Correlation between radiologic features on contrastenhanced CT and pathological tumor grades in pancreatic neuroendocrine neoplasms

Contrast-enhanced computed tomography(CT)contributes to the increasing detection of pancreatic neuroendocrine neoplasms(PNENs).Nevertheless,its value for differentiating pathological tumor grades is not well recognized.In this report,we have conducted a retrospective study on the relationship between the 2017 World Health Organization(WHO)classification and CT imaging features in 94 patients.Most of the investigated features eventually provided statistically significant indicators for discerning PNENs G3 from PNENs G1/G2,including tumor size,shape,margin,heterogeneity,intratumoral blood vessels,vascular invasion,enhancement pattern in both contrast phases,enhancement degree in both phases,tumor-to-pancreas contrast ratio in both phases,common bile duct dilatation,lymph node metastases,and liver metastases.Ill-defined tumor margin was an independent predictor for PNENs G3 with the highest area under the curve(AUC)of 0.906 in the multivariable logistic regression and receiver operating characteristic curve analysis.The portal enhancement ratio(PER)was shown the highest AUC of 0.855 in terms of quantitative features.Our data suggest that the traditional contrastenhanced CT still plays a vital role in differentiation of tumor grades and heterogeneity analysis prior to treatment.

Leveraging machine learning techniques for predicting pancreatic neuroendocrine tumor grades using biochemical and tumor markers

BACKGROUND The incidence of pancreatic neuroendocrine tumors (PNETs) is now increasing rapidly. The tumor grade of PNETs significantly affects the treatment strategy and prognosis. However, there is still no effective way to non-invasively classify PNET grades. Machine learning (ML) algorithms have shown potential in improving the prediction accuracy using comprehensive data. AIM To provide a ML approach to predict PNET tumor grade using clinical data. METHODS The clinical data of histologically confirmed PNET cases between 2012 and 2018 were collected. A method of minimum P for the Chi-square test was used to divide the continuous variables into binary variables. The continuous variables were transformed into binary variables according to the cutoff value, while the P value was minimum. Four classical supervised ML models, including logistic regression, support vector machine (SVM), linear discriminant analysis (LDA) and multi-layer perceptron (MLP) were trained by clinical data, and the models were labeled with the pathological tumor grade of each PNET patient. The performance of each model, including the weight of the different parameters, were evaluated. RESULTS In total, 91 PNET cases were included in this study, in which 32 were G1, 48 were G2 and 11 were G3. The results showed that there were significant differences among the clinical parameters of patients with different grades. Patients with higher grades tended to have higher values of total bilirubin, alpha fetoprotein, carcinoembryonic antigen, carbohydrate antigen 19-9 and carbohydrate antigen 72-4. Among the models we used, LDA performed best in predicting the PNET tumor grade. Meanwhile, MLP had the highest recall rate for G3 cases. All of the models stabilized when the sample size was over 70 percent of the total, except for SVM. Different parameters varied in affecting the outcomes of the models. Overall, alanine transaminase, total bilirubin, carcinoembryonic antigen, carbohydrate antigen 19-9 and carbohydrate antigen 72-4 affected the outcome greater than other parameters. CONCLUSION ML could be a simple and effective method in non-invasively predicting PNET grades by using the routine data obtained from the results of biochemical and tumor markers.

Pancreatic neuroendocrine tumor Grade 1 patients followed up without surgery:Case series

Among the three grades of neuroendocrine tumors(NETs),the prognosis for Grade 1(G1) with surgery is very good.Therefore,we evaluated the prognoses of pancreatic NET(PNET) G1 patients without surgery.A total of 8 patients who were diagnosed with NET G1,with an observation period of more than 6 mo until surgery or without surgery,were recruited.The patients who underwent surgery were ultimately diagnosed using specimens obtained during the surgery,whereas the patients who did not undergo surgery were diagnosed using specimens obtained by endoscopic ultrasonography-guided fine needle aspiration.Overall,we mainly evaluated the observation period and tumor growth.The observation period for the five cases with surgery ranged from 6-80 mo,and tumor growth was observed in one case.In contrast,the observation period for the three cases without surgery ranged from 17-54 mo,and tumor growth was not observed.Therefore,although the first-choice treatment for NETs is surgery,our experience includes certain NET G1 patients who were followed up without surgery.

