% confidence interval 0.05–0.79 and P = 0.02) and the time to recurrence after hepatectomy Conclusions The serum transferrin level is a useful predictor of poor overall survival in patients with colorectal liver metastases after hepatic reaction.

Background Although indications of laparoscopic hepatectomy have been expanded, the laparoscopic approach after right hepatic lobectomy has a very high burden. The purpose of this study was to evaluate patients undergoing laparoscopic repeat hepatectomy for recurrent hepatic tumors after open right lobectomy. Patients and methods Five cases of laparoscopic repeat hepatectomy for recurrent hepatic tumors after open right lobectomy were included in the study. Results All the tumors in segment 3 were intraoperatively detected and curatively resected by partial hepatectomy. The tumors in segment 2 could not be detected intraoperatively due to hypertrophic liver deformity and adhesion. They were curatively resected by anatomical subsegmental approach. Conclusion For recurrent tumors located in segment 2 after right lobectomy, anatomical subsegmental approach should be preferred, not only from an oncological standpoint, but also for securing curative laparoscopic resection and overcoming anatomical difficulties.

Objectives The aim of this study was to clarify the effectiveness of combination chemotherapy targeting gemcitabine (GEM)-induced nuclear factor kappa B as adjuvant therapy for pancreatic cancer. Methods Patients who were planned after curative surgery (residual tumor classification R0 or R1) for pancreatic cancer to receive six cycles of adjuvant chemotherapy of regional arterial infusion of nafamostat mesilate with GEM between June 2011 and April 2017 were enrolled in this single-center, institutional review board-approved phase II trial (UMIN000006163). The Kaplan-Meier method was used to estimate disease-free survival and overall survival. Results In 32 patients [male/female: 18/14; age: median, 65.5 years (range, 48-77 years); pathological stage (Union for International Cancer Control 8th): IA/IB/IIA/IIB/III, 2/2/9/18/1, respectively] who met the eligibility criteria, the median overall survival and disease-free survival were 36.4 months (95% confidence interval, 31.7-48.3) and 16.4 months (95% confidence interval, 14.3-22.0), respectively. Grade 4 treatment-related hematological toxicities were seen in 5 patients (15.6%) (all neutropenia). One patient developed grade 3 nonhematological toxicities (rash). Conclusions Adjuvant chemotherapy with regional arterial infusion of nafamostat mesilate and GEM is safe and has potential as an option in adjuvant setting after curative surgery for pancreatic cancer.

The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum d-dimer levels for venous thromboembolism (VTE) after hepatectomy. We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum d-dimer level postoperatively and computed tomography was performed when d-dimer level was ≥ 20 μg/mL. VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019. Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum d-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

Aim This study sought to evaluate the incidence, risk factors, and clinical outcomes of portal vein thrombosis after hepatectomy. Furthermore, we proposed a novel classification and treatment strategy for portal vein thrombosis after hepatectomy. Methods We retrospectively analyzed 398 patients who underwent hepatectomy and enhanced computed tomography imaging within 14 days after surgery in our hospital from 2009 to 2019. Portal vein thrombosis was classified into three categories according to the location of the thrombus – main, hilar, and peripheral – with main portal vein thrombosis further subclassified into three grades. Each patient's treatment strategy was determined based on their portal vein thrombosis classification and grading. From 2015, enhanced computed tomography imaging was performed routinely on patients who underwent anatomical hepatectomy on postoperative day 7. Results Portal vein thrombosis was diagnosed in 57 patients (14.3%) during the study period. Multivariate analysis revealed that a Pringle maneuver time of 75 minutes or longer was a significant predictor of portal vein thrombosis (P = .012). In total, 52 patients (91%) with portal vein thrombosis recovered by surgery, anticoagulant therapy, or without specific treatment. There was no instance of mortality recorded. Conclusions Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy., Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy.

