Prognostic Significance of Lymphatic, Venous and Perineural Invasion After Neoadjuvant Chemotherapy in Patients with Gastric Adenocarcinoma.

BACKGROUND: The significance of perineural (PNI), lymphatic (LI) and venous invasion (VI) in gastric cancer patients who have received neoadjuvant chemotherapy is unclear. The aim of this study is to determine the incidence and prognostic significance of LI, VI and PNI in these patients. PATIENTS AND METHODS: Consecutive patients treated with neoadjuvant chemotherapy followed by gastrectomy with D2 lymphadenectomy were reviewed. Presence of LI, VI and PNI was recorded and correlated with clinical outcomes. RESULTS: A total of 243 patients underwent gastrectomy after neoadjuvant therapy for gastric adenocarcinoma. LI was identified in 129 (53%), VI in 107 (44%) and PNI in 116 (48%) of patients. Presence of LI (HR, 2.95, CI 1.91-4.56), VI (HR, 2.66, CI 1.78-3.98) and PNI (HR, 3.85, CI 2.49-5.95) was associated with poorer survival (all p < 0.001). Multivariable analysis revealed that ypT stage (HR, 1.35, CI 1.05-1.74), ypN stage (HR, 1.53, CI 1.28-1.83) and PNI (HR, 2.11, CI 1.31-3.42) were independent predictors of survival. CONCLUSIONS: LI, VI and PNI are associated with poorer survival, with PNI having prognostic significance independent of lymph node status. These factors may be useful for further prognostication, in particular when multiple factors are present, and appear especially useful for prognostic stratification in patients with no nodal involvement.

Large retroperitoneal isolated fibrous cyst in absence of preceding trauma or acute pancreatitis.

BACKGROUND: Isolated retroperitoneal cystic masses are uncommon with an estimated incidence of 1/5750 to 1/250,000. The majority present with size related symptoms, complications, or a mass. Approximately a third of patients are asymptomatic and are diagnosed incidentally. Aetiologies of retroperitoneal cystic masses (RPC) include mesenteric, omental, splenic and enteric duplication cysts. Neoplastic RPCs can be divided into epithelial (mucinous or serous cystadenoma), mesothelial (mesothelioma), germ cell (cystic teratoma) and cystic changes in a solid neoplasm (paraganglioma, neurilemmoma, sarcoma). CASE PRESENTATION: A 53 year-old man presented to us with abdominal pain related to a large mass in his left upper quadrant with associated anorexia and weight loss. He gave no history of previous trauma and denied having symptoms or a history of pancreatitis. He said he had felt this mass increasing in size over the course of several years. Clinical examination of his abdomen revealed a large firm left sided mass extending to his left upper quadrant. Imaging with computed tomography (CT) and magnetic resonance imaging cholangio-pancreatogram (MRCP) revealed a 13.7 cm × 12.2 cm × 10.9 cm cystic lesion in the retroperitoneum which was separate from the kidney, pancreas, spleen and bowel. At laparotomy, this mass was easily dissected from the surrounding viscera and was excised completely intact. Histopathological assessment found the mass to be a large fibrous pseudocyst with no epithelial lining. CONCLUSION: We present a rare case of an isolated large retroperitoneal fibrous pseudocyst unrelated to previous pancreatitis which was successfully managed with surgery.

Evidence to support the use of laparoscopic over open appendicectomy for obese individuals: a meta-analysis.

BACKGROUND: Laparoscopic appendicectomy (LA) in the obese population has been controversial. A recent SAGES guideline and a Cochrane Review have suggested a benefit for LA over the open approach but did not provide supporting data. This study is the first systematic review and meta-analysis to compare the LA with open surgery in the obese population to provide a quantitative estimate of the relative benefits. METHODS: A comprehensive search of the online databases identified seven retrospective and prospective randomized studies that contained sufficient data on obese patients. Analysis was based on intention-to-treat. We calculated pooled odds ratios (ORs) and 95 % confidence intervals using a random-effects model. RESULTS: The LA group contained more females (43 vs. 32 %, p < 0.001), had fewer perforations (18 vs. 23 %; p < 0.001), and fewer overall complications (OR: 0.49; 95 % CI: 0.37-0.63), including fewer wound infections (OR: 0.34; 95 % CI: 0.18-0.66). There was no difference in the intra-abdominal abscess rate between the groups (OR: 0.99; 95 % CI: 0.29-3.37). The LA group had a shorter length of stay (2.46 vs. 3.63 days; p < 0.001) but a longer operation time (96 vs. 78 min, p < 0.001). There was no heterogeneity between the studies. CONCLUSIONS: This meta-analysis of the current published data establishes the laparoscopic approach to appendicectomy as the preferred technique for the obese population, delivering a 50 % reduction in morbidity, with a 66 % reduction in wound infections and a significantly shorter inpatient hospital stay without increasing the intra-abdominal abscess rate.

Stricture rate after chemoradiotherapy and radiotherapy for oesophageal squamous cell carcinoma: a 20-year experience.

BACKGROUND: Definitive chemoradiation for oesophageal squamous cell carcinoma (SCC) is the first-line treatment in many centres. However, it is not without morbidity. We assess outcomes for patients treated with definitive chemoradiotherapy and radiotherapy. METHODS: A retrospective review of a prospectively maintained database (Radiotherapy Department, Canterbury District Health Board) was undertaken. All patients who underwent definitive radiotherapy for oesophageal SCC between October 1996 and April 2015 were included. RESULTS: Sixty patients underwent chemoradiotherapy with curative intent and 17 underwent definitive radiotherapy with curative intent. Median age was 69 years (44-84 years) for those undergoing chemoradiotherapy and 73 years (36-85 years) for those who underwent definitive radiotherapy. Tumour location in all patients was upper third in 14 (18%), middle third in 39 (51%), lower third in 22 (29%) cases and junctional tumour in two (3%). Staging information was complete for 73 of 77 patients (stage I 16/77 (21%), stage II 40/77 (52%), stage III 17/77 (22%)). Median dose of external beam radiotherapy for those who underwent definitive chemotherapy was 50.4 Gy (30-63 Gy) and 60 Gy (50-64 Gy) for definitive radiotherapy. Median length of follow-up was 39 months (range 4-120 months). Strictures developed in 58% of all patients (52% chemoradiotherapy and 76% definitive radiotherapy). Twenty-four (32%) patients were dilated and 14 (18%) stented. The chemoradiotherapy group had higher 5-year survival than definitive radiotherapy group (34% versus 6%, P = 0.0034). CONCLUSION: Oesophageal SCC treated with chemoradiation has a 5-year survival rate of 34%. Post-treatment strictures occur in 52% of patients with chemoradiotherapy and 76% with definitive radiotherapy.