Combining local regional therapy and systemic therapy:Expected changes in the treatment landscape of recurrent hepatocellular carcinoma

Improvements in early screening,new diagnostic techniques,and surgical treatment have led to continuous downward trends in hepatocellular carcinoma(HCC)morbidity and mortality rates.However,high recurrence and refractory cancer after hepatectomy remain important factors affecting the long-term prognosis of HCC.The clinical characteristics and prognosis of recurrent HCC are heterogeneous,and guidelines on treatment strategies for recurrent HCC are lacking.Therapies such as surgical resection,radiofrequency ablation,and transhepatic arterial chemoembolization are effective for tumors confined to the liver,and targeted therapy is a very important treatment for unresectable recurrent HCC with systemic metastasis.With the deepening of the understanding of the immune microenvironment of HCC,blocking immune checkpoints to enhance the antitumor immune response has become a new direction for the treatment of HCC.In addition,improvements in the tumor immune microenvironment caused by local treatment may provide an opportunity to improve the therapeutic effect of HCC treatment.Ongoing and future clinical trial data of combined therapy may develop the new treatment scheme for recurrent HCC.This paper reviews the pattern of recurrent HCC and the characteristics of the immune microenvironment,demonstrates the basis for combining local treatment and systemic treatment,and reports current evidence to better understand current progress and future approaches in the treatment of recurrent HCC.

Survival prognostic analysis of laparoscopic D2 radical resection for locally advanced gastric cancer: A multicenter cohort study

BACKGROUND With the development of minimally invasive surgical techniques,the use of laparoscopic D2 radical surgery for the treatment of locally advanced gastric cancer(GC)has gradually increased.However,the effect of this procedure on survival and prognosis remains controversial.This study evaluated the survival and prognosis of patients receiving laparoscopic D2 radical resection for the treatment of locally advanced GC to provide more reliable clinical evidence,guide clinical decision-making,optimize treatment strategies,and improve the survival rate and quality of life of patients.METHODS A retrospective cohort study was performed.Clinicopathological data from 652 patients with locally advanced GC in our hospitals from December 2013 to December 2023 were collected.There were 442 males and 210 females.The mean age was 57±12 years.All patients underwent a laparoscopic D2 radical operation for distal GC.The patients were followed up in the outpatient department and by telephone to determine their tumor recurrence,metastasis,and survival.The follow-up period ended in December 2023.Normally distributed data are expressed as the mean±SD,and normally distributed data are expressed as M(Q1,Q3)or M(range).Statistical data are expressed as absolute numbers or percentages;theχ^(2) test was used for comparisons between groups,and the Mann-Whitney U nonparametric test was used for comparisons of rank data.The life table method was used to calculate the survival rate,the Kaplan-Meier method was used to construct survival curves,the log rank test was used for survival analysis,and the Cox risk regression model was used for univariate and multifactor analysis.RESULTS The median overall survival(OS)time for the 652 patients was 81 months,with a 10-year OS rate of 46.1%.Patients with TNM stages II and III had 10-year OS rates of 59.6%and 37.5%,respectively,which were significantly different(P<0.05).Univariate analysis indicated that factors such as age,maximum tumor diameter,tumor diffe-rentiation grade(low to undifferentiated),pathological TNM stage,pathological T stage,pathological N stage(N2,N3),and postoperative chemotherapy significantly influenced the 10-year OS rate for patients with locally advanced GC following laparoscopic D2 radical resection for distal stomach cancer[hazard ratio(HR):1.45,1.64,1.45,1.64,1.37,2.05,1.30,1.68,3.08,and 0.56 with confidence intervals(CIs)of 1.15-1.84,1.32-2.03,1.05-1.77,1.62-2.59,1.05-1.61,1.17-2.42,2.15-4.41,and 0.44-0.70,respectively;P<0.05].Multifactor analysis revealed that a tumor diameter greater than 4 cm,low tumor differentiation,and pathological TNM stage III were independent risk factors for the 10-year OS rate in these patients(HR:1.48,1.44,1.81 with a 95%CI:1.19-1.84).Additionally,postoperative chemotherapy emerged as an independent protective factor for the 10-year OS rate(HR:0.57,95%CI:0.45-0.73;P<0.05).CONCLUSION A maximum tumor diameter exceeding 4 cm,low tumor differentiation,and pathological TNM stage III were identified as independent risk factors for the 10-year OS rate in patients with locally advanced GC following laparoscopic D2 radical resection for distal GC.Conversely,postoperative chemotherapy was found to be an independent protective factor for the 10-year OS rate in these patients.