Accuracy of tumor grade by preoperative curettage and associated clinicopathologic factors in clinical stage Ⅰ endometriod adenocarcinoma

Background Preoperative tumor grading becomes one of the most important predictors for lymphadenectomy at primary surgery for clinical stage Ⅰ endometriod adenocarcinoma. However, there is an inconsistency of tumor grade between preoperative curettage and final hysterectomy specimens, and its associated factors are poorly understood. This study aimed to evaluate the accuracy of tumor grade by preoperative curettage so as to achieve a better stratified management for clinical stage Ⅰ endometriod adenocarcinoma. Methods Clinical data of totally 687 patients with clinical stage Ⅰ endometriod adenocarcinoma who underwent preoperative curettage and primary surgery were retrospectively collected. Compared with final hysterectomy specimens, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of tumor grade by preoperative curettage were calculated and their associations with clinicopathologic parameters, including age, status of menopause, position of uterus, location and size of lesion, histological grade, depth of myometrial invasion, cervical invasion, extrauterine spread, peritoneal cytology, metastasis to retroperitoneal lymph node, serum CA125 level, and hormone receptor status, were analyzed. Results In final hysterectomy specimens, 139 of 259 grade 1 patients by curettage were upgraded to grade 1 or 2; 31 of 296 grade 2 were upgraded to grade 3, with a significantly discrepant rate of 40.9% （281/687） and an upgraded rate of 24.7% （170/687）. The specificity and negative predictive value for grade 3 were 90.7% and 89.9%, while the sensitivity and positive predictive value for grade 1 were 67.1% and 40.9%, respectively. Conclusions Preoperative tumor grade by curettage does not accurately predict final histological results, especially in those classified as grade 1. Complete surgical staging seems to be necessary for clinical stage Ⅰ endometriod adenocarcinoma.

The association of inherited variation in the CLOCK gene with breast cancer tumor grade

Background:Sufficient sleep and maintenance of circadian rhythm are important to health.We have shown that short duration of sleep before diagnosis is associated with higher-grade tumors among breast cancer patients.Earlier studies suggest that genetic variation in the CLOCK gene is associated with risk of cancers,including breast cancer.Studies of the association of genetic variation,including in CLOCK,and tumor grade,a standard marker of tumor aggressiveness,are lacking.Methods:We investigated the relationship between single nucleotide polymorphisms(SNPs)in the CLOCK gene and tumor grade and estrogen receptor,progesterone receptor,and human epi-dermal growth factor receptor 2 status in 293 breast cancer patients.Nine SNPs were determined by standard TaqMan assays.Tumor grade,receptor status,and other clinical variables were abstracted from medical records.Results:Two SNPs were excluded because of poor genotyping performance.None of the remaining seven variants had a statistically significant association with breast cancer tumor grade or with receptor status.Conclusion:As with all novel studies,further work is needed to examine the association of CLOCK and other genes in the circadian rhythm pathway with breast cancer tumor grade in other populations.

Tumor regression grades:Potential outcome predictor of locally advanced rectal adenocarcinoma after preoperative radiotherapy

