Patterns of care for brachytherapy in Japan.

This study aimed to assess the current state of brachytherapy (BT) resources, practices and resident education in Japan. A nationwide survey was undertaken encompassing 177 establishments facilitating BT in 2022. Questionnaires were disseminated to each BT center, and feedback through online channels or postal correspondence was obtained. The questionnaire response rate was 90% (159/177), and every prefecture had a response in at least one center. The number of centers in each prefecture ranged from 0.6 to 3.6 (median: 1.3) per million population. The annual number of patients in each center ranged from 0 to 272 (median: 31). While most prefectures provided intracavitary (IC) BT for gynecological cancers and interstitial (IS) BT for prostate cancer, only one-third of the prefectures provided IS BT for cancer sites other than the prostate. The institutional image-guided BT implementation rate was 71%. IC and IS BT was performed for 15.4% of IC BT cases of gynecological cancer. Only 47% of the BT training centers answered that they could provide adequate training in BT for residents. The most common reason for this finding was the insufficient number of patients in each center. The results show that, although BT has achieved uniformity in terms of facility penetration, new technologies are not yet widespread enough. Furthermore, IS BT, which requires advanced skills, is limited to a few BT centers, and considerable number of BT training centers do not have sufficient caseloads to provide the necessary experience for their residents.

A national survey on the medical physics workload of external beam radiotherapy in Japan†.

Several staffing models are used to determine the required medical physics staffing, including radiotherapy technologists, of radiation oncology departments. However, since Japanese facilities tend to be smaller in scale than foreign ones, those models might not apply to Japan. Therefore, in this study, we surveyed workloads in Japan to estimate the optimal medical physics staffing in external beam radiotherapy. A total of 837 facilities were surveyed to collect information regarding radiotherapy techniques and medical physics specialists (RTMPs). The survey covered facility information, staffing, patient volume, equipment volume, workload and quality assurance (QA) status. Full-time equivalent (FTE) factors were estimated from the workload and compared with several models. Responses were received from 579 facilities (69.2%). The median annual patient volume was 369 at designated cancer care hospitals (DCCHs) and 252 across all facilities. In addition, the median FTE of RTMPs was 4.6 at DCCHs and 3.0 at all sites, and the average QA implementation rate for radiotherapy equipment was 69.4%. Furthermore, advanced treatment technologies have increased workloads, particularly in computed tomography simulations and treatment planning tasks. Compared to published models, larger facilities (over 500 annual patients) had a shortage of medical physics staff. In very small facilities (about 140 annual patients), the medical physics staffing requirement was estimated to be 0.5 FTE, implying that employing a full-time medical physicist would be inefficient. However, ensuring the quality of radiotherapy is an important issue, given the limited number of RTMPs. Our study provides insights into optimizing staffing and resource allocation in radiotherapy departments.

Current status and issues with the dosimetric assay of iodine-125 seed sources at medical facilities in Japan: a questionnaire-based survey†.

In conducting dosimetric assays of seed sources containing iodine-125 (125I), several major guidelines require the medical physicist to verify the source strength before patient treatment. Japanese guidelines do not mandate dosimetric assays at medical facilities, but since 2017, three incidents have occurred in Japan wherein seeds with incorrect strengths were delivered to medical facilities. Therefore, this study aimed to survey the current situation and any barriers to conducting the dosimetric assay of iodine-125 seeds at medical facilities in Japan. We conducted a questionnaire-based survey from December 2020 to April 2021, to examine whether seed assay and verification of the number of seeds delivered were being performed. We found that only 9 facilities (16%) performed seed assay and 28 (52%) verified the number of seeds. None of the facilities used an assay method that ensured traceability. The reasons for not performing an assay were divided into two categories: lack of resources and legal issues. Lack of resources included lack of instruments, lack of knowledge of assay methods, shorthand, or all of the above, whereas legal issues included the inability to resterilize iodine-125 seeds distributed in Japan and/or purchase seeds dedicated to the assay. Dosimetric assays, including simple methods, are effective in detecting calibration date errors and non-radioactive seeds. The study findings suggest that familiarization of medical personnel with these assay methods and investigation of the associated costs of labor and equipment should be recommended, as these measures will lead to medical reimbursement for quality assurance.

Time course change of the insulin requirements during the perioperative period in hepatectomy and pancreatectomy by using an artificial pancreas STG-55.