To evaluate omega-3 fatty acid-rich enteral nutrient effects in patients with unresectable or recurrent biliary tract or pancreatic cancers during chemotherapy. Enteric nutritional supplements containing omega-3 fatty acids (Racol®) was administered to aforementioned patients with cancers during chemotherapy. The skeletal muscle mass and blood test data were obtained pre-administration and 28 and 56 days after. Patients with pancreatic cancer were administered the digestive enzyme supplement pancrelipase (LipaCreon®) 28 days after the start of Racol® administration. The number of chemotherapies skipped due to neutropenia was recorded for 2 months before and after enteral nutrient initiation. In all 39 patients, the skeletal muscle mass increased on day 56 versus baseline (median 17.3 kg vs. 14.8 kg, p p = 0.03), and retinol-binding protein (mean: 2.56 mg/dL vs. 2.42 mg/dL, p = 0.05) increased. Patients with pancreatic cancer showed increased blood eicosapentaenoic acid concentration on day 56 versus baseline (median: 48.1 μg/mL vs. 37.0 μg/mL, p = 0.04) and increased skeletal muscle mass (median 16.8 kg vs. 14.4 kg, p = 0.006). Baseline median neutrophil count increased significantly from 2200/μL at baseline to 2500/μL (p = 0.04). Patients with biliary tract cancer during chemotherapy also exhibited increased skeletal muscle mass following omega-3 supplementation (median 17.3 kg vs. 15.8 kg, p = 0.01). In patients undergoing chemotherapy for unresectable or post-recurrence pancreatic and biliary tract cancers, high-omega-3 fatty acid nutrition therapy use improved skeletal muscle maintenance and chemotherapy dosing intensity.

Background Whole-layer laparoscopic cholecystectomy (W-LC) has recently been advocated as a total biopsy for potentially malignant neoplasms of the gallbladder; however, it is not an injury-proof procedure. This study reports W-LC using the segment IV approach (technique for securing the whole-layer gallbladder at the medial origin of the cystic plate).MethodsTwenty among twenty-five patients diagnosed with potentially malignant gallbladder polyps underwent this technique.ResultsMostly, W-LC was performed successfully (median operative time 135 min) without intraoperative and postoperative complications. Pathological findings indicated that cholesteric polyps was the most common type (n=13), followed by adenomatous polyps (25%) and carcinoma in situ (5%).ConclusionsWe conclude that the segment IV approach is appropriate for performing total biopsy in patients diagnosed with potentially malignant gallbladder polyps.

BACKGROUND/AIM After primary resection of hepatocellular carcinoma (HCC), the impact of patient's characteristics at the initial hepatectomy, on long-term remnant liver function has not been reported. The aim of this study was to identify factors associated with the deterioration of remnant liver function among patients who developed recurrent HCC. PATIENTS AND METHODS A total of 51 patients with intrahepatic recurrence after initial hepatic resection for HCC were included. We retrospectively investigated the relation between patient characteristics and the degree of deterioration of remnant liver function upon recurrence. RESULTS In univariate analysis, significant predictors of deterioration of remnant liver function consisted of preoperative gastro-esophageal varices (p=0.0101), preoperative transcatheter arterial chemoembolization (p=0.0230) and hepatectomy beyond Makuuchi's criteria (p=0.0101). In multivariate analysis, the only significant independent predictor of deterioration of remnant liver function was hepatectomy beyond Makuuchi's criteria (p=0.0498). CONCLUSION Hepatectomy beyond Makuuchi's criteria at the initial hepatectomy may predict deterioration of remnant liver function upon recurrence of HCC.

Pancreatic neuroendocrine tumor (PNET) cases are increasing; however, the treatment indication and procedure remain unestablished. The present study evaluated the indication, feasibility and safety of laparoscopic distal pancreatectomy (LDP) with our technique for PNET. A total of 13 patients with insulinoma and nonfunctional PNET

The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection. Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, “scooping-out” versus “cutting.” The participants were then further divided into “small” and “large” subgroups according to the tumor’s depth and diameter. Finally, they were categorized into two groups, namely “standard” and “advanced.” Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system. Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P

The superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score–matched (PSM) analysis. A total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis. Applying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33–0.90) for disease-free survival and 0.61 (95% CI, 0.24–1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014). AR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter.