AIM:To analyze tumor regression grade(TRG)for prognosis of locally advanced rectal adenocarcinoma(LARA)treated with preoperative radiotherapy.METHODS:One hundred and ninety patients with clinical stageⅡ/ⅢLARA were studied.All patients underwent radical surgery(between 2004 and 2010)after 30-Gy/10-fraction preoperative radiotherapy(preRT).All 190 patients received a short course of preRT and were reassessed for disease recurrence and survival;the slides of surgical specimens were reviewed and classified according to Mandard TRG.We compared patients with good response(Mandard TRG1 or TRG2)vs patients with bad/poor response(Mandard TRG3-5).Outcomes evaluated were 5-year overall survival(OS),5-year disease-free survival(DFS),and local,distant and mixed recurrence.Fisher’s exact test orχ2 test,logrank test and proportional hazards regression analysis were used to calculate the probability that Mandard TRG was associated with patient outcomes.RESULTS:One hundred and sixty-six of 190 patients(87.4%)were identified as Mandard bad responders(TRG3-5).High Mandard grade was correlated with tumor height(41.7%<6 cm vs 58.3%≥6 cm,P=0.050),yp T stage(75%yp T0-2 vs 25%yp T3-4,P=0.000),and yp N stage(75%yp N0 vs 25%yp N1,P=0.031).In univariate survival analysis,Mandard grade bad responders had significantly worse OS and DFSthan good responders(TRG1/2)(OS,83.1%vs 96.4%,P=0.000;DFS,72.3%vs 92.0%,P=0.002).In multivariate survival analysis,Mandard bad responders had significantly worse DFS than Mandard good responders(DFS 3.8 years(95%CI:1.2-12.2 years,P=0.026).CONCLUSION:Mandard grade good responders had a favorable prognosis.TRG may be a potential predictor for DFS in LARA after pre-RT.

Alterations of tumor-related genes do not exactly match the histopathological grade in gastric adenocarcinomas

AIM:To investigate the diverse characteristics of different pathological gradings of gastric adenocarcinoma (GA) using tumor-related genes.METHODS:GA tissues in different pathological gradings and normal tissues were subjected to tissue arrays.Expressions of 15 major tumor-related genes were detected by RNA in situ hybridization along with 3' terminal digoxin-labeled anti-sense single strandedoligonucleotide and locked nucleic acid modifying probe within the tissue array.The data obtained were processed by support vector machines by four different feature selection methods to discover the respective critical gene/gene subsets contributing to the GA activities of different pathological gradings.RESULTS:In comparison of poorly differentiated GA with normal tissues,tumor-related gene TP53 plays a key role,although other six tumor-related genes could also achieve the Area Under Curve (AUC) of the receiver operating characteristic independently by more than 80%.Comparing the well differentiated GA with normal tissues,we found that 11 tumor-related genes could independently obtain the AUC by more than 80%,but only the gene subsets,TP53,RB and PTEN,play a key role.Only the gene subsets,Bcl10,UVRAG,APC,Beclin1,NM23,PTEN and RB could distinguish between the poorly differentiated and well differentiated GA.None of a single gene could obtain a valid distinction.CONCLUSION:Different from the traditional point of view,the well differentiated cancer tissues have more alterations of important tumor-related genes than the poorly differentiated cancer tissues.

RELATION BETWEEN MORPHOMETRIC GRADES OF BLADDER TUMOR AND PROGNOSIS

The relation between morphometric grades (M grading) of 84 cases of bladder tumor and prognoses was evaluated. The results shown that the higher the M grading, the lower the survival rate and the higher the recurrence rate. As the M grade increases, the tumor has partial of total absence of ABO(H) antigens of tumor cell surface and could be accompanied with muscular invasion. When recurring, the tumor has a poor prognosis if M grading increases from lower to higher grades. The morphometric grading system is able to make a quantitative pathologic diagnosis and can predict the biological behavior of bladder tumors.

Synchronous Mucinous Borderline Tumor of the Ovary and Low-Grade Appendiceal Mucinous Neoplasm

We present a rare case of synchronous mucinous borderline tumor of the ovary and low-grade appendiceal mucinous neoplasm (LAMN). We performed a left adnexectomy to diagnose the left ovarian borderline malignancy and an ileostomy because of the swollen appendix during the operation. It was diagnosed as left ovarian mucinous borderline malignancy and LAMN. LAMN causes peritoneal dissemination, ovarian metastasis, and peritoneal pseudomyxoma. The appendix and ovary are close to each other anatomically and can metastasize if there is a tumor in either. For ovarian mucinous tumors, it is necessary to search the gastrointestinal tract, especially the appendix, as the primary lesion. For appendix tumors, it is necessary to search for the ovary. Since LAMN may be associated with borderline ovarian malignancies, as in this case, there is a possibility of the duplication of tumors when searching for ovarian mucinous tumors as the primary tumor and if ovarian tumors are found. Since LAMN and mucinous ovarian tumors have similar histological features, immunohistochemical staining is useful for their differentiation because they show different immunostaining patterns.

