Treatment of Gastric Cancer Means Surgery, but Not Surgery Alone.

Despite numerous studies, gastric cancer (GC) still presents a high mortality rate in Eastern and Western countries, increasing attention for new therapeutic strategies [...].

Multivisceral Resection for Locally Advanced Gastric Cancer: A Systematic Review and Evidence Quality Assessment.

Patients with locally advanced gastric cancer (LAGC) often require multivisceral resection (MVR) of the involved organs to achieve R0 resection and local disease control. The aim of the present study was to systematically review all available literature on the postoperative and long-term outcomes of MVR for gastric cancer. The PubMed database was systematically searched by two independent investigators for studies concerning MVR for LAGC. In total, 30 original studies with 3362 patients met our inclusion criteria. R0 resection was achieved in 67.77% (95% CI, 65.75-69.73%) of patients. The spleen, colon and pancreas comprised the most frequently resected organs in the context of MVR. Pancreatic fistulae (10.08%, 95% CI, 7.99-12.63%), intraabdominal abscesses (9.92%, 95% CI, 7.85-12.46%) and anastomotic leaks (8.09%, 95% CI, 6.23-10.45%) constituted the most common postoperative complications. Using the available data, we estimated the mean 1-year survival at 62.2%, 3-year survival at 33.05%, and 5-year survival at 30.21% for the entire cohort. The survival rates were mainly correlated with lymphatic invasion, tumor size and patient age. Therefore, gastrectomy, together with MVR, is feasible and may offer a survival advantage compared to gastrectomy alone or no other surgical treatment in a selected group of patients. Consequently, both patient and tumor characteristics should be carefully assessed to optimize candidate selection.

Complete mesogastric excision for gastric cancer: is it the future of gastric cancer surgery?

Gastric cancer remains undoubtedly one of the most common and deadly cancers worldwide. The global incidence shows wide geographic variation with a high prevalence in Asia. Besides that, there are evident differences in epidemiology, histopathology, tumor location, diagnosis and treatment strategy between east and west countries. Gastric cancer represents an aggressive disease, with many factors influencing its development and also recurrence after surgical resection. New knowledge of disease spread and new routes of metastases are now emerging and the 'novel' concept of complete mesogastric excision for gastric cancer is under consideration and debate. This article aims to analyze and highlight this new concept after a careful literature review, offering also a view toward the future.

Laparoscopic vs Open Treatment for Gastric and Non-Gastric Gastrointestinal Stromal Tumors: a Two-Center Experience.

We retrospectively reviewed the medical records of 109 patients who underwent curative laparoscopic or open resection for different types of gastrointestinal stromal tumors (GIST). Only primary GIST patients who did not receive preoperative chemotherapy or oral imatinib treatment were included in the analysis. We divided the patients into 2 groups according to the surgical approach:a laparoscopic group (LAP) and a laparotomic group (OPEN). Our aim was to confirm the feasibility and safety of laparoscopic surgery for GISTs that differed in size and location, and to assess its long-term oncologic outcome in terms of overall survival (OS) and disease-free survival (DFS). Furthermore, we performed a surgical short-term outcome analysis. The two groups did not differ with respect to age at operation, gender, BMI or comorbidities. Even the NIH and AFIP risk classifications were not significantly different between the two groups. Furthermore, in our analysis, there was no significant difference in mean tumor size or location between the two groups. Wedge resection was the most frequently performed procedure. The conversion rate was 7.8%. The operative time was 194.75 (60- 350) min for the open group and 181.70 (57-480) min for the laparoscopic group. Our data clearly indicated that the long-term oncologic outcome and DFS of laparoscopic resection were not inferior to those of traditional open operations and laparoscopic resection was still feasible in cases with large tumors: the median size of the tumor was 4.5 cm (3-25) and the tumor was larger than 4.5 cm in 47.7% of the cases in the LAP group. With regard to short-term outcomes, our study demonstrated that the LAP group had fewer complications, faster gastrointestinal recovery, reduced use of analgesic drugs and shorter postoperative hospital stay (each p<0.05). In conclusion, our experience confirms that GISTs are very uncommon cancers for which the prognosis is closely related to size, localization and class of risk. In light of our clinical data, laparoscopic resection for gastric and non-gastric GISTs is a safe, feasible and oncologically correct procedure. The most important advantage of this technique is that it ensures a better postoperative outcome compared with open surgery, without worsening the prognosis.