Aim We investigated the prognostic impact of osteosarcopenia, which is the combination of osteopenia and sarcopenia, in patients with colorectal liver metastases (CRLM) after hepatic resection. Methods One hundred and eighteen patients were analyzed retrospectively. Osteopenia was evaluated with computed tomographic measurement of pixel density in the midvertebral core of the 11th thoracic vertebra. Sarcopenia was evaluated with psoas muscle areas at the third lumbar vertebra. Osteosarcopenia was defined as the concomitant occurrence of osteopenia and sarcopenia. Results Osteosarcopenia was identified in 38 (32%) of the patients. In univariate analysis, the overall survival was significantly worse in patients with lymph node metastases (P = .01), extrahepatic lesion (P = .01), sarcopenia (P = .02), osteosarcopenia (P, This study aimed to investigate the impact of preoperative osteosarcopenia, which is defined as the concomitant occurrence of osteopenia and sarcopenia, on the outcomes of patients with colorectal liver metastases (CRLM) after hepatic resection in conjunction with other nutritional markers including sarcopenia and osteopenia, as well as inflammatory parameters. We found that osteosarcopenia was the strong predictor for outcomes in patients who underwent liver resection for CRLM. To the best of our knowledge, this is the first study to report the prognostic value of osteosarcopenia in patients with malignancies.

Although pancreatectomy with lymph node (LN) and nerve plexus dissection has usually been performed for pancreatic cancer, recent randomized controlled trials have questioned its survival benefits. However, superior mesenteric artery (SMA) LN dissection has still been included in standard treatment guidelines. A total of 94 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer without LN enlargement around the SMA on imaging were identified between 2008 and 2017. Disease-free survival (DFS), overall survival (OS), and complications were compared between those with LN and hemicircumferential nerve plexus dissection around the SMA (SMA ly+) and those without thorough LN and nerve plexus dissection around the SMA (SMA ly−) after adjusting for major prognostic factors. A total of 78 and 16 patients with SMA ly+ and SMA ly− were identified, respectively. Our data demonstrated no difference in DFS and OS rates between both groups (P = 0.18 and 0.83, respectively). Patients with SMA ly+ had significantly more complications, particularly severe diarrhea, compared to those with SMA ly− (P = 0.001). LN and nerve plexus dissection around the SMA did not prolong survival and significantly increased the frequency of severe diarrhea, suggesting that performing in all cases carries less practical significance.

A soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD.This study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF.Twenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p 0.01), soft pancreatic remnant (p 0.01), high intraoperative blood loss (p 0.01), high intraoperative amylase level of pancreatic juice (p 0.01), and low pancreatic fibrosis (p 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 10

Objective: The goal of surveillance after therapy of localized esophageal cancer (LEC) is to identify actionable relapses amenable to salvage; however, the current surveillance algorithms are not optimized. We report on a large cohort of LEC patients with actionable locoregional relapses (LRRs). Methods: Between 2000 and 2013, 127 (denominator = 752) patients with actionable LRR were identified. Histologic/cytologic confirmation was the gold standard. All surveillance tools (imaging, endoscopy, fine needle aspiration) were assessed. Results: Most patients were men (89%), had adenocarcinoma (79%), and had no new symptoms (72%) when diagnosed with LRR. In trimodality patients, endoscopic confirmation of positron emission tomography-computed tomography-suspected LRR occurred in only 44%, and 56% required additional tools (e.g., fine needle aspiration). Alternatively, in bimodality patients, endoscopy confirmed LRRs in 81%. Trimodality patients had a higher risk of subsequent LRR/distant metastases after the first LRR than the bimodality patients (p = 0.03). In all patients, 78% of the subsequent relapses were distant. For patients who were salvaged, survival was significantly prolonged (50.6 vs. 25.1 months, p < 0.01). Conclusions: Patients live longer after successful salvage of the LRR than if salvage is not possible. After LRR, patients have a high risk of subsequent distant metastasis and whether the second relapse is local or distant, survival is uniformly poor.

Background: Overexpression of Galectin-3 (Gal-3), a β-galactoside binding protein, has been noted in many tumour types but its functional significance and clinical utility in gastric adenocarcinoma (GAC) are not well known. Methods: We studied 184 GAC patients characterised by histologic grade, sub-phenotypes (diffuse vs intestinal), and ethnicity (Asians vs North Americans). Immunohistochemistry was performed to assess the expression of Gal-3 in human GACs and we correlated it to the clinical outcomes. Cell proliferation, invasion, co-immunoprecipitation and kinase activity assays were done in genetically stable Gal-3 overexpressing GC cell lines and the parental counterparts to delineate the mechanisms of action and activity of inhibitors. Results: Most patients were men, Asian, and had a poorly differentiated GAC. Gal-3 was over-expressed in poorly differentiated (P=0.002) tumours and also in diffuse sub-phenotype (P=0.02). Gal-3 overexpression was associated with shorter overall survival (OS; P=0.026) in all patients. Although, Gal-3 over-expression was not prognostic in the Asian cohort (P=0.337), it was highly prognostic in the North American cohort (P=0.001). In a multivariate analysis, Gal-3 (P=0.001) and N-stage (P=

