Risk factors of poor prognosis and portal vein tumor thrombosis after curative resection of solitary hepatocellular carcinoma

BACKGROUND:Predictors of poor prognosis of solitary hepatocellular carcinoma(SHCC),a subgroup encompassing most patients with the malignancy,are still controversial.Hence,risk factors for portal vein tumor thrombosis(PVTT) in SHCC are obscure.The present study was designed to address this issue.METHOD:Clinicopathological and follow-up data for 156 consecutive patients with SHCC following curative hepatic resection were analyzed using uni-and multi-variate analyses.RESULTS:Univariate analysis showed that PVTT,tumornode-metastasis(TNM) stage,Edmondson-Steiner grade and preoperative serum alpha-fetoprotein(AFP) level were associated with the overall and disease-free survival,whereas tumor size only influenced the overall survival.In multivariate Cox regression tests,Edmondson-Steiner grade and TNM stage were independent prognostic markers for both overall and diseasefree survival.In addition,the Chi-square test showed that AFP level and Edmondson-Steiner grade were correlated with PVTT.Among them,only Edmondson-Steiner grade was shown to be of independent significance for PVTT in multi-variate logistic regression analysis.Additionally,AFP,the sole preoperative factor for PVTT,was not adequately sensitive and specific.CONCLUSIONS:Factors relating to post-surgical prognosis and PVTT in SHCC are all tumor-related.Of these,EdmondsonSteiner grade and TNM stage might be of particular importance in survival analysis.In addition,accurate prediction of PVTT by clinicopathological parameters before surgery remains difficult.

Prognostic Factors for Patients after Curative Resection for Proximal Gastric Cancer

The factors influencing the long-term survival of patients with proximal gastric cancer (PGC) after curative resection were investigated. Data from 171 patients who underwent curative resection for PGC were retrospectively analyzed. The patients were grouped according to the clinicopathological factors and operative procedures. The tumor depth (T stage) and lymph node metastasis (pN stage) were graded according to the fifth edition of TNM Staging System published by UICC in 1997. The metastatic lymph node ratio (MLR) was divided into four levels: 0%, 30%. The data of survival rate were analyzed by Kaplan-Meier method (log-rank test) and Cox regression model. The 5-year overall survival rate of 171 patients was 37.32%. The univariate analysis demonstrated that the survival time of the postoperative patients with PGC was related to tumor size (χ2=4.57, P=0.0325), gross type (χ2=21.38, P30% (χ2=13.34, P=0.0003), TNM Ⅲ (χ2=14.05, P=0.0002) or TNM Ⅳ stage (χ2=4.37, P=0.0366); and combining splenectomy was beneficial to the cases of T3 (χ2=5.68, P=0.0171) or MLR >30% (χ2=6.11, P=0.0134). It was concluded that MLR, pN stage, TNM stage, T stage, and gross type had advantages in providing a precise prognostic evaluation for patients undergoing curative resection for PGC, in which MLR was the most valuable index. TG and combining splenectomy were useful to improve the prognosis to patients with PGC of TNM Ⅲ/Ⅲ stage, serosa invasion, or extensive regional lymph node metastasis.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer(GC)in the middle-or lower-third regions with gastric outlet obstruction(GOO).Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy.This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy(SPGJ)for obstruction relief,in a patient with GOO.CASE SUMMARY During the initial esophagogastroduodenoscopy,an advanced growth was detected in the lower part of the stomach,which caused an obstruction in the pyloric ring.Following this,a computed tomography(CT)scan revealed the presence of lymph node metastases and tumor invasion in the duodenum,but no evidence of distant metastasis was found.Consequently,we performed a modified SPGJ,a complete laparoscopic SPGJ combined with No.4sb lymph node dissection,for obstruction relief.Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab(programmed death ligand-1 inhibitor)were administered thereafter.A preoperative CT showed partial response;therefore,completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy,and pathological complete remission was achieved.CONCLUSION Laparoscopic SPGJ combined with No.4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.

mPGES-1 expression in non-cancerous liver tissue impacts on postoperative recurrence of HCC