Mixed pancreatic ductal adenocarcinoma and well-differentiated neuroendocrine tumor:A case report

BACKGROUND Pancreatic mixed neuroendocrine-non-neuroendocrine neoplasms(MiNENs)are rare malignancies affecting the pancreas.The World Health Organization defines MiNENs as neoplasms composed of morphologically recognizable neuroendocrine and non-neuroendocrine components,each constituting 30%or more of the tumor volume.Adenocarcinoma-neuroendocrine carcinoma is the most frequent MiNEN combination.A well-differentiated neuroendocrine tumor(NET)component is rarely reported in MiNENs.CASE SUMMARY Here we report a rare case with intermingled components of ductal adenocarcinoma and grade 1 well-differentiated NET in the pancreas.The two tumors show distinct histology and significant differentiation discrepancy(poorly differentiated high grade adenocarcinoma and well-differentiated low grade NET),and also present as metastases in separate lymph nodes.Next generation sequencing of the two components demonstrates KRAS and TP53 mutations in the ductal adenocarcinoma,but no genetic alterations in the NET,suggesting divergent origins for these two components.Although tumors like this meet the diagnostic criteria for MiNEN,clinicians often find the diagnosis and staging confusing and impractical for clinical management.CONCLUSION Mixed NET/non-NET tumors with distinct histology and molecular profiles might be better classified as collision tumors rather than MiNENs.

A Case of Low-Grade Appendiceal Mucinous Neoplasm of Its Difficultly to Distinguish from a Right Ovarian Tumor Due to Postmenopause

We here present a rare case of appendiceal tumor mimicking ovarian tumor in menopause woman. The patient was a 56-year-old woman, G1P1, who presented to our hospital with a right adnexal cyst diagnosed at another hospital. Transvaginal echocardiography showed a cyst in the right adnexal region, and pelvic contrast-enhanced MRI revealed a small cyst in the same region. The left ovary was atrophic and identifiable. It was unclear whether the cyst was contiguous with the gastrointestinal tract. Blood tests showed no elevation of tumor markers. We considered its possibility of a gastrointestinal origin, but since right normal ovary was not found, we thought the tumor was of ovarian origin and decided on a laparoscopic resection of the right adnexa. Intraoperatively, we observed atrophied bilateral normal ovaries, and the pelvic tumor was contiguous to the appendix. Surgeons performed a laparoscopic appendectomy after consultation with us. After resection we searched the abdominal and pelvic cavities, but found no obvious disseminated lesions. The histological diagnosis was low-grade appendiceal mucinous neoplasm (LAMN), a rare benign tumor of the appendix. Appendiceal tumors can be difficult to differentiate from right ovarian tumors due to their close anatomic location in the pelvis. It is possible to determine whether the tumor is of ovarian or appendiceal origin by identifying normal ovaries and the location of the feeding vessels into the tumors. In our case, there were no lesions other than the appendix, but LAMN can metastasize to the ovary, cause pseudomyoxoma peritonei, or be an overlapping tumor with an ovarian tumor. If an appendiceal tumor is diagnosed after surgery for ovarian tumor, the intra-abdominal cavity should be searched for metastasis or dissemination, and a thorough search for ovarian lesions should be performed with the possibility of an overlapping tumor in mind.

