European Journal of Surgical Oncology

Editorial Board

2012-06-01

The EURECCA project: Data items scored by European colorectal cancer audit registries

2012-06-01

Abstract: Aims: The EURECCA (European Registration of Cancer Care) consortium is currently formed by nine independently founded national colorectal audit registrations, of which most already run for many years. The cumulative experience of EURECCA’s participants could be used to identify a ‘core dataset’ that covers all important aspects needed for high quality auditing and at the same time lacking needless data items that only consumes administrative effort. The aim of this study is to compare the data items used by the nine registries participating in EURECCA to identify a core dataset and explore options for future research.Methods: All colorectal outcome registrations participating in the EURECCA project were asked to supply a list with all the data items they score. Items were scored ‘present’ if they appeared literally in a registration or in case they could be calculated using other items in the same registration. The definition of a ‘shared data item’ was that at least eight of the nine participating registries scored the item.Results: The number of registered data items varied between 254 (Belgium) and 83 (Norway). Among the 45 variables were patient data, data about preoperative staging, surgical treatment, pre- or postoperative radio- and/or chemotherapy, and follow-up. Items about tumour recurrence or quality of life were scored too little to become shared data items.Conclusions: A total of 45 items were collected by 8 or more of the participating registries and subsequently met the criteria for a shared data item.

Intensified neoadjuvant chemoradiotherapy in locally advanced rectal cancer – impact on long-term quality of life

2012-06-01

Abstract: Aims: In spite of advances in rectal cancer surgery and the use of preoperative 5-fluorouracil-(5-FU) based chemoradiotherapy (CRT) in stage II and III disease distant metastases still occur in about 35–40% of the patients. Intensified preoperative CRT (ICRT) using other drugs in conjunction with 5-FU has been investigated in order to improve the pathological complete remission (pCR) rate and thereby prognosis of patients with locally advanced rectal cancer. However, acute toxicity, especially diarrhea, was reported to be high and no improvement in pCR rates has been observed in randomized trials. Long-term results of these trials are pending. In the present analysis we investigated the impact of ICRT on health related quality of life and long term toxicity.Methods: The present study included 119 patients with locally advanced rectal cancer who underwent neoadjuvant CRT followed by surgery within controlled clinical trials. Patients received ICRT (n = 83) or standard CRT (n = 36). Evaluation of HRQoL was performed using EORTC QLQ-C30 and QLQ-CR29 questionnaires.Results: The overall rating of global health status/QLQ scale of the EORTC QLQ-C30 questionnaire was identical in both patient groups but patients in the CRT group showed better results in four out of nine function scales. Concerning symptom scales, patients in the CRT arm exhibited significantly less diarrhea (p = 0.028) and less disorders with taste (0.042).Conclusions: This data suggests that higher gastrointestinal acute toxicity caused by ICRT might lead to a higher risk of long-term deterioration of “gastrointestinal QoL”. Future results of randomized trials investigating ICRT versus CRT should be discussed in the light of long-term QoL data.

Lymph node ratio is an independent prognostic factor in patients with rectal cancer treated with preoperative chemoradiotherapy and curative resection

2012-06-01

Abstract: Purpose: To evaluate the prognostic effect of lymph node ratio (LNR) in patients with locally advanced rectal cancer who were treated with curative resection after preoperative chemoradiotherapy (CRT).Methods: Between October 2001 and December 2007, 519 patients who had undergone curative resection of primary rectal cancer after preoperative CRT were enrolled. Of these, 154 patients were positive for lymph node (LN) metastasis and were divided into three groups according to the LNR (≤0.15 [n=80], 0.16–0.3 [n=44], >0.3 [n=30]) to evaluate the prognostic effect on overall survival (OS) and disease-free survival (DFS).Results: LNR (≤0.15, 0.16–0.3, and >0.3) was significantly associated with 5-year OS (90.3%, 75.1%, and 45.1%; p<0.001) and DFS (66.7%, 55.8%, and 21.9%; p<0.001) rates. In a multivariate analysis, LNR (≤0.15, 0.16–0.3, and >0.3) was a significant independent prognostic factor for OS (hazard ratios [HRs], 1, 3.609, and 8.197; p<0.001) and DFS (HRs, 1, 1.699, and 3.960; p<0.001). LNR had a prognostic impact on OS and DFS in patients with <12 harvested LNs, as well as in those with ≥12 harvested LNs (p<0.05).Conclusion: LNR was a significant independent prognostic predictor for OS and DFS in patients with locally advanced rectal cancer who were treated with curative resection after preoperative CRT.