Introduction: To investigate changes in insulin requirements over time in patients who underwent hepatectomy and pancreatectomy with perioperative glycemic control by an artificial pancreas (STG-55). Materials and methods: We included 56 patients (22 hepatectomies and 34 pancreatectomies) who were treated with an artificial pancreas in the perioperative period and investigated the differences in insulin requirements by organ and surgical procedure. Results: The mean intraoperative blood glucose level and total insulin doses were higher in the hepatectomy group than in the pancreatectomy group. The dose of insulin infusion increased in hepatectomy, especially early in surgery, compared to pancreatectomy. In the hepatectomy group, there was a significant correlation between the total intraoperative insulin dose and Pringle time, and in all cases, there was a correlation with surgical time, bleeding volume, preoperative CPR, preoperative TDD, and weight. Conclusions: Perioperative insulin requirements may be mainly dependent on the surgical procedure, invasiveness, and organ. Preoperative prediction of insulin requirements for each surgical procedure contributes to good perioperative glycemic control and improvement of postoperative outcomes.

Clinical implications and optimal extent of lymphadenectomy for intrahepatic cholangiocarcinoma: A multicenter analysis of the therapeutic index.

Aims: Lymph node metastases (LNM) are associated with lethal prognosis in intrahepatic cholangiocarcinoma (ICC). Lymphadenectomy is crucial for accurate staging and hopes of possible oncological treatment. However, the therapeutic implications and optimal extent of lymphadenectomy remain contentious. Methods: To clarify the prognostic value and optimal extent of lymphadenectomy, the therapeutic index (TI) for each lymph node was analyzed for 279 cases that had undergone lymphadenectomy in a multi-institutional database. Tumor localization was divided into hilar lesions (n = 130), right peripheral lesions (n = 60), and left peripheral lesions (n = 89). In addition, the lymph node station was classified as Level 1 (LV1: hepatoduodenal ligament node), Level 2 (LV2: postpancreatic or common hepatic artery nodes), or Level 3 (LV3: gastrocardiac, left gastric artery, or celiac artery nodes). Results: Lymph node metastases were confirmed in 109 patients (39%). Five-y survival rates were 45.3% for N0 disease, 27.1% for LV1-LNM, 22.9% for LV2-LNM, and 7.3% for LV3-LNM (P < 0.001). LV3-LNM were the most frequent and earliest recurrence outcome, including multisite recurrence, followed by LV2, LV1, and N0 disease. The 5-year TI (5year-TI) for lymphadenectomy was 7.2 for LV1, 5.5 for LV2, and 1.9 for LV3. Regarding tumor location, hilar lesions showed 5-year TI >5.0 in LV1 and LV2, whereas bilateral peripheral lesions showed 5-year TI > 5.0 in LV1. Conclusion: The implications and extent of lymphadenectomy for ICC appear to rely on tumor location. In the peripheral type, the benefit of lymphadenectomy would be limited and dissection beyond LV1 should be avoided, while in the hilar type, lymphadenectomy up to LV2 could be recommended.

[Technical Report: Quality Assurance for 125I Seed Sources in Permanent Prostate Brachytherapy].

This technical report provides useful information on the current status and issues of quality control in 125I seed source strength measurement for Permanent Prostate Brachytherapy in Japan.With the spread of 125I seed brachytherapy, the traceability of source strength measurements with the single-seed assay was established in Japan. This allows medical facilities to measure reference air kerma rate of 125I seeds with their own well-type of ionization chamber. However, it is difficult to maintain the traceability chain because the 125I reference air kerma rate standards have been hardly utilized by medical facilities so far. Meanwhile, some serious incidents of contamination of the different source strengths and dead seeds were reported in Japan.To address the specific issues in Japan, JASTRO Brachytherapy Subcommittee established a working group (WG) in 2021. The goal of this WG is to investigate the management methods of source strength measurement used in medical facilities, and to discuss the ideal and practicable methods of source management such as verifying the number of seeds and source strength. Initially, a questionnaire survey was conducted to facilities offering 125I seed brachytherapy in Japan. Sixty-seven out of 95 facilities responded (response rate 70.5%). This survey revealed that 41% of facilities did not perform either confirmation of the number of seeds or measurement of source strength. There are several reasons why the source strength was not measured in those facilities. For example, 125I seeds are provided under the sterilized conditions; quality assurance by source suppliers is reliable; and there is not sufficient staff.The single-seed assay is regarded as an internationally standardized and the most reliable measurement method. Therefore, it is an essential measurement technique to ensure traceability of source strength measurements. However, our survey found that most Japanese facilities do not perform single-seed assays. Meanwhile, some facilities have performed batch assay as an alternative method, in which all of the multiple sources in a batch are measured while loaded into sterilized cartridges. Although the measurement by the batch assay is less accurate than the one by the single-seeded assay, the batch assay does not require re-sterilization of the source and can be performed quickly. It might be useful to detect unexpected errors such as differences in the number of sources and abnormalities in source strength.In this report, we will introduce several methods of source strength measurement that have been implemented in medical facilities. The quality assurance of 125I seed sources in prostate interstitial brachytherapy should be provided not only by the source suppliers but also by the medical facilities that use sources to treat patients. We hope that medical facilities will refer to this technical report and use it as an aid to quality assurance in their own facilities.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection.