Clinical characteristics and outcome of primary hepatic neuroendocrine tumors after comprehensive therapy

BACKGROUND Primary hepatic neuroendocrine tumors(PHNETs),a group of neuroendocrine neoplasms,are extremely rare.There are only few case reports about PHNETs in the literature.The lack of large samples and multicenter research results in poor diagnostic and therapeutic approaches.AIM To discuss the clinical characteristics,diagnosis,and treatment of PHNETs and risk factors related to survival.METHODS We retrospectively analyzed the clinical data,imaging features,immunohistochemistry data,and treatment efficacy of 40 patients who were pathologically diagnosed with PHNETs and admitted to The First Affiliated Hospital of Zhengzhou University from January 1,2014 to November 15,2019.Finally,survival analysis was performed to identify the risk factors for survival.RESULTS The main symptoms and signs included intermittent abdominal pain(19 patients,47.5%)and bloating(8 patients,20.0%).The positive rates of tested tumor markers were recorded as follows:Carbohydrate antigen 19-9(CA19-9)(6 patients,15.0%),CA72-4(3 patients,7.5%),carcinoembryonic antigen(7 patients,17.5%),and alpha-fetoprotein(6 patients,15.0%).Immunohistochemical staining results showed positivity for Syn in 38(97.4%)of 39 patients,for chromogranin A in 17(65.4%)of 26 patients,for CD56 in 35(94.6%)of 37 patients,for AE1/AE3 in 28(87.5%)of 32 patients,and for Ki-67 in all 40(100.0%)patients.The overall survival rate was significantly related to the tumor grade,AE1/AE3,and Ki-67.tumor number,tumor size,metastasis,and treatment)and overall survival.CONCLUSION Higher grade,negative AE1/AE3,and higher Ki-67 are associated with a worse survival rate.Kinds of treatment and other parameters have no significant influence on overall survival.

Clinical and pathological characteristics and prognosis of 132 cases of rectal neuroendocrine tumors

BACKGROUND Neuroendocrine tumors(NETs)frequently occur in the gastrointestinal tract,lung,and pancreas,and the rectum and appendix are the sites with the highest incidence.Epidemiology statistics show that an estimated 8000 people every year in the United States are diagnosed with NETs occurring in the gastrointestinal tract,including the stomach,intestine,appendix,colon,and rectum.The pathological changes and clinical symptoms of NETs are not specific,and therefore they are frequently misdiagnosed.AIM To investigate the clinical symptoms,pathological characteristics,treatment,and prognosis of rectal neuroendocrine tumors(RNETs)by analyzing the clinical and pathological data of 132 RNET cases at our hospital.METHODS All RNETs were graded according to Ki-67 positivity and mitotic events.The tumors were staged as clinical stages I,II,III,and IV according to infiltrative depth and tumor size.COX proportional hazard model was used to assess the main risk factors for survival.RESULTS These 132 RNETs included 83 cases of G1,21 cases of G2,and 28 cases of G3(neuroendocrine carcinoma)disease.Immunohistochemical staining showed that 89.4%of RNETs were positive for synaptophysin and 39.4%positive for chromogranin A.There were 19,85,23,and 5 cases of clinical stages I,II,III,and IV,respectively.The median patient age was 52.96 years.The diameter of tumor,depth of invasion,and pathological grade were the main reference factors for the treatment of RNETs.The survival rates at 6,12,36,and 60 mo after operation were 98.5%,94.6%,90.2%,and 85.6%,respectively.Gender,tumor size,tumor grade,lymph node or distant organ metastasis,and radical resection were the main factors associated with prognosis of RNETs.Multivariate analysis showed that tumor size and grade were independent prognostic factors.CONCLUSION The clinical symptoms of RNETs are not specific,and they are easy to misdiagnose.Surgery is the main treatment method.The grade and stage of RNETs are the main indices to evaluate prognosis.

