Fluorescence-Guided Surgery in the Combined Treatment of Peritoneal Carcinomatosis from Colorectal Cancer: Preliminary Results and Considerations.

BACKGROUND: Indocyanine green (ICG) is a near-infrared fluorescent contrast agent, which preferentially accumulates in cancer tissue. The aim of our study was to investigate the role of fluorescence imaging (FI) with ICG (ICG-FI) for detecting peritoneal carcinomatosis (PC) from colorectal cancer (CRC). METHODS: Four CRC patients with PC scheduled for cytoreductive surgery + hyperthermic intraperitoneal chemotherapy were enrolled in this prospective study. At a median time of 50 min after 0.25 mg/kg ICG injected intravenously, intraoperative ICG-FI using Fluobeam® was performed in vivo and ex vivo on all specimens. The Peritoneal Cancer Index was used to estimate the likelihood of complete cytoreduction. RESULTS: No severe complications were recorded. ICG-FI took a median of 20 min (range 10-30, IQR 15-25). Sixty-nine nodules were harvested. Fifty-two nodules had been diagnosed preoperatively by conventional imaging (n = 30; 43%) or intraoperatively by visual inspection/palpation (n = 22; 32%). With ICG-FI, 47 (90%) nodules were hyperfluorescent, and five hypofluorescent. Intraoperative ICG-FI identified 17 additional hyperfluorescent nodules. On histopathology, 16 were metastatic nodules. Sensitivity increased from 76.9%, with the conventional diagnostic procedures, to 96.9% with ICG-FI. The positive predictive value of ICG-FI was 98.4%, and test accuracy was 95.6%. Diagnostic performance of ICG-FI was significantly better than preoperative (p = 0.027) and intraoperative conventional procedures (p = 0.042). The median PCI score increased from 7 to 10 after ICG-FI (p < 0.001). CONCLUSIONS: Our results suggest that intraoperative ICG-FI can improve outcomes in patients undergoing CS for PC from CRC. Further studies are needed to determine the role of ICG-FI in this patient population.

Indocyanine Green Fluorescence Imaging-Guided Surgery in Primary and Metastatic Liver Tumors.

BACKGROUND: After surgery for liver tumors, recurrence rates remain high because of residual positive margins or undiagnosed lesions. It has been suggested that detection of hepatic tumors can be obtained with near-infrared fluorescence imaging (FI). Indocyanine green (ICG) has been used with contrasting results. The aims of this study were to explore ICG-FI-guided surgery methodology and to assess its potential applications. MATERIALS AND METHODS: Out of 14 patients with liver tumors, 5 were not operated on, and 9 patients (3 primary and 6 metastatic tumors) underwent surgery. ICG (0.5 mg/kg) was injected intravenously 24 hours before surgery. Fluorescence was investigated prior to resection to detect liver lesions, during hepatic transection to guide surgery, on both cross-section and benchtop to assess surgical margins, and for pathological evaluation. RESULTS: All operations were successful and had a short duration. ICG-FI detected all already known lesions (n = 10), and identified 2 additional small tumors (1 hepatocarcinoma and 1 metastasis, diagnostic improvement = 20%). Two hepatocarcinomas were hyperfluorescent; the remaining one, with a central hypofluorescent area and a hyperfluorescent ring, was indeed a mixed cholangiohepatocarcinoma. All metastatic nodules were hypofluorescent with a hyperfluorescent rim. In all cases, in vivo and ex vivo fluorescence revealed clear liver margins. Postoperative pathological examination greatly benefited of liver fluorescence to assess radicality. CONCLUSION: ICG-FI-guided surgery was shown to be an effective tool to improve both intraoperative staging and radicality in the surgical treatment of primary and metastatic liver tumors.

A Regressive Model to Study the Hospitalization for Laparoscopic Appendectomy: A Multicenter Study.