A multi-centre analysis of the impact of updated risk stratification on follow-up of gastric gastro-intestinal stromal tumours in the post-imatinib era

2012-06-01

Abstract: Background: Previously Gastro-Intestinal Stromal Tumours (GISTs) have been risk stratified histologically according to their size and mitotic index. However, gastric GISTs have a lower likelihood of recurrence and so the Miettinen criteria are now used to risk stratify patients. Records were reviewed from multiple centres to determine if these changes altered patients’ clinical care and also to determine the survival of patients following the introduction of imatinib therapy.Methods: Prospective databases of GISTs undergoing surgical resection and those reviewed by the regional sarcoma MDT were cross-referenced and added to by searching a variety of clinical and pathology coding datasets, to identify patients diagnosed between January 2000 and March 2010. Patients undergoing resection for localised disease were re-scored using Miettinen criteria and Kaplan–Meier analysis was used to determine survival outcomes.Results: The search identified 203 patients; including 132 gastric GISTs, 89 of which had resections of untreated localised disease. These were reassessed, of which approximately one third were scored as intermediate risk. Following reclassification, 26 of 29 of intermediate risk cases moved to low risk groups, representing 27.7% of all those remaining in follow-up at the time of audit. Median survival was not reached after a median follow-up of 3.85 years and 4-year survival was estimated at 72%.Conclusions: Clinicians involved in the follow-up of gastric GISTs should reassess the pathology of all intermediate and high risk patients in order to decrease patient exposure to stressful interventions, as well as hospital workload, and expenditure on unnecessary observation.

Non-curative gastrectomy for metastatic gastric cancer: Rationale and long-term outcome in multicenter settings

P. Kulig, M. Sierzega, T. Kowalczyk, P. Kolodziejczyk, J. Kulig — 2012-06-01

Abstract: Background: Metastatic gastric cancer remains a significant problem as the majority of Western patients are diagnosed with disseminated disease and no routine therapeutic regimen is accepted in such cases.Methods: A cohort of 3141 patients with gastric cancer operated between 1990 and 2005 was evaluated using a multicenter data set held by the Polish Gastric Cancer Study Group to determine potential risks and benefits of non-curative gastrectomy for metastatic disease. Additionally, parameters of Quality of Life (QoL) were evaluated prospectively in 140 patients undergoing gastrectomy using the QLQ-C30 questionnaire.Results: Gastrectomy was carried out in 2258 patients. Distant organ metastases were diagnosed in 951 patients, 415 of which underwent non-curative gastrectomy. The overall mortality rates were significantly higher in patients undergoing non-resectional surgery (10%) than either curative (3%, P < 0.001) or non-curative (4%, P = 0.002) gastrectomy. The overall median survival in patients with metastatic disease was significantly higher for non-curative gastrectomy (10.6 months, 95% confidence interval (CI) 9.3–11.9) than for non-resective operations (4.4 months, 95% CI 4.0 to 4.8, P < 0.001). The hazard ratio of death in patients subject to non-resectional surgery compared to those treated by gastrectomy was 2.923 (95% CI 2.473 to 3.454, P < 0.001). A gradual impairment in QoL parameters was found over 12 months after non-curative resections but changes did not reach statistical significance and individual parameters were similar to gastrectomy without distant metastases.Conclusion: Non-curative gastrectomy for metastatic gastric cancer is associated with significantly better survival compared to non-resective surgery and does not impair quality of life.

Metastatic lymph node ratio versus number of metastatic lymph nodes as a prognostic factor in gastric cancer

2012-06-01

Abstract: Objective: Knowledge of prognostic factors in gastric cancer is essential to decide on single patient management. We aim to establish the value of lymph node ratio compared to lymph node involvement in the prediction of gastric cancer survival and treatment approach.Methods: Charts of ninety-six consecutive patients undergoing gastrectomy for resectable gastric cancer were reviewed between January 1996 and December 2005. Receiver operating characteristic (ROC) curves were plotted to verify the accuracy of metastatic lymph node ratio (MLNR) and number of metastatic lymph node (NMLN) cut-off values for survival prediction. Patients were divided into two groups according to ROC curve cut-offs and accuracy in prognosis was reviewed.Results: ROC curves showed that 5 metastatic nodes and a node ratio value of 20% had the best survival prognostic correlation. The median survival of patients with MLNR and NMLN were similar according to cut-off determinations (≤5/>5 metastatic nodes and ≤20/>20% lymph node ratio). Five-year survival rates were 70.9% vs 17.1% and 72.4% vs 15.6%, respectively (p < 0.001). Positive correlation coefficient was found between the number of excised nodes and the number of metastatic nodes.Conclusion: Number of metastatic lymph nodes showed greater accuracy than lymph node ratio for survival prediction in gastric cancer.

