Delaying Surgery After Neoadjuvant Chemotherapy Affects Survival in Patients with Colorectal Peritoneal Metastases: A BIG-RENAPE Network Multicentric Study.

BACKGROUND: Multimodal treatment for patients with peritoneal metastases (PM) from colorectal cancer (CRC), including perioperative chemotherapy (CT) plus complete resection, is associated with prolonged survival. The oncologic impact of therapeutic delays is unknown. OBJECTIVE: The aim of this study was to assess the survival impact of delaying surgery and CT. METHODS: Medical records from the national BIG RENAPE network database of patients with complete cytoreductive (CC0-1) surgery of synchronous PM from CRC who received at least one neoadjuvant CT cycle plus one adjuvant CT cycle were retrospectively reviewed. The optimal interval between the end of neoadjuvant CT to surgery, surgery to adjuvant CT, and total interval without systemic CT were estimated using Contal and O'Quigley's method plus restricted cubic spline methods. RESULTS: From 2007 to 2019, 227 patients were identified. After a median follow-up of 45.7 months, the median overall survival (OS) and progression-free survival (PFS) was 47.6 and 10.9 months, respectively. The best cut-off period was 42 days in the preoperative interval, no cut-off period was optimal in the postoperative interval, and the best cut-off period in the total interval without CT was 102 days. In multivariate analysis, age, biologic agent use, high peritoneal cancer index, primary T4 or N2 staging, and delay to surgery of more than 42 days (median OS 63 vs. 32.9 months; p = 0.032) were significantly associated with worse OS. Preoperative delay of surgery was also significantly associated with PFS, but only in univariate analysis. CONCLUSION: In selected patients undergoing complete resection plus perioperative CT, a period of more than 6 weeks from completion of neoadjuvant CT to cytoreductive surgery was independently associated with worse OS.

Intra-abdominal recurrence from colorectal carcinoma: Differences and similarities between local and peritoneal recurrence.

BACKGROUND: Peritoneal recurrences from colo-rectal cancer can be isolated (PR) or associated with local recurrences (LR). The purpose of this study was to analyze patterns and outcomes of LR and PR. METHODS: Analyze from a prospective database of 108 patients treated with CCS plus HIPEC at two cancer centers between 2008 and 2015. RESULTS: The population was divided into an LPR group (presence of LR with or without PR, n = 56) and a PR group (isolated PR, n = 52). The patients characteristics (age, sex, Charlson score, PCI) or perioperative treatments were comparable between the groups. The median number of resected organs for tumor involvement (respectively, 2 vs 1; p < 0.001), the percentage of patients with metastatic lymph nodes (LN+) from the resected specimen (respectively, 25% vs 7%; p = 0.016) and the mortality rate (respectively, 9% vs 0%; p = 0.023) were significantly higher in the LPR group. After a median follow-up of 32 (1-108) months, median overall survival was comparable between the two groups (respectively, 46 vs 42 months; p = 0.262). CONCLUSIONS: LR is associated with a higher incidence of organ invasion, LN involvement (25%) and postoperative mortality. Optimal surgical resection of LR with systematic lymphadenectomy of invaded organs seems mandatory.

Significance of lymph node involvement in local recurrence of colorectal cancer.

BACKGROUND: There are few data on lymphatic spread concomitant to local recurrence (LR) of colorectal cancer (CRC). The objectives of this study were to determine variables associated with lymphatic spread, to analyze the distribution of LN+, and understand the underlying mechanisms. METHODS: A total of 76 patients underwent resection of LR of CRC between January 2007 and December 2018 at Institut cancérologique de l'Ouest and were retrospectively reviewed. RESULTS: Twenty-five (32.9%) patients had lymph node (LN) involvement with LR. Lymphatics from the mesocolon-rectum and aorto-iliac compartments were involved in 21%, 20.3% and 18.1%, 20.3% for pelvic and retroperitoneal LRs, respectively. In multivariate analysis, the only predictive factor for LN invasion (LN+) was a primary positive LN status (odds ratio, 5.3; P = .007). Despite a trend toward a worse median overall survival in the LN+ group, the difference was not significant in comparison with the LN- group (46 vs. 57 months; P = 0.31) or with the LN- plus LN not assessed groups (46 months vs not reached; P = .07). CONCLUSIONS: LN invasion with LR from CRC is a frequent occurrence without significant impact on survival. The only predictive factor is a primary positive nodal status.

Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy.

BACKGROUNDS: Central pancreatectomy (CP) is an alternative to pancreaticoduodenectomy and distal pancreatectomy in benign tumours of pancreatic isthmus management. It is known for a high post-operative pancreatic fistula (POPF) rate. The purpose of this study was to compare POPF incidence between pancreatico-jejunostomy (PJ) and pancreatico-gastrostomy (PG). METHODS: Fifty-eight patients (mean age 53.9 ± 1.9 years) who underwent a CP in four French University Hospitals from 1988 to 2011 were analysed. The distal pancreatic remnant was either anastomosed to the stomach (44.8%, n = 25) or to a Roux-en-Y jejunal loop (55.2%, n = 35) with routine external drainage allowing a systematic search for POPF. POPF severity was classified according to the International Study Group on Pancreatic Fistula (ISGPF) and Clavien-Dindo classifications. RESULTS: The groups were similar on sex ratio, mean age, ASA score, pancreas texture, operative time and operative blood loss. Mean follow-up was 36.2 ± 3.9 months. POPF were significantly more frequent after PG (76.9 versus 37.5%, P = 0.003). PG was associated with significantly higher grade of POPF both when graded with ISGPF classification (P = 0.012) and Clavien-Dindo classification (P = 0.044). There was no significant difference in post-operative bleeding (0.918) and delayed gastric emptying (0.877) between the two groups. Hospital length of stay was increased after PG (23.6 ± 3.5 days versus 16.5 ± 1.9 days, P = 0.071). There was no significant difference in incidence of long-term exocrine (3.8 versus 19.2%, P = 0.134) and endocrine (7.7 versus 9.4%, P = 0.575) pancreatic insufficiencies. CONCLUSION: PG was associated with a significantly higher POPF incidence and severity in CP. We recommend performing PJ especially in older patients to improve CP outcomes.

Safety and feasibility of pancreaticoduodenectomy in the elderly: a matched study.

OBJECTIVES: To compare the clinical outcomes after pancreaticoduodenectomy (PD) in patients older than 70 years old against a matched cohort of patients younger than 70. METHODS: A search of the department database revealed that 285 consecutive patients underwent PD from 1996 to 2009. Forty-one patients (14%) were identified to be older than 70 years (group 1), and they were matched with 41 patients younger than 70 (group 2) according to sex, body mass index, American Society of Anesthesiologists score and tumor staging. Medical comorbidities, preoperative CA19-9 and hemoglobin levels, operative and histopathologic data, postoperative course, and survival outcomes were compared between the 2 groups of patients. RESULTS: Statistical analyses revealed no significant difference between the 2 groups, except for preoperative CA19-9 and hemoglobin levels, operating time, duration of hospitalization, and the number of lymph nodes removed. These parameters, however, did not have an impact on morbidity, mortality, and overall survival. CONCLUSIONS: Based on our study, perioperative morbidity, mortality, and overall survival are not poorer in patients older than 70. Thus, PD should not be contraindicated solely on the basis of chronological age. Moreover, PD can be rationally proposed to patients meeting the "fit elderly" definition.