Appendicitis is a most common abdominal condition worldwide, and appendectomy especially laparoscopic appendectomy is among the most commonly performed general surgeries. In this study, data were collected from patients who underwent laparoscopic appendectomy surgery at the Evangelical Hospital "Betania" in Naples, Italy. Linear multiple regression was used to obtain a simple predictor that can also assess which of the independent variables considered to be a risk factor. The model with R2 of 0.699 shows that comorbidities and complications during surgery are the main risk factors for prolonged LOS. This result is validated by other studies conducted in the same area.

Inflammatory and nutritional status is a predictor of long-term outcome in patients undergoing surgery for gastric cancer. Validation of the Naples prognostic score.

PURPOSE: Oncological outcome depends not only on tumor behaviour but also on nutritional and immune-inflammatory host status. Data in gastric cancer are limited. The main aim of this study was to prospectively assess Naples prognostic score (NPS) in gastric cancer patients. NPS was also compared with prognostic nutritional index (PNI), controlling nutritional status (CONUT) score and systemic inflammation score (SIS). METHODS: Overall survival (OS) and complication rates of 415 patients undergoing gastric cancer surgery from January 2000 to December 2015 were calculated. Disease-free survival (DFS) rates were assessed in 307 radically resected patients. MaxStat analysis was used to identify the best cut-off values. NPS scores were divided into 3 groups (NPS 0-3). The receiver-operating-characteristic (ROC) curve for censored survival data was used to compare the prognostic performance of scoring systems. RESULTS: NPS positively correlated with current scoring systems (p<0.001) and advanced tumor stages (p<0.001). Patients with elevated NPS scores experienced more postoperative complications (all patients: p=0.003; radically resected patients: p=0.010). NPS1 and NPS2 patients had a higher hazard ratio (HR) than NPS0 patients for OS (NPS1 HR 2.04, NPS2 HR 4.27; p<0.001) and DFS (NPS1 HR 1.70, NPS2 HR 4.98; p<0.001). Among the different scoring systems, only NPS was selected as an independent significant predictor for OS (p=0.024) and DFS (p=0.009). NPS was assigned the best prognostic performance by ROC analysis, equalling TNM staging system, and correctly identified highrisk patients. CONCLUSIONS: NPS is an easy to calculate prognostic score strongly associated with outcome in patients undergoing gastric cancer surgery. KEY WORDS: Gastric cancers, Immune-nutritional and inflammatory host status, Naples prognostic score.

Preoperative Neutrophil to Lymphocyte Ratio and Lymphocyte to Monocyte Ratio are Prognostic Factors in Gastric Cancers Undergoing Surgery.

BACKGROUND: Cancer outcome is considered to result from the interplay of several factors, among which host inflammatory and immune status are deemed to play a significant role. The neutrophil-to-lymphocyte ratio (NLR) and the lymphocyte-to-monocyte ratio (LMR) have been profitably used as surrogate markers of host immunoinflammatory status and have also been shown to correlate with outcome in several human tumors. However, only a few studies on these biomarkers have been performed in gastric cancer patients, yielding conflicting results. METHODS: Data were retrieved from a prospective institutional database. Overall survival (OS) of 401 patients undergoing surgery for gastric cancer between January 2000 and June 2015 as well as disease-free survival (DFS) rates in 297 radically resected patients were calculated. MaxStat analysis was used to select cutoff values for NLR and LMR. RESULTS: NLR and LMR did not significantly correlate with tumor stage. Patients with a high NLR and a low LMR experienced more tumor recurrences (p < 0.001) and had a higher hazard ratio (HR) for both OS (HR = 2.4 and HR = 2.10; p < 0.001) and DFS (HR = 2.99 and HR = 2.46; p < 0.001) than low NLR and high LMR subjects. Both biomarkers were shown to independently predict OS (HR = 1.65, p = 0.016; HR = 2.01, p = 0.002, respectively) and DFS (HR = 3.04, p = 0.019; HR = 4.76, p = 0.002, respectively). A score system combining both biomarkers was found to significantly correlate with long-term results. CONCLUSIONS: A simple prognostic score including preoperative NLR and LMR can be used to easily predict outcome in gastric cancer patients undergoing surgery.