Background: Predictive biomarkers or signature(s) for oesophageal cancer (OC) patients undergoing preoperative therapy could help administration of effective therapy, avoidance of ineffective ones, and establishment new strategies. Since the hedgehog pathway is often upregulated in OC, we examined its transcriptional factor, Gli-1, which confers therapy resistance, we wanted to assess Gli-1 as a predictive biomarker for chemoradiation response and validate it. Methods: Untreated OC tissues from patients who underwent chemoradiation and surgery were assessed for nuclear Gli-1 by immunohistochemistry and labelling indices (LIs) were correlated with pathologic complete response (pathCR) or

// Elena Elimova 1, 8 , Rebecca S. Slack 2 , Hsiang-Chun Chen 2 , Venkatram Planjery 1 , Hironori Shiozaki 1 , Yusuke Shimodaira 1 , Nick Charalampakis 1 , Quan Lin 1 , Kazuto Harada 1 , Roopma Wadhwa 1 , Jeannelyn S. Estrella 3 , Dilsa Mizrak Kaya 1 , Tara Sagebiel 4 , Jeffrey H. Lee 5 , Brian Weston 5 , Manoop Bhutani 5 , Mariela Blum Murphy 1 , Aurelio Matamoros 4 , Bruce Minsky 6 , Prajnan Das 6 , Paul F. Mansfield 7 , Brian D. Badgwell 7 and Jaffer A. Ajani 1 1 Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 2 Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 3 Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 4 Department of Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 5 Department of Gastroenterology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 6 Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 7 Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA 8 Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada Correspondence to: Jaffer A. Ajani, email: jajani@mdanderson.org Keywords: localized gastric adenocarcinoma, cancer surveillance, cost-effectiveness analysis, imaging studies, esophagogastroduodenoscopy Received: December 02, 2016 Accepted: June 02, 2017 Published: July 13, 2017 ABSTRACT Purpose: After therapy of localized gastric adenocarcinoma (GAC) patients, the costs of surveillance, relapse patterns, and possibility of salvage are unknown. Materials and Methods: We identified 246 patients, who after having a negative peritoneal staging, received therapy (any therapy which included surgery) and were surveyed (every 3–6 months in the first 3 years, then yearly; ~10 CTs and ~7 endoscopies per patient). We used the 2016 Medicare dollars reimbursed as the “costs” for surveillance. Results: Common features were: Caucasians (57%), men (60%), poorly differentiated histology (76%), preoperative chemotherapy (74%), preoperative chemoradiation (59%), and had surgery (100%). At a median follow-up of 3.7 years (range, 0.1 to 18.3), the median overall survival (OS) was 9.2 years (95% CI, 6.0 to 11.2). Tumor grade ( p = 0.02), p/yp stage ( p < 0.001), % residual GAC ( p = 0.05), the R status ( p = 0.01), total gastrectomy ( p = 0.001), and relapse type ( p = 0.02) were associated with OS. Relapse occurred in 79 (32%) patients (only 8% were local-regional) and 90% occurred within 36 months of surgery. P/yp stage ( p < 0.001) and total gastrectomy ( p = 0.01) were independent prognosticators for OS in the multivariate analysis. Only 1 relapsed patient had successful salvage therapy. The estimated reimbursement for imaging studies and endoscopies was $1,761,221.91 (marked underestimation of actual costs). Conclusions: The median OS of localized GAC patients was excellent with infrequent local-regional relapses. Rigorous surveillance had a low yield and high “costs”. Our data suggest that less frequent surveillance intervals and limiting expensive investigations to symptomatic patients may be warranted.