Variation in the peritoneal cancer index scores between surgeons and according to when they are determined (before or after cytoreductive surgery)

D. Elias, A. Souadka, F. Fayard, A. Mauguen, F. Dumont, C. Honore, D. Goere — 2012-06-01

Abstract: Introduction: The prognosis of peritoneal carcinomatosis (PC) is highly dependent on the extent of the PC. This extent is calculated by the peritoneal cancer index (PCI). In the future, the indications for complete cytoreductive surgery (CRS) + hyperthermic intraperitoneal chemotherapy (HIPEC) should be partially based on the PCI. This raises the question of the concordance between the PCI scores calculated by different surgeons, and a possible variation before and after CRS.Objective: To analyze variations in the PCI score between surgeons and according to when it is determined (before and after surgery).Patients and methods: Prospective recording of the PCI score independently calculated by senior and junior surgeons, before CRS (when the surgeon decided to perform this procedure), and after CRS, in 75 consecutive patients. A concordance analysis was conducted.Results: The origins of the PC were colorectal (n = 38), pseudomyxoma (n = 22), mesothelioma (n = 8) and miscellaneous lesions (n = 7). Concordance between the PCI score was very high (close to 90%) among the senior surgeons and junior surgeons before and after CRS. After CRS, the mean PCI score increased by 1.75 (IC-95%: 2.09–1.41). This high concordance was similar whatever the level of the PCI score and whatever the origin of the tumor.Conclusion: The PCI is a reliable tool for measuring the extent of PC. It is easy to use and inter-surgeon concordance is high. It increases by approximately 2 before and after CRS.Synopsis:: Concordance in scoring the peritoneal cancer index (PCI) is high among surgeons. The PCI increases by approximately two points when scored after instead of before cytoreductive surgery. In conclusion, the PCI is a reliable tool for assessing the extent of peritoneal carcinomatosis.

Cytoreductive surgery and intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis: Prognosis and treatment of recurrences in a cohort study

P.H. Cashin, W. Graf, P. Nygren, H. Mahteme — 2012-06-01

Abstract: Background: Cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) treatment of colorectal peritoneal carcinomatosis (PC) is gaining acceptance, but controversy remains. The primary aims were to analyse the outcome and prognostic variables of colorectal PC patients treated with CRS and IPC, and to report on the outcome of additional surgical treatments of subsequent recurrences.Methods: Patients referred for treatment of colorectal PC between 1996 and 2010 were included in a cohort. The following data was collected: clinicopathological parameters, survival, recurrences, perioperative chemotherapy and type of IPC (hyperthermic intraperitoneal chemotherapy, HIPEC; or sequential postoperative intraperitoneal chemotherapy, SPIC). Multivariable analyses were conducted on potential prognostic factors for overall survival (OS).Results: In the 151-patient cohort, the median OS was 34 months (range: 2–77) for CRS and HIPEC with five-year survival predicted at 40% (five-year disease-free survival 32%). For CRS and SPIC, the OS was 25 months (range: 2–188) with five-year survival at 18%. Open-and-close patients survived 6 months (range: 0–14) with no five-year survival (HIPEC vs. SPIC p = 0.047, SPIC vs. open-and-close p < 0.001). Adjuvant systemic chemotherapy was a noteworthy independent prognostic factor in the multivariable analysis. OS for patients undergoing additional surgical treatment of recurrences was 25 months vs. 10 months with best supportive care or palliative chemotherapy (p = 0.01).Conclusion: Substantial long-term survival is possible in patients with colorectal PC. HIPEC was associated with better OS than SPIC and adjuvant systemic chemotherapy may improve the outcome in patients. Good OS is achievable in selected patients undergoing additional surgical treatment of isolated liver or peritoneal recurrences after prior complete CRS.

