The risk of lymph node metastasis in T1 colorectal cancer: new parameters to assess the degree of submucosal invasion.

PURPOSE: In T1 colorectal cancer, the depth is the main factor assessing the degree of submucosal invasion (DSI) to predict the risk of lymph node metastasis (LNM). The width (WSI) and the area of submucosal invasion (ASI) have been suggested as additional parameters to assess the risk of LNM. A review of the literature was undertaken on the correlation between WSI and ASI parameters and the incidence of LNM. METHODS: A Medline, PubMed, and Cochrane Library search was performed to retrieve all studies reporting correlation between WSI/ASI and risk of LNM in T1 colorectal cancer. RESULTS: Eight studies including 1727 patients were identified. All considered the degree of WSI and its influence on LNM: seven assessed different width cut-off of submucosal invasion, and one study the mean width of submucosal invasion in patients having or not involved lymph nodes. The WSI was significantly a prognostic factor for LNM (p < 0.05) in four studies. Both 2 and 3 mm seem to be the most discriminatory cut-off values of submucosal width invasion in defining the risk difference of LNM above and below the cut-off (2 mm, OR = infinite; 3 mm, OR = 6.9). Patients having a cut-off ≤ 5 mm of WSI showed a low risk (5.6%) of LNM rendering radical surgery unnecessary. Four studies assessed the risk of LNM according to the involved submucosal area (width × depth). In two of these, the ASI was a significant prognostic factor for LNM (p < 0.05). CONCLUSION: The WSI and ASI seem to be reliable prognostic factors for LNM in T1 colorectal cancer. There is no agreement on ideal cut-off value.

Surgery after FOLFIRINOX treatment for locally advanced and borderline resectable pancreatic cancer: increase in tumour attenuation on CT correlates with R0 resection.

OBJECTIVES: To assess factors associated with radical resection (R0) of pancreatic ductal adenocarcinoma (PDAC) after induction treatment with FOLFIRINOX. METHODS: Patients with either locally advanced (LA) and borderline resectable (BR) PDAC undergoing surgical exploration after FOLFIRINOX were retrospectively enrolled. Two pancreatic radiologists reviewed the CT blinded to the final outcome and assessed chemotherapy response and resectability. Patients were then divided into R0 resected (group A) and not resected/R1 resected (group B), which were compared. RESULTS: Of 59 patients included, 19 were defined as unresectable (32%), 33 borderline resectable (56%) and 7 resectable (12%) during the blind radiological evaluation after FOLFIRINOX. Once in a surgical setting, 27% were non-resectable, whereas 73% received surgical resection with a 70% R0 rate. Consequent sensitivity and specificity were 86% and 29%. At imaging review, significant decreases in longest tumour dimension were observed in both groups: from 32 mm (95% CI 15-55) to 21 (10-44) in group A and from 34 (18-70) to 26 (7-60) in group B, p < 0.05. However, a significant increase in tumour attenuation in all phases was only observed for R0 resected, from 52 HU (26-75) to 65 (35-92) in arterial phase (p < 0.001) and from 62 (36-96) to 78 (40-120) in the venous (p = 0.001). CONCLUSION: After neoadjuvant FOLFIRINOX, CT predicted resectability with acceptable sensitivity but low specificity. The observation of increased tumour attenuation at CT scan after FOLFIRINOX treatment might represent a reliable predictor of R0 resection. KEY POINTS: • CT drives the assessment of PDAC resectability after FOLFIRINOX • CT predicts resectability with acceptable sensitivity but low specificity • Significant increase in tumour attenuation was only observed for R0 resected PDAC • Tumour attenuation after FOLFIRINOX represents a reliable predictor of R0 resection.

Preoperative Pancreatic Resection (PREPARE) score: a prospective multicenter-based morbidity risk score.

OBJECTIVES: Development of a simple preoperative risk score to predict morbidity related to pancreatic surgery. BACKGROUND: Pancreatic surgery is standardized with little technical diversity among institutions and unchanging morbidity and mortality rates in recent years. Preoperative identification of high-risk patients is potentially one of the rare avenues for improving the clinical course of patients undergoing pancreatic surgery. METHODS: Using a prospectively collected multicenter database of patients undergoing pancreatic surgery (n=703), surgical complications were classified according to the Clavien-Dindo classification. A new scoring system for preoperative identification of high-risk patients that included only objective preoperatively assessable variables was developed using a multivariate regression model. Subsequently, this scoring system was prospectively validated from 2011 to 2013 (n=429) in a multicenter setting. RESULTS: Eight independent preoperatively assessable variables were identified and included in the scoring system: systolic blood pressure, heart rate, hemoglobin level, albumin level, ASA (American Society of Anesthesiologists) score, surgical procedure, elective surgery or not, and disease of pancreatic origin or not. On the basis of 3 subgroups (low risk, intermediate risk, high risk), the proposed scoring system reached an accuracy of 75% for correctly predicting occurrence or nonoccurrence of major surgical complications in 80% of all analyzed patients within the validation cohort (c-statistic index=0.709, P<0.001, 95% confidence interval=0.657-0.760). CONCLUSIONS: We present an easily applied scoring system with convincing accuracy for identifying low-risk and high-risk patients. In contrast to other systems, the score is exclusively based on objective preoperatively assessable characteristics and can be rapidly and easily calculated.