Efficacy of texture analysis of pre-operative magnetic resonance imaging in predicting microvascular invasion in hepatocellular carcinoma

BACKGROUND Presence of microvascular invasion(MVI)indicates poorer prognosis postcurative resection of hepatocellular carcinoma(HCC),with an increased chance of tumour recurrence.By present standards,MVI can only be diagnosed postoperatively on histopathology.Texture analysis potentially allows identification of patients who are considered‘high risk’through analysis of pre-operative magnetic resonance imaging(MRI)studies.This will allow for better patient selection,improved individualised therapy(such as extended surgical margins or adjuvant therapy)and pre-operative prognostication.AIM This study aims to evaluate the accuracy of texture analysis on pre-operative MRI in predicting MVI in HCC.METHODS Retrospective review of patients with new cases of HCC who underwent hepatectomy between 2007 and 2015 was performed.Exclusion criteria:No preoperative MRI,significant movement artefacts,loss-to-follow-up,ruptured HCCs,previous hepatectomy and adjuvant therapy.Fifty patients were divided into MVI(n=15)and non-MVI(n=35)groups based on tumour histology.Selected images of the tumour on post-contrast-enhanced T1-weighted MRI were analysed.Both qualitative(performed by radiologists)and quantitative data(performed by software)were obtained.Radiomics texture parameters were extracted based on the largest cross-sectional area of each tumor and analysed using MaZda software.Five separate methods were performed.Methods 1,2 and 3 exclusively made use of features derived from arterial,portovenous and equilibrium phases respectively.Methods 4 and 5 made use of the comparatively significant features to attain optimal performance.RESULTS Method 5 achieved the highest accuracy of 87.8%with sensitivity of 73%and specificity of 94%.CONCLUSION Texture analysis of tumours on pre-operative MRI can predict presence of MVI in HCC with accuracies of up to 87.8%and can potentially impact clinical management.

Biochemical recurrence of pathological T2+localized prostate cancer after robotic-assisted radical prostatectomy:A 10-year surveillance

BACKGROUND pT2+prostate cancer(PCa),a term first used in 2004,refers to organ-confined PCa characterized by a positive surgical margin(PSM)without extracapsular extension.Patients with a PSM are vulnerable to biochemical recurrence(BCR)following radical prostatectomy(RP);however,whether adjuvant radiotherapy(aRT)is imperative to PSM after RP remains controversial.This study had the longest follow-up on pT2+PCa after robotic-assisted RP since 2004.Moreover,we discussed our viewpoints on pT2+PCa based on real-world experiences.AIM To conclude a 10-year surveillance on pT2+PCa and compare our results with those of the published literature.METHODS Forty-eight patients who underwent robotic-assisted RP between 2008 and 2011 were enrolled.Two serial tests of prostate specific antigen(PSA)≥0.2 ng/mL were defined as BCR.Various designed factors were analyzed using statistical tools for BCR risk.SAS 9.4 was applied and significance was defined as P<0.05.Univariate,multivariate,linear regression,and receiver operating characteristic(ROC)curve analyses were performed for statistical analyses.RESULTS With a median follow-up period of 9 years,25(52%)patients had BCR(BCR group),and the remaining 23(48%)patients did not(non-BCR group).The median time for BCR test was 4 years from the first postoperative PSA nadir.Preoperative PSA was significantly different between the BCR and non-BCR groups(P<0.001),and ROC curve analysis of preoperative PSA suggested a cutoff value of 19.09 ng/mL(sensitivity,0.600;specificity:0.739).The linear regression analysis showed no correlation between time to BCR and preoperative PSA(Pearson’s correlation,0.13;adjusted R2=0.026).CONCLUSION Robotic-assisted RP in pT2+PCa of worse conditions can provide better BCR-free survival.A surgical technique limiting the PSM in favorable situations is warranted to lower the pT2+PCa BCR rate.Preoperative PSA cut-off value of 19.09 ng/mL is a predictive factor for BCR.Based on our experiences and review of the literature,we do not recommend routine aRT for pT2+PCa.

Intra and extra pelvic multidisciplinary surgical approach of retroperitoneal sarcoma:Case series report