Secondary endoscopic submucosal dissection for locally recurrent or incompletely resected gastric neoplasms

AIM To investigate the feasibility and safety of secondary endoscopic submucosal dissection(ESD) for residual or locally recurrent gastric tumors. METHODS Between 2010 and 2017, 1623 consecutive patients underwent ESD for gastric neoplasms at a single tertiary referral center. Among these, 28 patients underwent secondary ESD for a residual or locally recurrent tumor. Our analysis compared clinicopathologic factors between primary ESD and secondary ESD groups. RESULTS The en bloc resection and curative rate of resection of secondary ESD were 92.9% and 89.3%, respectively. The average procedure time of secondary ESD was significantly longer than primary ESD(78.2 min vs 55.1 min, P = 0.004), and the adverse events rate was not significantly different but trended slightly higher in the secondary ESD group compared to the primary ESD group(10.7% vs 3.8%, P = 0.095). Patients who received secondary ESD had favorable outcomes without severe adverse events. During a mean follow-up period, no local recurrence occurred in patients who received secondary ESD. CONCLUSION Secondary ESD of residual or locally recurrent gastric tumors appears to be a feasible and curative treatment though it requires greater technical efficiency and longer procedure time.

Patterns and prognosis of locally recurrent rectal cancer following multidisciplinary treatment

AIM:To investigate the patterns and decisive prognostic factors for local recurrence of rectal cancer treated with a multidisciplinary team(MDT) modality.METHODS:Ninety patients with local recurrence were studied,out of 1079 consecutive rectal cancer patients who underwent curative surgery from 1999 to 2007.For each patient,the recurrence pattern was assessed by specialist radiologists from the MDT using imaging,and the treatment strategy was decided after discussion by the MDT.The associations between clinicopathological factors and long-term outcomes were evaluated using both univariate and multivariate analysis.RESULTS:The recurrence pattern was classified as follows:Twenty-seven(30%) recurrent tumors were evaluated as axial type,21(23.3%) were anterior type,8(8.9%) were posterior type,and 13(25.6%) were lateral type.Forty-one patients had tumors that were evaluated as resectable by the MDT and ultimately received surgery,and R0 resection was achieved in 36(87.8%) of these patients.The recurrence pattern was closely associated with resectability and R0 resection rate(P < 0.001).The recurrence pattern,interval to recurrence,and R0 resection were significantly associated with 5-year survival rate in univariate analysis.Multivariate analysis showed that the R0 resection was the unique independent factor affecting long-term survival.CONCLUSION:The MDT modality improves patient selection for surgery by enabling accurate classification of the recurrence pattern;R0 resection is the most significant factor affecting long-term survival.

Boron neutron capture therapy: moving towards targeted therapy for locally recurrent head and neck squamous cell carcinoma

Locally recurrent head and neck squamous cell carcinoma(HNSCC)is often unresectable,and a repeat course of radiotherapy is associated with incremental toxicities.Boron neutron capture therapy(BNCT)is a novel targeted radiotherapy modality that can achieve a high dose gradient between cancerous and adjacent normal tissues.However,the relationships among the dose resulting from BNCT,tumor response to BNCT,and survival are not completely understood.Recently,a study published in Radiotherapy and Oncology investigated the efficacy of BNCT in the treatment of patients with locally recurrent HNSCC and the factors associated with favorable treatment response and survival.In this article,the findings,strengths and limitations of this study are discussed in depth,and the significance of the study and motivations for future research are highlighted.