AIM:To investigate whether microsomal prostaglandin E synthase-1 (mPGES-1) expression in hepatocellular carcinoma (HCC) and in non-cancerous liver affects HCC prognosis after hepatectomy. METHODS: The relationship between patient clinical prof iles, tumor factors, surgical determinants, and mPGES-1 expression and the recurrence-free survival rate were examined in 64 patients who underwent curative hepatectomy between March 2003 and December 2006. RESULTS: The scores for mPGES-1 expression were higher in well differentiated and moderately differentiated HCC tissues than in poorly differentiated HCC tissues (well differentiated, 5.1 ± 2.7; moderately differentiated, 5.1 ± 1.7; poorly differentiated, 3.0 ± 1.8). In noncancerous liver tissues, the mPGES-1 levels were higher in injured liver tissues than in normal tissues. Cirrhotic livers had higher mPGES-1 levels than livers with chronic hepatitis (normal livers, 3.3 ± 0.7; chronic hepatitic livers, 5.4 ± 1.9; cirrhotic livers, 6.4 ± 1.6). A univariate analysis revealed that the recurrence-free survival rate was signif icantly lower in patients with vascular invasion,a higher mPGES-1 level in non-cancerous liver tissue,a larger tumor diameter (≥5 cm), and a lower serum albumin level (≤3.7 g/dL). The mPGES-1 expression in HCC tissues did not correlate well with postoperative recurrence. A multivariate analysis demonstrated that the presence of vascular invasion and higher mPGES-1 levels were statistically significant independent predictors for early postoperative recurrence of HCC.CONCLUSION: Increased mPGES-1 expression in noncancerous liver tissues is closely associated with the early recurrence of HCC after curative resection.

Successful treatment of basaloid squamous cell carcinoma in the rectosigmoid colon: A case report and review of literature

BACKGROUND Compared with colorectal adenocarcinoma,basaloid squamous cell carcinomas(BSCCs)arising in the colorectum are rare and have very poor prognosis.To date,only nine cases have been reported.Most BSCCs are extensively involved in metastasis to the lymph node,liver,and lung at diagnosis.Despite many clinicians attempting to effectively treat BSCCs,therapeutic consensus has not been established due to lack of information.CASE SUMMARY A 58-year-old woman presented with abdominal pain,diarrhea,fever,and hematochezia.She was referred from a department of gynecology and was diagnosed with a suspicious leiomyosarcoma of the rectum or a pedunculated myoma of the uterus.An exophytic growing mass at the right lateral wall of the rectum with an internal cystic portion and hemorrhage was observed on magnetic resonance imaging.The patient underwent low anterior resection and total hysterectomy with bilateral salphingo-oophorectomy.Histopathological findings revealed a cellular mass with a solid growth pattern and few glandular structures,many foci of intratumoral necrosis,and a palisading pattern.The pathologist diagnosed tumor as a BSCC,and the patient received chemotherapy with fluorouracil/leucovorin without radiotherapy.The patient is currently alive 8 years after the surgery with no manifestations of metastatic colon cancer.CONCLUSION Our case suggest that curative resection and chemotherapy play important roles in improving survival,and radiotherapy may be an option to avoid radiationassociated enteritis.

Analysis of 300 consecutive cases of pancreatic adenocarcinoma in a single-center in China

BACKGROUND： Most of the reports on the prognostic indicators of patients with pancreatic adenocarcinoma are from developed countries. The present study focused on the prognostic indicators of Chinese patients with pancreatic adenocarcinoma. METHODS： A total of 300 patients with pancreatic adenocarcinoma who had undergone curative resection were included. The resection and R0/R1 resection rates for adenocarcinomas from different parts of the pancreas were calculated and clinical characteristics were analyzed.RESULTS： In 3427 patients diagnosed with pancreatic adenocarcinomas, only 300（8.8%） were eligible for radical resection. The total median survival of these patients was 19 months, and their 1-, 3-, and 5-year survival rates were 72.5%, 28.0% and 23.4%, respectively. The prognostic factors included socioeconomic status, smoking history, symptoms, high blood glucose, and various tumor characteristics, including perineural and vascular invasion, lymph node metastases, and CA19-9 levels before and after operation. Operation-associated prognostic indicators included operation time, blood loss and transfusions, pancreatic fistula, and complications. Independent predictors of mortality included poor socioeconomic status, smoking history, symptoms, CA19-9, perineural invasion and lymph node metastasis, grade of fistula and complications. Patient survival was not correlated with either resection margin or adjuvant chemotherapy in multivariate analysis.CONCLUSIONS： The survival rates of patients with curative resection for pancreatic adenocarcinoma in China are close to those in developed countries, but curative resection rate is far below. Socioeconomic status, symptoms, and CA19-9 are the three most prominent prognostic factors, which are helpful in patient selection and perioperative care.