BACKGROUND Retroperitoneal sarcoma(RPS) is a rare malignancy arising from mesenchymal cells that most commonly presents as an abdominal mass and is associated with poor prognosis.Although several studies have assessed the survival benefits of wide excision,few have reported detailed methods for achieving wide excision in patients with RPS.AIM To describe our experience with multidisciplinary surgical resection of RPS using intra-and extra-pelvic approaches.METHODS Multidisciplinary surgery is an anatomical approach that combines intra-and extra-peritoneal access within the same surgery to achieve complete RPS removal.This retrospective review of the records of patients who underwent multidisciplinary surgery for RPS analyzed surgical and survival outcomes.RESULTS Eight patients underwent 10 intra-and extra-pelvic surgical resections,and their median mass size was 12.75 cm(range,6-45.5 cm).Using an intrapelvic approach,laparoscopy-assisted surgery was performed in four cases and laparotomy surgery in six.Using an extrapelvic approach,ilioinguinal and posterior approaches were used in four cases each,and the prone position and midline skin incision were shared in one.All patients’ RPS masses were removed completely,and four achieved R0 resection through intra-and extra-pelvic surgery.The median estimated blood loss was 2000 m L(range,300-20000 m L) and the median hospitalization was 12.6 d(range,9-69 d).Reoperation was needed in two patients(one for wound necrosis and the other for bowel perforation and wound necrosis).The median overall survival rate and median progression-free survival were 64.6 and 13.7 mo,respectively.CONCLUSION RPS is therapeutically challenging because of its location and high risk of recurrence.Therefore,intra-and extra-pelvic surgical approaches can improve the macroscopic security of the surgical margin.

Optimal proximal resection margin distance for gastrectomy in advanced gastric cancer

BACKGROUND The conventional guidelines to obtain a safe proximal resection margin(PRM)of5-6 cm during advanced gastric cancer(AGC)surgery are still applied by many surgeons across the world.Several recent studies have raised questions regarding the need for such extensive resection,but without reaching consensus.This study was designed to prove that the PRM distance does not affect the prognosis of patients who undergo gastrectomy for AGC.AIM To investigate the influence of the PRM distance on the prognosis of patients who underwent gastrectomy for AGC.METHODS Electronic medical records of 1518 patients who underwent curative gastrectomy for AGC between June 2004 and December 2007 at Asan Medical Center,a tertiary care center in Korea,were reviewed retrospectively for the study.The demographics and clinicopathologic outcomes were compared between patients who underwent surgery with different PRM distances using one-way ANOVA and Fisher’s exact test for continuous and categorical variables,respectively.The influence of PRM on recurrence-free survival and overall survival were analyzed using Kaplan-Meier survival analysis and Cox proportional hazard analysis.RESULTS The median PRM distance was 4.8 cm and 3.5 cm in the distal gastrectomy(DG)and total gastrectomy(TG)groups,respectively.Patient cohorts in the DG and TG groups were subdivided into different groups according to the PRM distance;≤1.0 cm,1.1-3.0 cm,3.1-5.0 cm and>5.0 cm.The DG and TG groups showed nostatistical difference in recurrence rate(23.5%vs 30.6%vs 24.0%vs 24.7%,P=0.765)or local recurrence rate(5.9%vs 6.5%vs 8.4%vs 6.2%,P=0.727)according to the distance of PRM.In both groups,Kalpan-Meier analysis showed no statistical difference in recurrence-free survival(P=0.467 in DG group;P=0.155 in TG group)or overall survival(P=0.503 in DG group;P=0.155 in TG group)according to the PRM distance.Multivariate analysis using Cox proportional hazard model revealed that in both groups,there was no significant difference in recurrence-free survival according to the PRM distance.CONCLUSION The distance of PRM is not a prognostic factor for patients who undergo curative gastrectomy for AGC.

Intermittent, low-dose, antiandrogen monotherapy as an alternative therapeutic option for patients with positive surgical margins after radical prostatectomy

The aim of the present study was to determine whether oncologic outcomes and adverse events associated with active on/off intermittent antiandrogen monotherapy （daily bicalutamide, 50 mg per day） are comparable with those of standard external beam radiation therapy （EBRT） or combined androgen blockade （CAB） therapy in prostate cancers with positive surgical margins after radical prostatectomy. Two hundred twenty-three patients with positive surgical margins post-radical prostatectomy who underwent active surveillance （AS, n = 32）, EBRT without hormone therapy （n = 55）, intermittent antiandrogen monotherapy without EBRT （IAAM, n= 50）, or CAB without EBRT （n = 86）, between 2007 and 2014, were reviewed retrospectively. Pathologic outcomes, biochemical recurrence rates, radiological disease progression, and adverse events were collected from medical records. Biochemical recurrence rates, biochemical recurrence-free survival rates, and radiological recurrence were not different between the groups （P = 0.225, 0.896, and 0.284, respectively）. Adverse event rates and severities were lower for IAAM compared with EBRT or CAB （both P 〈 0.05）, but were comparable to those for AS （P = 0.591 and 0.990, respectively）. Grade ：〉3 adverse events were not reported in the IAAM or AS groups. Erectile dysfunction and loss of libido rates were lower in the IAAM group compared with the EBRT and CAB groups （P = 0.032）. Gastrointestinal complications were more frequently reported in the EBRT group （P = 0.008）. Active on/off IAAM treatment might be an appropriate treatment option for patients with positive surgical margins after radical prostatectomy. Furthermore, regarding oncologic outcomes, IAAM was comparable to standard EBRT but had a milder adverse event profile.