Surgical oncology during the post-COVID-19 era: What is next?

During first outburst of COVID-19, several strategies had been applied for surgical oncology patients to minimize COVID-19 transmission. COVID-19 infection seemed to compromise survival and major complication rates of surgical oncology patients. However, survival, tumor progression and recurrence rates of surgical oncology patients were associated to the consequences of COVID-19 pandemic on their management. In addition, the severity of COVID-19 infections has been downgraded. Therefore, management of surgical oncology patients should be reconsidered.

Intraoperative Flow Cytometry for the Characterization of Gynecological Malignancies.

Cell-cycle analysis has shown the presence of aneuploidy to be associated with poor prognosis. We developed an innovative rapid cell-cycle analysis protocol (the Ioannina protocol) that permitted the intraoperative identification of neoplastic cells in a plethora of malignancies. Herein, we aimed to investigate the potential role of cell-cycle analysis in the intraoperative characterization of gynecological malignancies. Women who underwent surgery for gynecological malignancies in our institution over a three-year period were included in this study. Permanent section pathology evaluation was used as the gold standard for malignancy evaluation. Total accordance was observed between flow cytometry and pathology evaluation. In total, 21 aneuploid cancers were detected following DNA index calculation. Of these, 20 were hyperploid and 1 was hypoploid. In addition, tumor samples were characterized by a significantly lower percentage of cells in G0/G1, as well as an induced tumor index. The response time for flow cytometry to obtain results was 5-6 min per sample. It seems that flow cytometry analyses for intraoperative tumor evaluation can be safely expanded to gynecological malignancies. This is a novel practical approach that has been proven valuable in several tumor types to date, and also seems to be reliable for gynecological malignancies. Intraoperative flow cytometry is expected to be crucial in decisions of lymph node dissection in endometrial cancers, due to its rapid response regarding the tumor invasion of part or all of the myometrial thickness. In this way, the surgeon can quickly modify the plane of dissection. Our results warrant the further investigation of applying iFC in larger, multicenter studies.

Detection of cancer cells and tumor margins during colorectal cancer surgery by intraoperative flow cytometry.

BACKGROUND: Flow Cytometry is an analytical technique for the precise quantification of cellular phenotype. Intraoperative Flow Cytometry (iFC) utilizes flow cytometry for DNA content/ploidy and cell cycle distribution analysis during surgery for cancer cell characterization and evaluation of tumor margins. Various types of cancers, including intracranial, head and neck, breast and liver malignancies have been evaluated with iFC. In the current study we present an intraoperative Flow Cytometry protocol for colorectal cancer cell detection and potential resection margin evaluation. MATERIALS AND METHODS: This study includes 106 colorectal cancer patients in which samples from cancer and normal colon epithelium were prospectively collected intraoperatively and comparatively assessed with iFC. Patients' demographics, tumor data and cytometry parameters were assessed. RESULTS: We have demonstrated that a cut-off value of 10.5% for tumor-index (fraction of cells in S and G2/M cell cycle phases) predicts with ∼91% accuracy (82.2% sensitivity and 99.9% specificity) the presence of cancer cells. Evaluation of tumor margins by iFC in the subpopulation of rectal cancer patients with or without neoadjuvant therapy, revealed an accuracy of 79% and 88%, respectively. CONCLUSION: Our data support that regarding colorectal cancer, iFC is a useful adjunct method for tumor cell identification and probably margin evaluation, which could be utilized in rectal cancer treatment in the era of organ sparing procedures.

Medical, Endoscopic and Surgical Management of Stricturing Crohn's Disease: Current Clinical Practice.

The development of fibrostenotic intestinal disease occurs in approximately one-third of patients with Crohn's disease and is associated with increased morbidity. Despite introducing new biologic agents, stricturing Crohn's disease remains a significant clinical challenge. Medical treatment is considered the first-line treatment for inflammatory strictures, and anti-TNF agents appear to provide the most considerable benefit among the available medical treatments. However, medical therapy is ineffective on strictures with a mainly fibrotic component, and a high proportion of patients under anti-TNF will require surgery. In fibrotic strictures or cases refractory to medical treatment, an endoscopic or surgical approach should be considered depending on the location, length, and severity of the stricture. Both endoscopic balloon dilatation and endoscopic stricturoplasty are minimally invasive and safe, associated with a small risk of complications. On the other hand, the surgical approach is indicated in patients not suitable for endoscopic therapy. This review aimed to present and analyze the currently available medical, endoscopic, and surgical management of stricturing Crohn's disease.