Neoadjuvant chemoradiotherapy for locally advanced gastric cancer with bulky lymph node metastasis:Five case reports

BACKGROUND Neoadjuvant chemoradiotherapy(NACRT)has not been accepted as a general therapy for gastric cancer because of its localized effect and toxicity for radiosensitive organs.However,if radiation therapy could compensate for the limited or inadequate treatment choices available for elderly patients and/or those at high risk,the available therapeutic options for advanced gastric cancer might increase.From this perspective,we present our experiences of five patients with advanced gastric cancer in whom we used NACRT therapy with interesting results.CASE SUMMARY We admitted five patients with clinical Stage III gastric cancer and bulky lymph node metastasis or adjacent organ invasion at the time of diagnosis.A total of 50 Gy of preoperative intensity modulated radiation therapy was delivered to the patients in doses of 2.0 Gy/d,together with a regimen of concomitant chemotherapy comprising two courses of oral tegafur/gimeracil/oteracil(S-1;65 mg/m2 per day)for three consecutive weeks followed by two weeks of rest,starting at the same time as radiotherapy.All patients underwent no residual tumor resection and a pathological complete response of the primary tumors was achieved in two patients.The incidence of hematological toxicity was low,although the digestive toxicities of anorexia and diarrhea developed in three of the five patients,necessitating termination of radiation therapy at 30 Gy and S-1 at three weeks.However,even 30 Gy of irradiation and half the dose of S-1 resulted in sufficient downstaging,indicating that even a reduced amount of NACRT could confer considerable effects.CONCLUSION Slightly reduced NACRT might be useful and safe for patients with locally advanced gastric cancer.

D1 versus Modified D2 Gastrectomy for Ca Stomach—A Prospective and Comparative Study

Background: Carcinoma stomach remains a major malignancy and accounts for 10.4% of cancer related deaths globally. Despite improvement in chemo-radiotherapy, surgery remains the primary curative modality with special emphasis on lymphadenectomy. However the extent of lymphadenectomy performed by surgeons all over the world differs. Generally speaking, in Japan and Korea, the standard curative protocol would entail a “D2” lymphadenectomy whereas in the western world it would be considered unnecessary and the standard protocol would entail a standard “D1” lymphadenectomy. Thus prompting a newer surgical therapy of modified D2 in dissection in which pancreas and spleen are preserved. Lymph nodes surrounding stomach are divided into 20 stations and these are classified into three groups depending upon the location of the primary tumour. Aims & Objectives: The aims and objectives are to compare: 1) operative time of modified D2 gastrectomy with that of D1 gastrectomy;2) operative morbidity and mortality of modified D2 gastrectomy with that of D1 gastrectomy;3) the disease recurrence between modified D2 & D1 gastrectomy. Materials & Method: The study entitled D1 versus modified D2 gastrectomy for Ca stomach—a prospective, comparative study was conducted in the Postgraduate Department of General Surgery, Government Medical College, Srinagar as a prospective, comparative study over a period of three years 2012-2014. Patients with resectable gastric cancer were taken as subjects for the study and were divided in 2 groups that were closely matched to avoid any bias. Assessment of both the groups was done in identical fashion as per standard protocol. One group underwent gastrectomy with D1 lymph node dissection whereas the other group underwent gastrectomy with a modified D2 lymph node dissection (spleen and pancreas preservation). The type of lymphadenectomy was decided on randomization (simple random sampling). Results: After comparing the two procedures, it was noted that: 1) modified D2 lymphadenectomy took on an average 2 hours more than D1 gastrectomy;2) operative mortality was same in both the procedures. Operative morbidity was seen more in modified D2 group than D1 group however this difference was statistically insignificant;3) number of recurrence was quite significant in D1 group but no recurrence was seen in modified D2 group. Conclusion: On the basis of the study, we recommend that modified D2 gastrectomy is a better procedure than D1 gastrectomy for patients of carcinoma stomach undergoing curative resection.