Coexistence and local Mittag–Leffler stability of fractional-order recurrent neural networks with discontinuous activation functions

In this paper, coexistence and local Mittag–Leffler stability of fractional-order recurrent neural networks with discontinuous activation functions are addressed. Because of the discontinuity of the activation function, Filippov solution of the neural network is defined. Based on Brouwer's fixed point theorem and definition of Mittag–Leffler stability, sufficient criteria are established to ensure the existence of (2k + 3)~n (k ≥ 1) equilibrium points, among which (k + 2)~n equilibrium points are locally Mittag–Leffler stable. Compared with the existing results, the derived results cover local Mittag–Leffler stability of both fractional-order and integral-order recurrent neural networks. Meanwhile discontinuous networks might have higher storage capacity than the continuous ones. Two numerical examples are elaborated to substantiate the effective of the theoretical results.

THREE-DIMENSIONAL CONFORMAL RADIATION THERAPY FOR LOCALLY RECURRENT NASOPHARYNGEAL CARCINOMA

Objective: To investigate the safety and effectiveness of three-dimensional conformal radiation therapy (3-D CRT) for locally recurrent nasopharyngeal carcinoma (NPC). Methods: From April 1998 to March 2000, 34 patients who had undergone previous external beam radiation therapy were retreated with 3-D CRT for locally recurrent NPC (33 poorly differentiated squamous cell carcinomas, 1 adenoma). The patients were re-staged according to Huaqing staging system with the following distribution: T1N0M0 in 5 cases, T2N0M0 in 11 cases, T3N0M0 in 12 cases, T4N0M0 in 6 cases. The maximal dimension of the gross tumor volume (GTV) ranged from 1.0 cm to 5.0 cm (median: 2.9 cm). CT simulation and 3-D planning were used to ensure full and conformal coverage of the planning target volume (PTV) by treated volume, while minimizing the absorbed dose of the adjacent normal tissue. 5–7 static conformal coplanar or noncoplanar portals were delivered for each fraction irradiation. The total dose delivered ranged from 65–70 Gy, with 2.5 Gy per fractionation, one fractionation per day, 5 days a week. Median follow-up time from 3-D CRT was 25 months (range: 12–36 months). Results: Over the follow-up period, local recurrence was observed in 3 patients, regional failure in 3, distant metastasis in 3, and six patients died; 88.2% (30/34) of the patient maintained local control, 82.4% (28/34) survived, and 76.5% (26/34) survived with no evidence of tumor. Acute complications were minor and few. The overall incidence of late complication was 20.6% (7/34), and severe complication was 14.7% (5/34), after re-irradiation with 3-D CRT. Conclusion: 3-D CRT is safety and effectiveness for most of the patients with locally recurrent NPC. Our preliminary results indicate a high local control rate and a low complication rate. The long-term curative effect and sequelae await further study.

Concurrent chemoradiotherapy using gemcitabine and nedaplatin in recurrent or locally advanced head and neck squamous cell carcinoma

BACKGROUND Patients with recurrent or locally advanced head and neck squamous cell carcinoma(HNSCC)typically have limited treatment options and poor prognosis.AIM To evaluate the efficacy and safety of two drugs with potent radio-sensitization properties including gemcitabine and nedaplatin as concurrent chemoradiotherapy regimens in treating HNSCC.METHODS This single-arm prospective study enrolled patients with HNSCC to receive gemcitabine on days 1 and 8 and nedaplatin on days 1 to 3 for 21 days.Intensitymodulated radiation therapy with a conventional fraction was delivered 5 days per week.Objective response rate(ORR),disease control rate,and toxicity were observed as primary endpoints.Overall survival(OS)and progression free survival were recorded and analyzed as secondary endpoints.RESULTS A total of 24 patients with HNSCC were enrolled.During the median 22.4-mo follow-up,both ORR and disease control rate were 100%.The one-year OS was 75%,and one-year progression-free survival(PFS)was 66.7%(median PFS was 15.1 mo).Recurrent HNSCC patients had a poorer prognosis than the treatment-naïve patients,and patients who achieved complete response had better survival than those in the PR group(all P<0.05).The most common grade 1-4(100%)or grade 3-4 toxicities(75%)were hematological,and the most common grade 3-4 non-hematological toxicity was mucositis in 17(71%)patients.CONCLUSION Gemcitabine plus nedaplatin with concurrent chemoradiotherapy is a therapeutic option for HNSCC with predictable tolerability.Considering the high adverse event rate,the optimized dose and schedule must be further explored.