BACKGROUND: Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR. METHODS: Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups. RESULTS: Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001]. CONCLUSION: M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

Multi-Institutional Study of End-to-End Dose Delivery Quality Assurance Testing for Image-Guided Brachytherapy Using a Gel Dosimeter.

PURPOSE: To quantify dose delivery errors for high-dose-rate image-guided brachytherapy (HDR-IGBT) using an independent end-to-end dose delivery quality assurance test at multiple institutions. The novelty of our study is that this is the first multi-institutional end-to-end dose delivery study in the world. MATERIALS AND METHODS: The postal audit used a polymer gel dosimeter in a cylindrical acrylic container for the afterloading system. Image acquisition using computed tomography, treatment planning, and irradiation were performed at each institution. Dose distribution comparison between the plan and gel measurement was performed. The percentage of pixels satisfying the absolute-dose gamma criterion was reviewed. RESULTS: Thirty-five institutions participated in this study. The dose uncertainty was 3.6% ± 2.3% (mean ± 1.96σ). The geometric uncertainty with a coverage factor of k = 2 was 3.5 mm. The tolerance level was set to the gamma passing rate of 95% with the agreement criterion of 5% (global)/3 mm, which was determined from the uncertainty estimation. The percentage of pixels satisfying the gamma criterion was 90.4% ± 32.2% (mean ± 1.96σ). Sixty-six percent (23/35) of the institutions passed the verification. Of the institutions that failed the verification, 75% (9/12) had incorrect inputs of the offset between the catheter tip and indexer length in treatment planning and 17% (2/12) had incorrect catheter reconstruction in treatment planning. CONCLUSIONS: The methodology should be useful for comprehensively checking the accuracy of HDR-IGBT dose delivery and credentialing clinical studies. The results of our study highlight the high risk of large source positional errors while delivering dose for HDR-IGBT in clinical practices.

Japanese Society for Radiation Oncology Consensus Guidelines of combined intracavitary and interstitial brachytherapy for gynecological cancers.

It has been postulated that the combination of intracavitary and interstitial brachytherapy (IC/IS) is effective and safe for large and irregularly shaped uterine cervical cancer patients. However, due to its invasiveness compared to conventional intracavitary brachytherapy (ICBT), it has to be said that the implementation speed of IC/IS is slow. Until now, there have been no guidelines for required equipment, human resources, and procedural guide focusing solely on IC/IS. The purpose of this guideline is to provide radiation oncologists and medical physicists who wish to start IC/IS with practical and comprehensive guidance for a safe IC/IS introduction and to help accelerate the spread of the utilization of IC/IS nationwide. This is the English translation of the Japanese IC/IS Guidelines, and it was created in an effort to share the Japanese approach to the management of locally advanced uterine cervical cancer worldwide.

A multicenter, open-label, single-arm study of anamorelin (ONO-7643) in patients with cancer cachexia and low body mass index.