Simple cholecystectomy is an adequate treatment for grade I T1bN0M0 gallbladder carcinoma:Evidence from 528 patients

BACKGROUND T1b gallbladder carcinoma(GBC)is defined as a tumor that invades the perimuscular connective tissue without extension beyond the serosa or into the liver.However,controversy still exists over whether patients with T1b GBC should undergo cholecystectomy alone or radical GBC resection.AIM To explore the optimal surgical approach in patients with T1b gallbladder cancer of different pathological grades.METHODS Patients with T1bN0M0 GBC who underwent surgical treatment between 2000 and 2017 were included in the Surveillance,Epidemiology,and End Results database.The Kaplan-Meier method and log-rank test were used to analyze the overall survival(OS)and disease-specific survival(DSS)of patients with T1b GBC of different pathological grades.Cox regression analysis was used to identify independent predictors of mortality and explore the selection of surgical methods in patients with T1b GBC of different pathological grades and their relationship with prognosis.RESULTS Of the 528 patients diagnosed with T1bN0M0 GBC,346 underwent simple cholecystectomy(SC)(65.5%),131 underwent SC with lymph node resection(SC+LN)(24.8%),and 51 underwent radical cholecystectomy(RC)(9.7%).Without considering the pathological grade,both the OS(P<0.001)and DSS(P=0.003)of T1b GBC patients who underwent SC(10-year OS:27.8%,10-year DSS:55.1%)alone were significantly lower than those of patients who underwent SC+LN(10-year OS:35.5%,10-year DSS:66.3%)or RC(10-year OS:50.3%,10-year DSS:75.9%).Analysis of T1b GBC according to pathological classification revealed no significant difference in OS and DSS between different types of procedures in patients with grade Ⅰ T1b GBC.In patients with grade Ⅱ T1b GBC,obvious survival improvement was observed in the OS(P=0.002)and DSS(P=0.039)of those who underwent SC+LN(10-year OS:34.6%,10-year DSS:61.3%)or RC(10-year OS:50.5%,10-year DSS:78.8%)compared with those who received SC(10-year OS:28.1%,10-year DSS:58.3%).Among patients with grade Ⅲ or Ⅳ T1b GBC,SC+LN(10-year OS:48.5%,10-year DSS:72.2%),and RC(10-year OS:80%,10-year DSS:80%)benefited OS(P=0.005)and DSS(P=0.009)far more than SC(10-year OS:20.1%,10-year DSS:38.1%)alone.CONCLUSION Simple cholecystectomy may be an adequate treatment for grade Ⅰ T1b GBC,whereas more extensive surgery is optimal for grades Ⅱ-Ⅳ T1b GBC.

Unique case of oligoastrocytoma with recurrence and grade progression:Exhibiting differential expression of high mobility group-A1 and human telomerase reverse transcriptase

Mixed gliomas, primarily oligoastrocytomas, account for about 5%-10% of all gliomas. Distinguishing oligoastrocytoma based on histological features alone has limitations in predicting the exact biological behavior, necessitating ancillary markers for greater specificity. In this case report, human telomerase reverse transcriptase(hT ERT) and high mobility group-A1(HMGA1); markers of proliferation and stemness, have been quantitatively analyzed in formalin-fixed paraffin-embedded tissue samples of a 34 years old patient with oligoastrocytoma. Customized florescence-based immunohistochemistry protocol with enhanced sensitivity and specificity is used in the study. The patient presented with a history of generalized seizures and his magnetic resonance imaging scans revealed infiltrative ill-defined mass lesion with calcified foci within the left frontal white matter, suggestive of glioma. He was surgically treated at our center for four consecutive clinical events. Histopathologically, the tumor was identified as oligoastrocytoma-grade Ⅱ followed by two recurrence events and final progression to grade Ⅲ. Overall survival of the patient without adjuvant therapy was more than 9 years. Glial fibrillary acidic protein, p53, Ki-67, nuclear atypia index, pre-operative neutrophillymphocyte ratio, are the other parameters assessed. Findings suggest that hT ERT and HMGA1 are linked to tumor recurrence and progression. Established markers can assist in defining precise histopathological grade in conjuction with conventional markers in clinical setup.