The Local Immunity of the Oral Cavity in Women with Recurrent Aphthous Stomatitis Associated with Urogenital Infection

This paper studied the dynamics of local immunity factors of the oral cavity in women with recurrent aphthous stomatitis against the background of urogenital infection. The research proves the maximum efficacy of hydroxyzine hydrochloride, aminodihydrophthalasindione sodium and Eplan used in multiple treatments of recurrent aphthous stomatitis in patients with urogenital infection as evidenced by a marked reduction in the coefficient of local immunity factors balance, which is observed as early as on day 7 of the therapy provided. Moreover, the findings show the growth of immunological parameters of oral fluid (lysozyme and SIgA), the normalization of the coefficient of local immunity factors balance in the treatment of recurrent aphthous stomatitis in women with urogenital infection, the improvement being observed 3 months after the treatment suggesting a favorable local immunity of the oral cavity.

Impact of primary tumor volume andlocation on the prognosis of patients withlocally recurrent nasopharyngeal carcinoma

Introduction:The properties of a tumor itself were considered the main factors determining the survival of patients with locally recurrent nasopharyngeal carcinoma(NPC)treated with intensity-modulated radiotherapy(IMRT).However,recurrent tumors were mainly evaluated by using the American Joint Committee on Cancer staging system,which was modeled on primary tumors and did not incorporate the tumor volume.This study aimed to investigate the prognostic values of the primary tumor location and tumor volume,and to determine whether evaluating these parameters could improve the current staging system.Methods:Magnetic resonance(MR)images for 229 patients with locally recurrent NPC who underwent IMRT were analyzed retrospectively.Results:The skull base,parapharyngeal space,and intracranial cavity were the most common sites of tumors.There was a difference in the survival between patients with T1 and T2 diseases(77.6%vs.50.0%,P<0.01)and those with T3 and T4 diseases(33.0%vs.18.0%,P=0.04)but no difference between patients with T2 and T3 diseases(50.0%vs.33.0%,P=0.18).Patients with a tumor volume≤38 cm3had a significantly higher survival rate compared with those with a tumor volume>38 cm3(48.7%vs.15.2%,P<0.01).Conclusions:A new staging system has been proposed,with T3 tumors being down-staged to T2 and with the tumor volume being incorporated into the staging,which may lead to an improved evaluation of these tumors.This new system can be used to guide the treatment strategy for different risk groups of recurrent NPC.

Study on the causes of local recurrence of rectal cancer after curative resection: analysis of 213 cases

AIM To study the local recurrent rate and the causes of rectal cancer after surgery. METHODS The clinicopathological data of 213 rectal cancer patients and the follow up information were analyzed. The overall recurrent rate and the recurrent rates from different surgical appreaches were calculated. The main causes of recurrence were investigated. RESULTS Among the 213 cases, 73 (34 27%) had local recurrence. The recurrent time ranged from 3 months to 62 months after the first operation. Most of the recurrence ( 65/73 , 89 04%) occurred within 3 years after operation. CONCLUSION Local recurrence had no significant correlation with surgical methods or pathological types, but closely related to Dukes′ stages, location of primary tumors and the length of the distal rectum resected. Early resection and a wide tumor free resection margin are key factors to prevent local recurrence.