BACKGROUND: Cancer cachexia is a syndrome characterized by anorexia and decreased body weight. This study evaluated the efficacy and safety of anamorelin, an orally active, selective ghrelin receptor agonist, in patients with cancer cachexia and a low body mass index (BMI). METHODS: This multicenter, open-label, single-arm study enrolled Japanese patients with non-small cell lung cancer or gastrointestinal cancer with cancer cachexia (BMI < 20 kg/m2 , involuntary weight loss > 2% in the last 6 months, and anorexia). Patients were administered 100 mg of anamorelin once daily for up to 24 weeks. The primary end point was a composite clinical response (CCR) at 9 weeks, which was defined as an increase in body weight of ≥5% from the baseline, an increase of ≥2 points in the score of the 5-item Anorexia Symptom Scale of the Functional Assessment of Anorexia/Cachexia Therapy, and being alive. RESULTS: One hundred two patients were eligible and enrolled. The means and standard deviations for age and BMI were 71.0 ± 8.2 years and 17.47 ± 1.48 kg/m2 , respectively. The CCR rate at 9 weeks was 25.9% (95% confidence interval [CI], 18.3%-35.3%), which met the primary end point with a lower 95% CI exceeding the prespecified minimum of 8%. Improvements in body weight and anorexia were durable and were accompanied by improvements in patients' global impression of change for appetite/eating-related symptoms and overall condition. Adverse drug reactions occurred in 37 of 101 treated patients (36.6%), with the most common being glycosylated hemoglobin increases, constipation, and peripheral edema. CONCLUSIONS: Anamorelin improved body weight and anorexia-related symptoms in patients with cancer cachexia and a low BMI with durable efficacy and favorable safety and tolerability. LAY SUMMARY: Anamorelin is a drug that stimulates appetite and promotes weight gain. This clinical trial was aimed at determining its efficacy and safety in Japanese cancer patients with a low body mass index and cachexia, a syndrome associated with anorexia and weight loss. Anamorelin was found to improve body weight and anorexia-related symptoms in these patients, and these effects were durable for up to 24 weeks. Moreover, anamorelin was generally well tolerated. These findings suggest that anamorelin is a valuable treatment option for patients with cancer cachexia and a low body mass index.

Impact of lymph node dissection on clinical outcomes of intrahepatic cholangiocarcinoma: Inverse probability of treatment weighting with survival analysis.

BACKGROUND: Lymph node metastasis (LNM) has been established as a critical risk factor for prognosis in intrahepatic cholangiocarcinoma (ICC). The clinical implications of lymph node dissection (LND) have been debated. This study aimed to clarify the prognostic impact of LND by multicenter retrospective analysis. METHODS: A total of 310 ICC patients who had undergone curative resection between 2000 and 2016 were retrospectively analyzed. The prognostic impact of LND was estimated under an inverse probability of treatment weighting (IPTW) approach using propensity scores. RESULTS: LND was performed for 224 patients (72%), with LNM pathologically confirmed in 90 patients (40%). Prognosis was poorer for patients with LNM (median survival, 16.9 months) than for those without (57.2 months; P < .0001). One-, 3-, and 5-year overall survival rates (OS) were comparable among LND+ (81.6%, 48.0%, and 37.5%, respectively) and LND- groups (81.6%, 55.4%, and 44.6%, respectively). However, advanced tumor, as characterized by larger tumor, multinodular lesions, and serosal invasion, was significantly more frequent in the LND+ group than in the LND- group. After IPTW adjusting for imbalances, 1-, 3-, and 5-year OS were better in the LND+ group (83.5%, 52.2%, and 42.8%, respectively) than in the LND- group (71.9%, 32.4%, and 23.4%, respectively; P = .046). LND thus showed significant prognostic impact (hazard ratio = 0.58, 95%CI = |0.39|-|0.84|, P = .005), especially in hilar ICC. However, peripheral ICC displayed no therapeutic benefit from LND. CONCLUSIONS: LND could have a significant role to play in improving oncologic outcomes. Therapeutic LND should be implemented on the basis of tumor location and tumor advancement.

Preoperative prognostic nutritional index predicts postoperative infectious complications and oncological outcomes after hepatectomy in intrahepatic cholangiocarcinoma.