The predictive value of histological tumor regression grading (TRG) for therapeutic evaluation in locally advanced esophageal carcinoma treated with neoadjuvant chemotherapy

Response criteria remain controversial in therapeutic evaluation for locally advanced esophageal carcinoma treated with neoadjuvant chemotherapy.We aimed to identify the predictive value of tumor regression grading(TRG) in tumor response and prognosis.Fifty-two patients who underwent neoadjuvant chemotherapy followed by esophagectomy and radical 2-field lymphadenectomy between June 2007 and June 2011 were included in this study.All tissue specimens were reassessed according to the TRG scale.Potential prognostic factors,including clinicopathologic factors,were evaluated.Survival curves were generated by using the Kaplan-Meier method and compared with the log-rank test.Prognostic factors were determined with multivariate analysis by using the Cox regression model.Our results showed that of 52 cases,43(83%) were squamous cell carcinoma and 9(17%) were adenocarcinoma.TRG was correlated with pathologic T(P = 0.006) and N(P < 0.001) categories.Median overall survival for the entire cohort was 33 months.The 1-and 2-year overall survival rates were 71% and 44%,respectively.Univariate survival analysis results showed that favorable prognostic factors were histological subtype(P = 0.003),pathologic T category(P = 0.026),pathologic N category(P < 0.001),and TRG G0(P = 0.041).Multivariate analyses identified pathologic N category(P < 0.001) as a significant independent prognostic parameter.Our results indicate that histomorphologic TRG can be considered as an alternative option to predict the therapeutic efficacy and prognostic factor for patients with locally advanced esophageal carcinoma treated by neoadjuvant chemotherapy.

Comparison of tumor regression grading systems for locally advanced gastric adenocarcinoma after neoadjuvant chemotherapy

BACKGROUND Current tumor regression grade(TRG)evaluations are based on various systems which brings confusion for oncologists and pathologists when interpreting results.The recent six-tier system(JGCA2017-TRG)recommended by the Japanese Gastric Cancer Association(JGCA)is worth investigating,as four-tier TRG systems are favored in various parts of the world.AIM To compare the predictive accuracies of five published TRG systems.METHODS Data were retrospectively collected from patients with locally advanced gastric cancer(LAGC)who underwent neoadjuvant chemotherapy followed by D2 Lymphadenectomy between January 2005 and January 2014 at our institution.Outcomes were overall survival(OS)and disease-free survival(DFS),which were evaluated separately using the following TRG systems:JGCA2017,JGCA,Becker,AJCC/CAP,and Mandard.RESULTS All five published TRG systems were independent predictors for OS and DFS.Concordance indices of the JGCA2017,JGCA,Becker,AJCC/CAP-TRG,and Mandard systems were 0.651/0.6480.652/0.649,0.693/0.695,0.688/0.685,and 0.674/0.675 for OS and DFS,respectively.The four-tier Becker system showed the highest c-index,which was significantly greater than that of the six-tier JGCA2017 and five-tier JGCA systems(P<0.05 in OS and DFS).When residual tumor percentages were reset as:“no residual tumor”,<10%,<100%,and“no response”,the rearranged cutoff values achieved a maximum c-index with 0.728 for OS and 0.737 for DFS,which was superior to the other five systems.CONCLUSION The newly introduced six-tier JGCA-TRG system cannot increase prognostic stratification.The four-tier Becker system is more suitable for LAGC patients.A population-based study is warranted to define the optimal criterion for TRG in LAGC patients.

Investigation of the factors influencing surgical treatment of duodenal gastrointestinal stromal tumors