Introduction The aim of this study was to introduce and examine a modified mechanical end-to-side esophagogastrostomy method (“reverse-Tornado" anastomosis) in laparoscopy-assisted proximal gastrectomy. Methods Five patients with gastric cancer who underwent laparoscopy-assisted proximal gastrectomy were analyzed retrospectively. Esophagogastrostomy in the anterior wall was performed in three patients, and esophagogastrostomy in the posterior wall was performed in two patients. Clinicopathological features, operative outcomes (operative time, operative blood loss), and postoperative outcomes (complications, postoperative hospital stay, reflux esophagitis) were evaluated. Results Operative time was normal (278 min). There was no marked operative blood loss, postoperative complications, prolonged hospital stay, or reflux esophagitis. Conclusion Esophagogastrostomy was completed in a normal time with reverse-Tornado anastomosis. This method can be safe and can enable good postoperative quality of life.

Surgical management of gastric cancer improves survival. However, for some time, surgeons have had diverse opinions about the extent of gastrectomy. Researchers have conducted many clinical studies, making slow but steady progress in determining the optimal surgical approach. The extent of lymph node dissection has been one of the major issues in surgery for gastric cancer. Many trials demonstrated that D2 dissection resulted in greater morbidity and mortality than D1 dissection. However, long-term outcomes demonstrated that D2 dissection resulted in longer survival than D1 dissection. In 2004, the Japan Clinical Oncology Group reported a pivotal trial which was performed to determine whether para-aortic lymph node dissection combined with D2 dissection was superior to D2 dissection alone and found no benefit of the additional surgery. Gastrectomy with pancreatectomy, splenectomy, and bursectomy was initially recommended as part of the D2 dissection. Now, pancreas-preserving total gastrectomy with D2 dissection is standard, and ongoing trials are addressing the role of splenectomy. Furthermore, the feasibility and safety of laparoscopic gastrectomy are well established. Survival and quality of life are increasingly recognized as the most important endpoints. In this review, we present perspectives on surgical techniques and important trials of these techniques in gastric cancer patients.

Background: Patients with localized gastric adenocarcinoma (LGAC), who get pre-operative therapy, have heterogeneous/unpredictable outcomes. Predictive clinical variables/biomarkers are not established. Methods: We analyzed 107 LGAC patients who had chemoradiation and surgery. LGACs were grouped for (1) presence/absence of signet ring cell histology (SRC) and (2) histologic grade: G2 or G3. %SRC was assessed (0, 1-10, 11-49, and 50-100%) and correlated with pathologic complete response (pathCR) or Results: Most patients were men (60%), had stage cIII LGAC (50%), and received chemotherapy before chemoradiation (93%). Most had G3 tumors (78%) and SRC (58%). Presence of SRC was associated with a lower rate of pathCR (11 vs. 36%, p = 0.004), and the association remained significant even with a low percentage of SRC (1-10%; p = 0.014). The higher the fraction of SRC, the lower was the probability of pathCR (p = 0.03). G3 and SRC led to a shorter overall survival (OS) (p = 0.046 and p = 0.038, respectively). yp stage independently prognosticated OS and recurrence-free survival (p < 0.001). Conclusion: Our novel findings suggest that LGACs with SRC are relatively chemoradiation resistant compared to LGACs without SRC. A higher fraction of SRC is associated with higher resistance. Upon validation/biomarker(s) evaluation, reporting of the fraction of SRC may be warranted.

Background/Aims: Preoperative lymph node staging in gastric cancer patients is important. The aim of this study was to assess the diagnostic accuracy of computed tomography (CT) in assessing lymph nodes in patients with gastric cancer. Methods: A total of 56 patients had undergone standardized gastric resection with lymphadenectomy between October 2013 and June 2015 were reviewed retrospectively. The short axis diameter of the largest lymph node per station was recorded when reviewing the preoperative CT images. Diagnostic accuracy was calculated by comparing CT with histopathological findings. Results: In 518 stations dissected at surgery, 56 included lymph nodes with metastasis. Among them, lymph nodes were visualized on preoperative CT in 26 stations. No lymph node was detected in 382 stations among 462 infiltration-negative stations. The cutoff of 12 mm had the highest accuracy rate of 0.896. Conclusion: The accuracy of CT in the preoperative diagnosis of lymph node metastasis in patients with gastric cancer remains poor. Therefore, surgeons should pay attention to the visibility of lymph nodes on CT. Detection of lymph nodes on CT can be utilized for a more accurate diagnosis such as fine-needle aspiration biopsy.