Extent of lymph node resection does not increase perioperative morbidity and mortality after surgery for stage I lung cancer in the elderly

2012-06-01

Abstract: Background & objectives: Pathologic evaluation of >10 lymph nodes (LNs) is considered necessary for accurate lung cancer staging. However, physicians have concerns about increased risk in perioperative mortality (POM) and morbidity with more extensive LN sampling, particularly in the elderly. In this study, we compared the outcomes in elderly patients with stage I non-small cell lung cancer (NSCLC) undergoing extensive (>10 nodes) and limited (≤10 nodes) LN resections.Methods: Using data from the Surveillance, Epidemiology and End Results registry linked to Medicare records, we identified 4975 patients ≥65 years of age with stage I NSCLC who underwent a lobectomy between 1992 and 2002. Risk of perioperative morbidity and POM after the evaluation of ≤10 vs. >10 LNs was compared among patients after adjusting for propensity scores.Results: Multiple regression analysis showed similar POM between the two groups (OR, 1,01; 95% CI, 0,71–1,44). Other postoperative complications were similar across groups except for thromboembolic events, which were more common among patients undergoing resection of >10 LNs (OR, 1,72; 95% CI, 1,12–2,63).Conclusions: These data suggest that evaluation of >10 LNs, which allows for more accurate staging, appears to be safe in the elderly patients undergoing lobectomy for stage I NSCLC without compromising postoperative recovery.

High expression of the transcriptional co-activator p300 predicts poor survival in resectable non-small cell lung cancers

X. Hou, Y. Li, R.-Z. Luo, J.-H. Fu, J.-H. He, L.-J. Zhang, H.-X. Yang — 2012-06-01

Abstract: Purpose: To investigate the correlation between p300 (a transcriptional co-activator) expression and clinical/prognostic characteristics in surgically resected NSCLC patients for the purpose of identifying patients with increased risk of cancer recurrence and providing them with tailored therapy.Methods: One hundred and sixty-nine completely resected NSCLC patients were included in this study. Paraffin-embedded primary tumour tissues of patients were supplied to produce a tissue microarray, and immunohistochemistry was used for the evaluation of p300 expression. The clinical/prognostic significance of p300 expression was analysed for statistical significance. Survival was calculated by the Kaplan–Meier method, and the log-rank test was used to assess differences in survival between the groups. The prognostic impact of clinicopathologic variables and p300 expression was evaluated using a Cox proportional hazards model.Results: High expression of p300 was associated with poor disease-free survival (p = 0.027) and overall survival (p = 0.006) in NSCLC patients. Further analysis suggested that this difference in overall survival also existed in patients with T2 (p = 0.040), positive lymph nodes (p = 0.023), stage IIIA (p = 0.003), adenocarcinoma (p = 0.021), and a well-differentiated histological grade score (p = 0.011). The multivariate Cox regression analysis showed that low p300 expression is an independent marker of better disease-free survival (relative risk = 0.628, p = 0.047) and overall survival (relative risk = 0.545, p = 0.024) in operable NSCLC patients.Conclusions: Low p300 expression is an independent prognostic marker of better survival in operable NSCLC patients. The combination of clinicopathological TNM staging classification with p300 expression may be useful in identifying patients with increased risk of cancer recurrence to provide them with tailored therapy.

Liver resection using bipolar InLine multichannel radiofrequency device: Impact on intra- and peri-operative outcomes

R. Daylami, H. Kargozaran, V.P. Khatri — 2012-06-01

Abstract: Aims: Liver resection is indicated for several primary and secondary liver lesions. We follow up our earlier experience with the use of InLine Multichannel Radiofrequency Device (ILMRD, Resect Medical Inc., Fremont, CA) a device that produces coagulative necrosis along the transection plane.Methods: The records of 68 consecutive patients who underwent liver resection for primary and metastatic liver tumors from August 2000 to December 2008 were reviewed. Data analyzed include demographic data as well as complexity of liver resection, intra-operative blood loss, use of portal triad clamping and transfusion of blood. Postoperative outcomes measured were morbidity, hospital and ICU length of stay.Results: The median estimated blood loss was 150 mL in the ILMRD group compared to 400 mL in the non-ILMRD group (p < 0.0001). Median length of stay was decreased in the ILMRD group by a day (7 vs. 8 p < 0.003). There was a significant decrease in frequency of parenchymal clamp time (57% vs 84%, p < 0.001) and median total portal triad clamp time (2.5 vs 30 min p < 0.0001). We also noted a significant decrease in the median portal triad clamp time (0 vs 25 min, p < 0.001) used during the parenchymal transection phase. Furthermore, use of the ILMRD device allowed us to perform more complex hepatic resections.Conclusion: Use of ILMRD to perform radiofrequency-assisted hepatic resection was associated with a significant decrease in intra-operative blood loss and earlier discharge from the hospital despite increasing complexity of resections and decreased use of portal triad clamping.