Stratified Platelet-to-lymphocyte Ratio:A Novel Target for Prognostic Prediction of Hepatocellular Carcinoma after Curative Liver Resection

Background and Aims:Platelet-to-lymphocyte ratio(PLR)has been shown to predict prognosis of cancers.We aimed to evaluate the prognostic value of stratification of PLR in patients after curative liver resection(CLR)for hepatocellular carcinoma(HCC).Methods:A total of 1804 patients who underwent CLR for suspected HCC between January 2007 and January 2014 were screened for the study.All of the patients were categorized into equal tertiles according to the number of patients and the distribution of PLR.Prognostic significance was determined for overall survival(OS)and was assessed using Kaplan-Meier analysis.Univariate and multi-variate Cox proportional hazard regression analyses were evaluated for association of all independent parameters with disease prognosis.Results:The optimal cut-off points of preoperative PLR were:(T1)11.98-75.00,(T2)75.00-113.33 and(T3)113.33-567.50.There were obvious differences in each PLR tertile with mortality within 36 months of CLR(Plog-rank<0.001).Multivariable analysis suggested that the level of PLR(HR=1.004,95%CI:1.001-1.008,P=0.006),portal vein thrombosis(HR=3.406,95%CI:1.185-9.794,P=0.023),number of nodules(HR=1.810,95%CI:1.345-2.437,P<0.001),Child-Turcotte-Pugh score(HR=1.741,95%CI:1.129-2.684,P=0.012)and microvascular invasion(HR=2.730,95%CI:1.777-4.196,P<0.001)were significant predictors of mortality.Kaplan-Meier analysis of overall survival(OS)demonstrated that each PLR tertile showed a progressively worse OS and apparent separation(Plog-rank=0.016).The highest 5-year OS rate following CLR(58%)was revealed in tertile 1.In contrast,the lowest 5-year OS rate(30%)was revealed in tertile 3.Conclusion:Stratified preoperative PLR could strengthen the predictive power for OS in HCC patients with CLR.

Integration of Prealbumin into Child-Pugh Classification Improves Prognosis Predicting Accuracy in HCC Patients Considering Curative Surgery

Background and Aims:The poor outcomes of hepatocellular carcinoma(HCC)patients may be due to not only malignant tumors but also limited liver function.Therefore,as stated in major guidelines,only patients with relatively normal liver function(Child-Pugh A)would be referred for curative hepatectomy.Even so,the postsurgery survival rate of patients is still extremely poor.Direct curative resection may benefit most patients.This study aimed to improve the prognosis predicting accuracy of the Child-Pugh scoring system.Methods:This study included two cohorts:cohort A being composed of 613 HCC patients,with a 23-month median postsurgery follow-up time;and cohort B being composed of 554 tumor-free chronic liver disease patients.Kaplan-Meier test and Cox model were used for survival analysis.Independent-samples t test or one-way ANOVA was used to test the differences between different groups.Results:Serum prealbumin levels were found inversely correlated with worsening of flbrotic scores(r=-0.482,p<0.001).Lower levels of presurgery prealbumin was an independent factor of poor postsurgery prognosis in Child-Pugh A patients,with a hazard ratio of 0.731(p=0.001).By integrating prealbumin together with total bilirubin level,serum albumin concentration and prothrombin time,a modified liver disease prognosis scoring system was developed to define traditional Child-Pugh A HCC patients as Modified Child-Pugh MCP-1,MCP-2 and MCP-3,with median postsurgery overall survival times of 44.00,28.00 and 11.00 months respectively.Conclusions:Preoperative serum prealbumin is a valuable prognosis predicting biomarker for Child-Pugh A HCC patients who may be under consideration for curative resection.With serum prealbumin included as one of the parameters,the MCP scoring system might improve the postsurgery survival predicting accuracy for HCC patients.