BACKGROUND Duodenal gastrointestinal stromal tumor(DGIST)is a rare tumor with a specific anatomic site and biological characteristics.As the incidence of lymph node metastasis is very low,the main treatment method is surgery.Two main surgical techniques(local resection and Whipple)are performed in patients with DGISTs.The critical question is which surgical technique to choose.AIM To identify factors influencing the choice of surgery for DGISTs.METHODS The clinicopathological data of patients with DGISTs who underwent surgery between January 1999 and January 2021 were analyzed.We used the Student’s ttest or Mann-Whitney U-test and theχ2 test or Fisher’s exact test to determine the differences between the two groups of patients.Furthermore,we used logistic analysis to identify the relevant factors and independent factors related to the type of surgery.The Kaplan-Meier method was used to analyze the patient’s survival information and Cox regression analysis was performed to determine prognostic risk factors.RESULTS Overall,86 patients were analyzed,including 43 men(50%)and 43 women(50%).We divided the patients into two groups based on surgical technique(local resection or Whipple surgery).There were no differences in the age,mitotic figures,and complications between the two groups;however,the tumor size,tumor location,risk grade,postoperative hospital stay,and abdominal drainage time were significantly different.Based on univariate logistic analysis,the Whipple procedure was chosen if the tumor size was≥5.0 cm,the tumor was located in the descending part of the duodenum,or the risk grade was medium or high.In our research,the five-year overall survival rate of patients was more than 90%.We also describe two DGIST patients with liver metastases at first diagnosis and analyzed their management in order to provide advice on complicated cases.CONCLUSION The Whipple procedure was performed if the primary tumor was in the descending part of the duodenum,tumor size was≥5.0 cm,or the tumor risk grade was medium or high.

Epilepsy associated tumors: Review article

Long-term epilepsy associated tumors(LEAT) represent a well known cause of focal epilepsies. Glioneuronaltumors are the most frequent histological type consisting of a mixture of glial and neuronal elements and most commonly ariseing in the temporal lobe. Cortical dysplasia or other neuronal migration abnormalities often coexist. Epilepsy associated with LEAT is generally poorly controlled by antiepileptic drugs while, on the other hand, it is high responsive to surgical treatment. However the best management strategy of tumor-related focal epilepsies remains controversial representing a contemporary issues in epilepsy surgery. Temporo-mesial LEAT have a widespread epileptic networkwith complex epileptogenic mechanisms. By using an epilepsy surgery oriented strategy LEAT may have an excellent seizure outcome therefore surgical treatment should be offered early, irrespective of pharmacoresistance, avoiding both the consequences of uncontrolled seizures as well as the side effects of prolonged pharmacological therapy and the rare risk of malignant transformation.

Analysis of long-term outcomes and application of the tumor regression grading system in the therapeutic assessment of resectable limited-disease small cell lung cancer

Objective The present study attempted to evaluate the value of neoadjuvant chemotherapy in limiteddisease small cell lung cancer(LD-SCLC),and to identify the predictive value of the tumor regression grading(TRG) system in LD-SCLC treatment-response and prognosis.Methods The records of patients with LD-SCLC(p-Stage I–IIIa) who underwent definitive radical resection at Shaanxi Provincial People's Hospital between March 1,2000 and March 31,2014 were retrospectively analyzed.We compared the disease-free survival(DFS) and overall survival(OS) rates between Group A patients(patients who underwent surgery combined with pre-and post-operative chemotherapy) and Group B patients(patients who underwent surgery combined with adjuvant chemotherapy only) using the Kaplan-Meier method and the Mantel-Cox test.The specimens of patients who received neoadjuvant chemotherapy were reassessed according to the TRG system.Results The median DFS for 27 patients was 16.267 months and the median OS was 81.167 months(1-year OS,74.07%;3-year OS,22.22%;5-year OS,14.81%).Thirteen patients received neoadjuvant chemotherapy,and their specimens were reassessed by TRG(pathological complete remission,3/13,23.08%).Patients in group A had a longer OS than those in group B(mean,93.782 months versus 42.322 months,P = 0.025),although there was no significant difference in DFS between the two groups(median 20.100 months versus 14.667 months,P = 0.551).Statistical analysis revealed that TRG Grade(G) 0(mean,61.222 months) was associated with better OS than G1-2(mean,31.213 months)(P = 0.311).Conclusion Our study indicated that neoadjuvant chemotherapy combined with surgical resection may represent a feasible treatment method for patients with LD-SCLC.The TRG system may be a valuable prediction tool to assess neoadjuvant chemotherapeutic efficacy,especially in patients with G0 disease as determined by TRG;these patients may attain an improved survival benefit with neoadjuvant chemotherapy.