Background Peritoneal metastases (PM) in patients with gastric adenocarcinoma (GAC) may be identified by diagnostic laparoscopy (DL) or imaging (I). Although prognosis is poor, some patients have excellent outcome. We compared the overall survival (OS) of patients in 3 groups: those with positive cytology (CY+) by DL (DL-CY+), those with gross PM (GPM) by DL (DL-GPM+) and with GPM obvious on I (I-GPM+). Methods 146 GAC patients were identified. The Kaplan–Meier analysis, univariate, and multivariate Cox proportional hazards regression models were employed. Results Patients were primarily men (67%), with good ECOG scores (0–1; 89%), had DL (84%), had poorly differentiated GAC (92%), and had received chemotherapy (89%). The median OS for all patients was 15 months (5%CI, 12.9–18.2 months). The DL-CY+ group had median OS of 22.5 months (95%CI, 15–29.3 months). Patients with I-GPM+ had four times the risk of death than those with DL-CY+ (P

Introduction The purpose of this study was to evaluate if a baseline, an interim or a post-chemoradiation (CTRT) 18-fluorodeoxy-glucose positron emission computed tomography (18F-FDG PET/CT) studies could provide information on pathologic response to CTRT and overall survival (OS). Materials and methods Thirty-one patients with histologically proven adenocarcinoma or squamous cell carcinoma of the oesophagus, fit for trimodality therapy were prospectively enrolled. Most were men (93.5%), and had a stage III cancer (74.2%). Chemotherapy consisted of oxaliplatin/5-fluorouracil (45.2%) and taxane/5-fluorouracil (54.8%). All patients underwent a baseline, an interim (performed 12 ± 2 days after the onset of CTRT) and a post-CTRT 18F-FDG PET/CT study. The 18F-FDG PET/CT variables evaluated were at baseline, interim and post-CTRT studies maximum standardised uptake value (SUVmax) and total lesion glycolysis (TLG). Clinical and 18F-FDG PET/CT parameters were correlated with pathologic complete response (pathCR) and OS. Results Among the 31 patients studied, 61.3% achieved a clinical complete response (cCR) and 87.1% had surgery. The median OS was 35.1 months (95% confidence interval (CI): 19.9–NA). PathCR rate was 22.2%. There was only a marginal association between cCR and pathCR ( p = 0.06). None of the other variables was predictive of pathCR. There was association between OS and baseline TLG ( p = 0.03) at the optimal cutoff TLG value of 75.15. Additionally, TLG and ΔTLG post-CTRT were also associated with OS ( p = 0.01 and 0.03, respectively). Conclusion None of the PET parameters is predictive of pathCR but TLG at baseline and post-CTRT are prognostic of OS.

In 2014, the U.S. Food and Drug Administration (FDA) approved ramucirumab for use in the second line setting of advanced or metastatic, gastric or gastroesophageal adenocarcinoma (GEAC) based on the result of Phase III clinical trials; REGARD and RAINBOW.We briefly review the mechanisms of angiogenesis, anti-angiogenic therapy, and current status of advanced GEAC treatment then highlight the challenges and future prospects of novel molecular targeted agents.Although both the REGARD and RAINBOW trials met their primary endpoints of significantly prolonged overall survival (OS) and progression-free survival (PFS), the magnitude of the difference is still relatively modest. Given that ramucirumab alone has a marginal effect, a combination of paclitaxel and ramucirumab is strongly preferred as a second line therapy. To maximize the impact of ramucirumab in patients with GEAC, we can leverage the recent pharmacokinetics (PK) data of ramucirumab from the REGARD and RAINBOW trials. In addition, the quest for identifying biomarkers to select patients who are likely to benefit the most should continue. It is our firm belief that taxanes should no longer be added to the frontline regimens in most cases, given the success of the taxane/ramucirumab in the second line setting.

Background/Aim: Malignant nodes in patients with localized esophageal adenocarcinoma (L-EAC) portend a poor prognosis. We assessed the correlation of the distribution of nodes with the outcome of patients undergoing chemoradiation/surgery (trimodality therapy). Methods: We studied 209 L-EAC patients who had confirmed or suspicious nodes at baseline staging. All patients received trimodality therapy and were grouped according to the nodal geography: above the diaphragm (AD), below the diaphragm (BD), or above and below the diaphragm (ABD). Survival estimates were calculated using the Kaplan-Meier method, and the outcomes of the groups were assessed by the log-rank test. Results: Patients were primarily Caucasian (91%) and male (93%), with a baseline stage III L-EAC (89%). The median follow-up was 2.8 years (range, 0.4-11.7). Of the 209 patients, 35% (n = 73) had AD nodes, 20% (n = 41) had BD nodes, and 45% (n = 95) had ABD nodes. ABD patients had a 5-year overall survival rate of 33%, whereas this rate was 55% in AD patients and 60% in BD patients (p = 0.02). Patients with a higher histology grade were also at a higher risk of relapse and had a poor survival (p < 0.01 for both). Conclusions: L-EAC patients in the ABD group had the worst outcome after trimodality treatment compared to those in the AD or BD group. Novel strategies are needed for ABD patients.