Patterns of local recurrence in rectal cancer after a multidisciplinary approach

Improvements in surgery and the application of combined approaches to fight rectal cancer have succeeded in reducing the local recurrence (LR) rate and when there is LR it tends to appear later and less often in isolation. Moreover, a subtle change in the distribution of LRs with respect to the pelvis has been observed. In general terms, prior to total mesorectal excision the most common LRs were central types (perianastomotic and anterior) while lateral and posterior forms (presa-cral) have become more common since the growth in the use of combined treatments. No differences have been reported in the current pattern of LRs as a function of the type of approach used, that is, neo-adjuvant therapies (short-term or long-course radiotherapy, orchemoradiotherapy versus extended lymphadenectomy, though there is a trend towards posterior or presacral LR in patients in the Western world and lateral LR in Asia. Nevertheless, both may arise from the same mechanism. Moreover, as well as the mode of treatment, the type of LR is related to the height of the initial tumor. Nowadays most LRs are related to the advanced nature of the disease. Involvement of the circumferential radial margin and spillage of residual tumor cells from lymphatic leakage in the pelvic side wall are two plausible mechanisms for the genesis of LR. The patterns of pelvic recurrence itself (pelvic subsites) also have important implications for prognosis and are related to the potential success of salvage curative approach. The re-operability for cure and prognosis are generally better for anastomotic and anterior types than for presacral and lateral recurrences. Overall survival after LR diagnosis is lower with radio or chemoradiotherapy plus optimal surgery approaches, compared to optimal surgery alone.

Update on the prevention of local recurrence and peritoneal metastases in patients with colorectal cancer

The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of colon cancer patients and 25% of rectal cancer patients and should be prevented. Strategies to prevent colon or rectal cancer local recurrence and peritoneal metastases include cytoreductive surgery and hyperthermic perioperative chemotherapy (HIPEC). These strategies can be used at the time of primary colon or rectal cancer resection if the HIPEC is available. At institutions where HIPEC is not available with the treatment of primary malignancy, a proactive second-look surgery is recommended. Several phase II studies strongly support the proactive approach. If peritoneal metastases were treated along with the primary colon resection, 5-year survival was seen and these results were superior to the results of treatment after peritoneal metastases had developed as recurrence. Also, prophylactic HIPEC improved survival with T3/T4 mucinous or signet ring colon cancers. A second-look has been shown to be effective in two published manuscripts. Unpublished data from MedStar Washington Cancer Institute also produced favorable date. Rectal cancer with peritoneal metastases may not be so effectively treated. There are both credits and debits of this proactive approach. Selection factors should be reviewed by the multidisciplinary team for individualized management of patients with or at high risk for peritoneal metastases.

Risk factors for local recurrence and appropriate surveillance interval after endoscopic resection

BACKGROUND Risk factors for local recurrence after polypectomy, endoscopic mucosal resection(EMR), and endoscopic submucosal dissection(ESD) have not been identified.Additionally, the appropriate interval for endoscopic surveillance of colorectal tumors at high-risk of local recurrence has not been established.AIM To clarify the clinicopathological characteristics of recurrent lesions after endoscopic colorectal tumor resection and determine the appropriate interval.METHODS Three hundred and sixty patients(1412 colorectal tumors) who underwent polypectomy, EMR, or ESD and received endoscopic surveillance subsequently for more than one year to detect local recurrence were enrolled in this study. The clinicopathological factors associated with local recurrence were determined via univariate and multivariate analyses.RESULTS Local recurrence was observed in 31 of 360(8.6%) patients [31 of 1412(2.2%)lesions] after colorectal tumor resection. Piecemeal resection, tumor size of more than 2 cm, and the presence of villous components were associated with colorectal tumor recurrence after endoscopic resection. Of these three factors, the piecemeal resection procedure was identified as an independent risk factor for recurrence. Colorectal tumors resected into more than five pieces were associated with a high risk of recurrence since the average period from resection torecurrence in these cases was approximately 3 mo. The period to recurrence in cases resected into more than 5 pieces was much shorter than that in those resected into less than 4 pieces(3.8 ± 1.9 mo vs 7.9 ± 5.0 mo, P < 0.05).CONCLUSION Local recurrence of endoscopically treated colorectal tumors depends upon the outcome of first endoscopic procedure. Piecemeal resection was the only significant risk factor associated with local recurrence after endoscopic resection.