BACKGROUND: In the surgical treatment of intrahepatic cholangiocarcinoma (ICC), postoperative complications may be predictive of long-term survival. This study aimed to identify an immune-nutritional index (INI) that can be used for preoperative prediction of complications. PATIENTS AND METHODS: Multi-institutional data from 316 patients with ICC who had undergone surgical resection were retrospectively analysed, with a focus on various preoperative INIs. RESULTS: Severe complications (Clavien-Dindo grade III-V) were identified in 66 patients (20.8%), including Grade V complications in 7 patients (2.2%). Comparison of areas under the receiver operating characteristic curve (AUCs) among various INIs identified the prognostic nutritional index (PNI) as offering the highest predictive value for severe complications (AUC = 0.609, cut-off = 50, P = 0.008). Multivariate analysis revealed PNI <  50 (odds ratio [OR] = 2.22, P = 0.013), hilar lesion (OR = 2.46, P = 0.026), and long operation time (OR = 1.003, P = 0.029) as independent risk factors for severe complications. In comparing a high-PNI group (PNI ≥ 50, n = 142) and a low-PNI group (PNI <  50, n = 174), the low-PNI group showed higher rates of both major complications (27% vs. 13.4%; P = 0.003) and infectious complications (14.9% vs. 3.5%; P = 0.0021). Furthermore, median survival time and 1- and 5-year overall survival rates were 34.2 months and 77.4 and 33.8% in the low-PNI group, respectively, and 52.4 months and 89.3 and 47.5% in the high-PNI group, respectively (P = 0.0017). CONCLUSION: Preoperative PNI appears useful as an INI correlating with postoperative severe complications and as a prognostic indicator for ICC.

Incomplete pseudo-Meigs' syndrome caused by endometrial ovarian cyst: A case report.

A 63-year-old female was admitted to our hospital with history of persistent dyspnea. Right pleural effusion and ovarian tumor were discovered, but here were no significant findings on thoracoscopy under local anesthesia. The pleural effusion was suspected to be secondary to Meigs' syndrome, and a diagnosis of endometriotic ovarian cyst was made. Since the pleural effusion resolved after surgery, the patient was diagnosed with incomplete pseudo-Meigs' syndrome. We consider this to be a valuable case, as there are no previously reported cases of pseudo-Meigs' syndrome derived from an endometriotic ovarian cyst, to the best of our knowledge.

Pd-catalyzed Regio- and Stereoselective Hydrostannylation of an Alkyl Ethynyl Ether/One-Pot Stille Coupling Enables the Synthesis of 14-Membered Macrolactone of Luminamicin.

Regio- and stereoselective hydrostannylation of alkyl ethynyl ethers generates alkenyl ethers, which are useful building blocks in organic synthesis. This efficient synthetic method, however, is limited. Here, we report not only an efficient method for a highly regio- and stereoselective Pd-catalyzed hydrostannylation of alkyl ethynyl ethers but also a scalable synthesis and construction of the core framework of luminamicin possessing all functional groups and stereocenters.

[Investigation of marginal ulcer after pancreatoduodenectomy].

BACKGROUND: Marginal ulcer after pancreatoduodenectomy (PD) is a relatively common complication, but if massive bleeding or ulcer perforation occurs together with the marginal ulcer, this condition may be fatal. OBJECTIVE: To identify the risk factors and management of marginal ulcer after PD. METHODS: In all, 438 patients who underwent PD from 2003 to 2017 were retrospectively reviewed and analyzed. After surgery, all patients were administered a histamine H2 receptor antagonist (H2RA) or a proton pump inhibitor (PPI), which was continued after discharge. Marginal ulcer was diagnosed by endoscopy or surgery. The risk factors for marginal ulcer were then investigated using univariate and multivariate analyses. RESULTS: After a median follow-up time of 2.7 years, 29 patients (6.6%) developed marginal ulcer. Seventeen patients developed marginal ulcer within 1 year after PD, and 7 patients developed marginal ulcer more than 3 years after PD. All 8 patients who underwent surgery for the treatment of marginal ulcer developed acute peritonitis. Two patients with acute peritonitis died within 1 month after surgery. A multivariate analysis found that discontinuation of PPI treatment was the only independent risk factor for marginal ulcer development (P<0.001). In contrast, sex, age, primary disease, procedure, operation time, volume of blood loss, pancreatic texture, development of postoperative pancreatic fistula, postoperative complications, poor glycemic control after PD, and discontinuation of H2RA therapy after PD were not significantly different between the patient group that developed marginal ulcer and the patient group that did not. Sixteen patients were not treated with antacids at the time of marginal ulcer development. The reason for discontinuation of antacids was the decision of the family physician in 8 cases and the decision of the patient in 3 cases. CONCLUSION: Marginal ulcer can still develop a long time after PD, and sometimes, it may be fatal. PPI administration should be continued even after a long time has passed, although this therapy is often discontinued for various reasons. It is therefore important for family physicians and patients to recognize the danger of marginal ulcer after PD.