Background: In patients with localized gastric adenocarcinoma (LGAC) who receive preoperative therapy, tools to predict response or prognosticate outcome before therapy are lacking. We used initial standardized uptake value (iSUV) of positron emission tomography (PET) to evaluate its association with overall survival (OS). Methods: We identified 60 patients with confirmed LGAC who were treated with preoperative chemoradiation and had a baseline PET in addition to other routine staging. Fisher's exact test and Wilcoxon's rank sum test were used to determine the association between iSUV and other variables, and the log-rank test and Cox proportional hazards model were used for survival analysis. Results: The median iSUV was 6 (range, 0-28). The presence of signet ring cells in pretreatment biopsies correlated highly with low iSUV (≤6; p = 0.0017). Patients with a high iSUV (>6) had a longer OS compared to those with a low iSUV (≤6; p = 0.0344). iSUV was not an independent predictor (p = 0.12); however, the risk of death was reduced for patients with an iSUV >6 (hazard ratio = 0.26). Conclusion: Our novel findings show that among LGAC patients treated with preoperative chemoradiation and surgery, those with a high iSUV have longer OS than patients with a low iSUV. iSUV appears to have a predictive role in patients with LGAC when treated with preoperative chemoradiation.

Background: Nearly 50% of gastric cancer patients are diagnosed with advanced gastric cancer (AGC). Therapy is palliative but results in ill effects. The median overall survival (OS) of AGC patients is often Methods: A retrospective analysis of AGC patients in our database was carried out. The patients were divided into two groups: asymptomatic or symptomatic. We sought to assess whether the delay of systemic therapy was harmful in asymptomatic patients. Results: A total of 135 patients were analyzed. Most patients were symptomatic (68%), males (67%), and had low ECOG scores (0-1; 85%). In univariate analyses, ECOG performance status 0 (p = 0.005), delayed initiation of therapy (p = 0.03), and lack of symptoms (p = 0.03) were associated with a longer OS. The multivariate model for OS identified only ECOG performance status as an independent prognosticator of longer OS (p = 0.02). Asymptomatic patients who had delayed (≥4 weeks) systemic therapy had an OS rate of 77% at 1 year compared to 58% for patients treated within 4 weeks (p = 0.47). Conclusion: Symptomatic AGC patients had a poor outcome compared to asymptomatic AGC patients. Treatment delay in asymptomatic patients had no detrimental effect on OS, suggesting that the timing of therapy can be based on patient selection.

Background: We have limited knowledge of the geographic distribution of resistant esophageal adenocarcinoma (EAC) in resected specimens, but its clinical importance can be enormous. Method: We selected patients with baseline stage III EAC who had had chemoradiation followed by surgery and had residual EAC (resistant cases only). Outcomes were correlated with various endpoints (percentage of resistant EAC and anatomic distribution). Results: A total of 100 clinical stage III patients were studied; 90% had an R0 resection, and 99% had either moderate or poorly differentiated EAC. Twelve percent had >50% residual cancer, 31% had 11-50% residual cancer, 53% had 1-10% residual cancer, and 3% had positive nodes only. Each compartment was frequently involved: mucosa/submucosa (66%), muscularis propria (76%), and serosa (62%); all compartments were involved in 35% of the cases. Lack of EAC (meaning response) was observed in the mucosa/submucosa (34%), muscularis propria (24%), serosa (38%), and nodes (42%). Although the endoscopic biopsies prior to surgery showed no EAC in 79% of the patients, in the surgical specimens, resistant EAC was frequently occurring in the mucosa/submucosa (66%). Conclusion: Contrary to our hypothesis that resistant EAC would be frequent in the nodes, our data show that its distribution is heterogeneous and unpredictable. Most importantly, the postchemoradiation biopsies are misleading, and a decision to delay/avoid surgery based on negative biopsies can be detrimental for the patients.