Prognostic factors for 5-year survival after local excision of rectal cancer

AIM:To evaluate the prognostic factors for 5-year survival after local excision of rectal cancer,and to examine the therapeutic efficacy and surgical indications for this procedure. METHODS:Clinical data,obtained from 106 local rectal cancer excisions performed between January 1980 and December 2005,were retrospectively analyzed.Survival analysis was performed using the Kaplan-Meier method,statistical comparisons were performed using the log-rank test,and multivariate analysis was performed using the Cox proportional hazards model. RESULTS:Transanal,transsacral,and transvaginal excisions were performed in 92,12,and 2 cases, respectively.The rate of complication,local recurrence, and 5-year survival was 6.6%,17.0%,and 86.7%, respectively.Univariate analysis showed that T stage, vascular invasion,and local recurrence were related to the prognosis of the cases(P<0.05).Multivariate analysis showed that T stage[P=0.011,95% confidence interval(CI)=1.194-3.878]and local recurrence(P=0.022,95%CI=1.194-10.160)were the major prognostic factors for 5-year survival of cases after local excision of rectal cancer. CONCLUSION:Local rectal cancer excision is associated with few complications,and suitable for stages Tis and T1 rectal cancer.Prevention of local recurrence,active postoperative follow-up,and administration of salvage therapy are the effective methods to increase the efficacy of local excision of rectal cancer.

Neoadjuvant vs adjuvant pelvic radiotherapy for locally advanced rectal cancer: Which is superior?

The treatment of locally advanced rectal cancer including timing and dosage of radiotherapy, degree of sphincter preservation with neoadjuvant radiotherapy, and short and long term effects of radiotherapy are controversial topics. The MEDLINE, Cochrane Library databases, and meeting proceedings from the American Society of Clinical Oncology, were searched for reports of randomized controlled trials and meta-analyses comparing neoadjuvant and adjuvant radiotherapy with surgery to surgery alone for rectal cancer. Neoadjuvant radiotherapy shows superior results in terms of local control compared to adjuvant radiotherapy. Neither adjuvant or neoadjuvant radiotherapy impacts overall survival. Short course versus long course neoadjuvant radiotherapy remains controversial. There is insufficient data to conclude that neoadjuvant therapy improves rates of sphincter preserving surgery. Radiation significantly impacts anorectal and sexual function and includes both acute and long term toxicity. Data demonstrate that neoadjuvant radiation causes less toxicity compared to adjuvant radiotherapy, and specifically short course neoadjuvant radiation results in less toxicity than long course neoadjuvant radiation. Neoadjuvant radiotherapy is the preferred modality for administering radiation in locally advanced rectal cancer. There are significant side effects from radiation, including anorectal and sexual dysfunction, which may be less with short course neoadjuvant radiation.

Risk factors for local recurrence following neoadjuvant chemoradiotherapy for rectal cancers