Prognostic Utility of the Glasgow Prognostic Score for the Long-Term Outcomes After Liver Resection for Intrahepatic Cholangiocarcinoma: A Multi-institutional Study.

OBJECTIVE: The usefulness of the modified Glasgow prognostic score (GPS) as a prognostic tool remains unclear for patients undergoing curative surgery for intrahepatic cholangiocarcinoma (ICC). Therefore, this study investigated the prognostic usefulness of the GPS for patients who underwent ICC surgery. METHOD: All ICC patients who had a curative-intent hepatectomy at 17 institutions between 2000 and 2016 were included. The correlation was assessed between the preoperative GPS and the baseline characteristics of the patients, histopathological parameters, surgical parameters, and the postresection overall survival (OS). RESULT: There were 273 patients who met the eligibility criteria between the years 2000 and 2016. The postoperative OS rates at 1, 3, and 5 years were 83.8%, 56.3%, and 41.5%, respectively (median OS, 47.7 months). A multivariate analysis revealed the factors that were associated with a worse OS, which included an increased GPS (hazard ratio = 1.62; 95% confidence interval [CI]: 1.01-2.53; P = 0.03), an elevated carcinoembryonic antigen level (hazard ratio = 1.60; 95% CI: 1.06-2.41; P = 0.02), an elevated carbohydrate antigen 19-9 level (hazard ratio = 1.55; 95% CI: 1.05-2.30; P = 0.03), undifferentiated carcinoma (hazard ratio = 2.41; 95% CI: 1.56-3.67; P < 0.01), and positive metastasis to the lymph nodes (hazard ratio = 2.54; 95% CI: 1.76-3.67; P < 0.01). In ICC patients after a hepatectomy, an elevated GPS was associated with poorer OS, even if the tumour factors that affected GPS were eliminated by propensity-score matching. CONCLUSION: Preoperative GPS can be useful to predict the postoperative outcomes of ICC patients. Therefore, this relatively simple and inexpensive scoring system can be utilized to further refine patient stratification as well as to predict survival.

Efficacy of surgical management for recurrent intrahepatic cholangiocarcinoma: A multi-institutional study by the Okayama Study Group of HBP surgery.

BACKGROUND: The prognosis of intrahepatic cholangiocarcinoma (ICC) has been poor, because of the high recurrence rate even after curative surgery. This study aimed to evaluate the prognostic impact of surgical resection of recurrent ICC. PATIENTS AND METHODS: A total of 345 cases of ICC who underwent hepatectomy with curative intent in 17 institutions were retrospectively analyzed, focusing on recurrence patterns and treatment modalities for recurrent ICC. RESULTS: Median survival time and overall 5-year recurrence-free survival rate were 17.8 months and 28.5%, respectively. Recurrences (n = 223) were classified as early (recurrence at ≤1 year, n = 131) or late (recurrence at >1 year, n = 92). Median survival time was poorer for early recurrence (16.3 months) than for late recurrence (47.7 months, p<0.0001). Treatment modalities for recurrence comprised surgical resection (n = 28), non-surgical treatment (n = 134), and best supportive care (BSC) (n = 61). Median and overall 1-/5-year survival rates after recurrence were 39.5 months and 84.6%/36.3% for surgical resection, 14.3 months and 62.5%/2.9% for non-surgical treatment, and 3 months and 4.8%/0% for BSC, respectively (p<0.0001). Multivariate analysis identified early recurrence, simultaneous intra- and extrahepatic recurrence, and surgical resection of recurrence as significant prognostic factors. In subgroup analyses, surgical resection may have positive prognostic impacts on intra- and extrahepatic recurrences, and even on early recurrence. However, simultaneous intra- and extrahepatic recurrence may not see any survival benefit from surgical management. CONCLUSION: Surgical resection of recurrent ICC could improve survival after recurrence, especially for patients with intra- or extrahepatic recurrence as resectable oligo-metastases.

Validation and performance of three-level procedure-based classification for laparoscopic liver resection.