T-category reflects the histopathologic characteristics of gallbladder cancer

2012-06-01

Abstract: Aims: Gallbladder (GB) cancer is a relatively uncommon gastrointestinal malignancy and is known to often result in unfavorable outcomes. Recent advances in aggressive surgical resection have improved the overall survival rate of patients with GB cancer. We aimed to evaluate the outcomes and prognostic factors of GB cancer following a surgical resection with curative intent.Methods: Between March 2001 and March 2009, 89 patients with GB cancer underwent surgical resection with curative intent at the National Cancer Center of Korea. We then conducted a retrospective analysis of clinicopathologic data.Results: Nineteen patients underwent simple cholecystectomy and 70 patients underwent extended cholecystectomy. Tumor-free resection margins were obtained in 84 cases. The 1-, 3- and 5-year disease-specific survival rates in the 89 patients were 85.8%, 68.0% and 64.1%, respectively. By multivariate analysis, only the T-category was significant (p < 0.001). The T-category showed a close correlation with all of the other histopathologic factors which were significant in univariate analysis.Conclusion: The T-category of GB cancer represents not only the depth of the primary tumor but also the aggressiveness of its histopathologic nature.

Biliary reconstruction when the liver hilum is inaccessible: The anterior approach

D.J. Grünhagen, S.W. Fenwick, G.J. Poston, H.Z. Malik — 2012-06-01

Abstract: Objective: This paper focuses on a novel approach to biliary reconstruction after previous extensive liver surgery.Summary background data: Bile leak and subsequent biliary strictures are not uncommon after extensive liver surgery. Biliary reconstruction is then required, but the liver hilum is usually inaccessible for further surgical intervention.Methods: A novel surgical technique is described in two patients with biliary stenosis after previous extensive liver surgery. Access to the biliary tree was obtained using an anterior approach. A previously inserted PTC drain was used as guidance to the bile duct suitable for creating a biliary-digestive anastomosis.Results: The described technique proved to cause complete biliary drainage in both patients. There was no treatment-related morbidity nor was further biliary intervention needed during follow-up.

Robotic radical parametrectomy with pelvic lymphadenectomy: Our experience and review of the literature

D. Vitobello, G. Siesto, C. Bulletti, A. Accardi, N. Iedà — 2012-06-01

Abstract: Aims: To evaluate the feasibility and safety of robotic radical parametrectomy (RRP) and pelvic lymphadenectomy for the management of occult invasive cervical cancer or local recurrence of endometrial cancer and to compare our outcomes with the evidence available in the literature.Methods: Starting from 07/2008 consecutive patients submitted to RRP have been included in this study. A comprehensive literature review of published papers about this subject was carried out.Results: During the study period 11 patients were managed; 7 and 4 patients had an occult cervical cancer and a vaginal recurrence of endometrial cancer, respectively. One intra-operative and one post-operative complications were recorded. Neither conversion to laparotomy, nor blood transfusions occurred. Three women required further adjuvant therapies. After a median follow-up of 19 months (range 8–36) one recurrence has been detected. The outcomes of other 200 women from 15 different papers have been collected and compared to our findings.Conclusions: Robotic surgery represents an effective alternative to accomplish radical parametrectomy with comparable results of those reported in the literature in terms of feasibility and safety. RRP is certainly a demanding procedure which however avoids radiotherapy in more than 80% of cases.

2012 Calendar of Events

2012-06-01

Joint ESSO-PSSO Educational Workshop: “Upper Gastrointestinal Cancer” 1-2 June 2012, Poznan, Poland

Announcements

2012-06-01

ESSO video workshops. The ESSO Education and Training Committee will organise 2 half-day video workshops in conjunction with the ESSO 32 congress. Running in parallel on the first day of the ESSO 32 congress (19th September), just before the opening, both workshops will have an interactive format and include case discussions.