Local recurrence(LR)has an adverse impact on rectal cancer treatment.Neoadjuvant chemoradiotherapy(nCRT)is increasingly administered to patients with progressive cancers to improve the prognosis.However,LR still remains a problem and its pattern can alter.Correspondingly,new risk factors have emerged in the context of nCRT in addition to the traditional risk factors in patients receiving non-neoadjuvant therapies.These risk factors are decisive when reviewing treatment options.This review aims to elucidate the distinctive risk factors related to LR of rectal cancers in patients receiving nCRT and to clarify their clinical significance.A search was conducted on PubMed to identify original studies investigating patients with rectal cancer receiving nCRT.Outcomes of interest,especially potential risk factors for LR in patients with nCRT,were then analyzed.The clinical importance of these risk factors is discussed.Remnant cancer cells,lymph-nodes and tumor response were found to be major risk factors.Remnant cancer cells decide the status of resection margins.Local excision following nCRT is promising in ypT0-1N0M0 cases.Dissection of lateral lymph nodes should be considered in advanced lowlying cancers.Although better tumor response resulted in a relatively lower recurrence rate,the evidence available is insufficient to justify a non-operative approach in clinical complete responders to nCRT.LR cannot be totally avoided by current multidisciplinary approaches.The related risk factors resulting from nCRT should be considered when making decisions regarding treatment selection.

Local recurrence is an important prognostic factor of hepatocellular carcinoma

AIM： To clarify the importance of complete treatment by PELT. METHODS： A total of 140 previously untreated cases of HCC were enrolled in this study from 1988 to 2002. The inclusion criteria were： a solitary tumor less than 4 cm in diameter or multiple tumors, fewer than four in number and less than 3 cm in diameter, without extrahepatic metastasis or vessel invasion. As general principles for the treatment of HCC, the patients underwent transcatheter arterial chemoembolization （TACE） prior to PEIT. After the initial treatment of the patients, ultrasonography and computed tomography were performed, and measurement of serum levels of α- fetoprotein （AFP） was determined. When tumor recurrences were detected, PEIT and/or TACE were repeated whenever the hepatic functional reserve of the patient permitted. We then analyzed the variables that could influence prognosis, including tumor size and number, the serum levels of AFP, the parameters of hepatic function （albumin, bilirubin, ALT, hepaplastin test, platelet number, and indocyanine green retention at 15 rain [ICG-R15]）, combined therapy with TACE, distant recurrence, and local recurrence. RESULTS： Univariate analysis identified the ICG test, serum levels of AFP and albumin, tumor size and number, and local recurrence, but not distant recurrence, as significant prognostic variables. In multivariate analysis using those five parameters, the ICG test, tumor size, tumor number, and local recurrence were identified as significant prognostic factors. In both univariate and multivariate analyses, the relative risk for the ICG test was the highest, followed by local recurrence. CONCLUSION： We found that local recurrence is an independent prognostic factor of HCC, indicating that achieving complete treatment for HCC on first treatment is important for improving the prognosis of patients with HCC. 2005 The WJG Press and Elsevier Inc. All rights reserved.

Abdominosacral resection for locally recurring rectal cancer

AIM To investigate feasibility and outcome of abdominalsacral resection for treatment of locally recurrent rectal adenocarcinoma.METHODS A population of patients who underwent an abdominalsacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.RESULTS At the time of abdomino-sacral resection, the mean age of patients was 55(range, 38-64). The median operating time was 380 min(range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 m L(range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type Ⅱ complication according to the ClavienDindo classification. Microscopically negative margins(R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a mediansurvival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.CONCLUSION Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Adenomyoepithelioma of the breast with malignant transformation and repeated local recurrence:A case report

BACKGROUND Adenomyoepithelioma(AME)of the breast is a rare type of benign breast tumor.Many AMEs show benign behavior,but reports of the malignant type are rare.We present the case of a patient with AME with repeated local recurrences and further malignant transformation.CASE SUMMARY A 53-year-old woman visited our hospital with a 16-mm palpable mass in the right breast.A core needle biopsy was performed.The pathological diagnosis was AME.Lumpectomy with a safety margin was performed without axillary lymph node dissection(ALND).Two years later,local recurrence developed,and the patient again underwent lumpectomy with a safety margin.The pathology showed malignant AME,and the margin was negative.Eight months later,local recurrence developed again in the same location,and a total mastectomy was performed without ALND.The pathological diagnosis was malignant AME.The patient was disease-free for three years posttreatment.CONCLUSION The treatment of AME requires caution,as it may exhibit repeated recurrences after local excision as well as malignant transformation.