// Yusuke Shimodaira 1 , Rebecca S. Slack 2 , Kazuto Harada 1 , Manoop S. Bhutani 3 , Elena Elimova 1 , Gregg A. Staerkel 4 , Nour Sneige 5 , Jeremy Erasmus 6 , Hironori Shiozaki 1 , Nikolaos Charalampakis 1 , Venkatram Planjery 1 , Dilsa Mizrak Kaya 1 , Fatemeh G. Amlashi 1 , Mariela A. Blum 1 , Heath D. Skinner 7 , Bruce D. Minsky 7 , Dipen M. Maru 5 , Wayne L. Hofstetter 8 , Stephen G. Swisher 8 , Jeannette E. Mares 1 , Jane E. Rogers 9 , Quan D. Lin 1 , William A. Ross 3 , Brian Weston 3 , Jeffrey H. Lee 3 and Jaffer A. Ajani 1 1 Department of Gastrointestinal Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 2 Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 3 Department of Gastroenterology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 4 Department of Anatomic Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 5 Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 6 Department of Diagnostic Radiology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 7 Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 8 Department of Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA 9 Department of Pharmacy, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA Correspondence to: Jaffer A. Ajani, email: // Keywords : esophageal carcinoma, fine-needle aspiration, endoscopic ultrasound, upper mediastinal lymph nodes, positron emission tomography Received : March 15, 2017 Accepted : April 17, 2017 Published : May 23, 2017 Abstract Implications of assessing the proximal and far para-tracheal or sub-carinal nodes (para-tracheal [PTN] or sub-carinal [SCN]) associated with lower primary esophageal carcinomas (ECs) are unclear. To evaluate the value of endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for PTN and SCN, we analyzed results by positron emission tomography (PET) avidity, 4 EUS node malignancy features, and EUS-FNA results in all patients with Siewert’s I or II EC. Of 133 patients (PTN, n =102; SCN, n =31) with EUS-FNA, 47 (35%) patients had malignant node, leading to treatment modifications. EUS-FNA diagnosed significantly more patients with malignant nodes ( p =0.02) even when PET and EUS features were combined. Among 94 PET-negative and EUS-negative patients, 9 (10%) had malignant EUS-FNA. At a minimum follow-up of 1 year, only 3 (5%) of 62 patients with benign EUS-FNA had evidence of malignancy in the nodal area of prior EUS-FNA. Patients with malignant EUS-FNA independently had a much shorter overall survival (OS) than those with benign EUS-FNA ( p

Purpose Patients with esophageal carcinoma (EC) who are treated with definitive chemoradiotherapy (bimodality therapy [BMT]) experience frequent relapses. In a large cohort, we assessed the timing, frequency, and types of relapses during an aggressive surveillance program and the value of the salvage strategies. Patients and Methods Patients with EC (N = 276) who received BMT were analyzed. Patients who had surgery within 6 months of chemoradiotherapy were excluded to reduce bias. We focused on local relapse (LR) and distant metastases (DM) and the salvage treatment of patients with LR only. Standard statistical methods were applied. Results The median follow-up time was 54.3 months (95% CI, 48.4 to 62.4). First relapses included LR only in 23.2% (n = 64), DM with or without LR in 43.5% (n = 120), and no relapses in 33.3% (n = 92) of patients. Final relapses included no relapses in 33.3%, LR only in 14.5%, DM only in 15.9%, and DM plus LR in 36.2% of patients. Ninety-one percent of LRs occurred within 2 years and 98% occurred within 3 years of BMT. Twenty-three (36%) of 64 patients with LR only underwent salvage surgery, and their median overall survival was 58.6 months (95% CI, 28.8 to not reached) compared with those patients with LR only who were unable to undergo surgery (9.5 months; 95% CI, 7.8 to 13.3). Conclusion Unlike in patients undergoing trimodality therapy, for whom surveillance/salvage treatment plays a lesser role, 1 in the BMT population, approximately 8% of all patients (or 36% of patients with LR only) with LRs occurring more than 6 months after chemoradiotherapy can undergo salvage treatment, and their survival is excellent. Our data support vigilant surveillance, at least in the first 24 months after chemotherapy, in these patients.