BACKGROUND: A procedure-based laparoscopic liver resection (LLR) classification (IMM classification) stratified 11 different LLR procedures into 3 grades. IMM classification assessed the difficulty of LLR differently than an index-based LLR classification (IWATE criteria), which scored each procedure on an index scale of 12. We validated the difference of 3 IMM grades using an external cohort, evaluated the IMM classification using the scores of the IWATE criteria, and compared the performance of IMM classification with the IWATE criteria and the minor/major classification. METHODS: Patients undergoing LLR without simultaneous procedures were selected from a prospectively maintained database at the Institut Mutualiste Montsouris (IMM cohort) and from the database of 43 Japanese institutions (JMI cohort). Surgical and postoperative outcomes were evaluated according to the 3 IMM grades using the JMI cohort. The 11 LLR procedures included in the IMM classification were scored according to the IWATE criteria. The area under the curves (AUCs) for surgical and postoperative outcomes were compared. RESULTS: In the JMI (n = 1867) cohort, operative time, blood loss, conversion rate, and major complication rate were significantly associated with a stepwise increase in grades from I to III (all, P < 0.001). In the IMM (n = 433) and JMI cohorts, IMM grades I, II, and III corresponded to three low-scoring, two intermediate-scoring, and six high-scoring LLR procedures as per the IWATE criteria, respectively. Mean ± standard deviation among the IMM grades were significantly different: 3.7 ± 1.4 (grade I) versus 7.5 ± 1.7 (grade II) versus 10.2 ± 1.0 (grade III) (P < 0.001) in the IMM cohort and 3.6 ± 1.4 (grade I) versus 6.7 ± 1.5 (grade II) versus 9.3 ± 1.4 (grade III) (P < 0.001) in the JMI cohort. The AUCs for surgical and postoperative outcomes are higher for the 3-level IMM classification than for the minor/major classification. CONCLUSIONS: The difference of 3 IMM grades with respect to surgical and postoperative outcomes was validated using an external cohort. The 3-level procedure-based IMM classification was in accordance with the index-based IWATE criteria. The IMM classification performed better than the minor/major classification for stratifying LLR procedures.

A multicenter prospective registration study on laparoscopic pancreatectomy in Japan: report on the assessment of 1,429 patients.

BACKGROUND: Prospective studies are needed to understand the safety and feasibility of laparoscopic pancreatectomy. The aim of the present study was to describe laparoscopic pancreatectomy currently undertaken in Japan, using a prospective registration system. METHODS: Patient characteristics and planned operations were registered preoperatively, and then the performed operation and outcomes were reported using an online system. Collected data were also compared between institutions based on their level of experience. This study was registered with UMIN000022836. RESULTS: Available data were obtained from 1,429 patients at 100 Japanese institutions, including 1,197 laparoscopic distal pancreatectomies (LDPs) and 232 laparoscopic pancreatoduodenectomies (LPDs). The rates of completion for planned operations were 92% for LDP and 91% for LPD. Postoperative complication rates after LDP and LPD were 17% and 30%, and 90-day mortality rates were 0.3% and 0.4%, respectively. Shorter operation time, less blood loss, and lower incidence of pancreatic fistula were observed in institutions experienced in LDP. A higher rate of pure laparoscopic procedure and shorter operation time were noted in institutions experienced with LPD. CONCLUSION: LDPs and LPDs are performed safely in Japan, especially in experienced institutions. Our data could support the next challenges in the field of laparoscopic pancreatectomy.

A single-institution retrospective analysis of gastric carcinoma with positive peritoneal lavage cytology and without serosal invasion: A case series.

BACKGROUND AND OBJECTIVES: Peritoneal dissemination of gastric cancer is often associated with serosal infiltration. The aim of this study was to evaluate the clinical importance of peritoneal lavage cytology in patients with gastric carcinoma without serosal invasion. The incidence and impact on prognosis of positive cytology were analyzed. METHODS: Of 2768 patients with gastric cancer, outcomes and pathological characteristics of 973 patients were reviewed retrospectively. All patients underwent peritoneal lavage at laparotomy for curative or palliative resection of gastric cancer between 1999 and 2017. Among these, 479 who underwent surgery from January 1999 to March 2012 were also reviewed to analyze 5-year survival. RESULTS: Of 973 patients enrolled, 338 (35%) did not have serosal invasion, and peritoneal cytology was positive in 4/338 (1.2%). Of these four patients, one had submucosal invasion and three had muscularis propria invasion. Of 635 patients with serosal invasion, peritoneal cytology was positive in 74/635 (12%). Of 479 patients reviewed for survival, cytology was positive in 32/479, with 3/32 (9%) surviving for five years, and cytology was negative in 447 patients with 266/447 (60%) surviving for five years. CONCLUSIONS: Cytologic evaluation should be routinely performed in patients with early-stage gastric cancer.