Transarterial Chemoembolization for Hepatocellular Carcinoma: Why, When, How?

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. It is principally associated with liver cirrhosis and chronic liver disease. The major risk factors for the development of HCC include viral infections (HBV, HCV), alcoholic liver disease (ALD,) and non-alcoholic fatty liver disease (NAFLD). The optimal treatment choice is dictated by multiple variables such as tumor burden, liver function, and patient's health status. Surgical resection, transplantation, ablation, transarterial chemoembolization (TACE), and systemic therapy are potentially useful treatment strategies. TACE is considered the first-line treatment for patients with intermediate stage HCC. The purpose of this review was to assess the indications, the optimal treatment schedule, the technical factors associated with TACE, and the overall application of TACE as a personalized treatment for HCC.

The Role of Curcumin in Cancer Treatment.

Curcumin is a polyphenol extracted from the rhizomes of the turmeric plant, Curcuma longa which has anti-inflammatory, and anticancer properties. Chronic inflammation is associated with the development of cancer. Curcumin acts on the regulation of various immune modulators, including cytokines, cyclooxygenase-2 (COX-2), and reactive oxygen species (ROS), which partly explains its anticancer effects. It also takes part in the downregulation of growth factors, protein kinases, oncogenic molecules and various signaling pathways, such as nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), c-Jun N-terminal kinase (JNK) and signal transducer and activator of transcription 3 (STAT3) signaling. Clinical trials of curcumin have been completed or are ongoing for various types of cancer. This review presents the molecular mechanisms of curcumin in different types of cancer and the evidence from the most recent clinical trials.

Touch Imprint Intraoperative Flow Cytometry as a Complementary Tool for Detailed Assessment of Resection Margins and Tumor Biology in Liver Surgery for Primary and Metastatic Liver Neoplasms.

Liver resection is the main treatment for primary and metastatic liver tumors in order to achieve long-term survival with good quality of life. The ultimate goal of surgical oncology is to achieve complete tumor removal with adequate clear surgical margins. Flow cytometry is a powerful analytical technique with applications such as phenotypic analysis and quantification of DNA content. Intraoperative flow cytometry (iFC) is the application of flow cytometry for DNA content/ploidy and cell cycle distribution analysis during surgery for tumor cell analysis and margin evaluation. It has been used for cell analysis of intracranial tumors and recently of head and neck carcinomas and breast carcinomas, as well as for tumor margin evaluation. Herein, we present a novel touch imprint iFC protocol for the detailed assessment of tumor margins during excision of malignant hepatic lesions. The protocol aims to offer information on surgical margins after removal of malignant liver tumors based on DNA content of cancer cells and to corroborate the results of iFC with that of histopathological analysis. Based on the established role of iFC in other types of malignancies, our specialized protocol has the potential, through characterization of cells in liver transection surface post hepatectomy, to offer significant information on the type of resection and tumor biology. This information can be used to effectively guide intra- and postoperative patient management.

Treatment of Gastric Cancer.

Surgery represents the only method for potentially curative intent for gastric cancer (GC) [...].

Clinical heterogeneity in patients with non-alcoholic fatty liver disease-associated hepatocellular carcinoma.

INTRODUCTION: The indisputable increase in nonalcoholic Fatty Liver Disease (NAFLD) prevalence (25% of population) has consequently led to an increase in Hepatocellular Carcinoma (HCC) and liver-related mortality worldwide. The characteristics of patients with HCC, secondary to NAFLD, are older age, large tumors due to late diagnosis, often without cirrhosis and high prevalence of the metabolic syndrome components, leading to an increased mortality rate. Although the mechanisms of disease remain partially obscure, insulin resistance, oxidative stress, apoptosis, iron overload, and excessive local and systemic inflammation are identified as culprits for hepatocarcinogenesis in the presence of NAFLD. AREA COVERED: In this review, the authors report that there are no uniform guidelines for surveillance and early diagnosis in this patient group. Barcelona Clinic Liver Cancer staging is generally applicable to HCC due to NAFLD and management depends on liver function, tumor characteristics, and cardiovascular comorbidity. Evidence suggests that HCC due to NAFLD can be associated with worse survival due to late diagnosis. EXPERT OPINION: The need for effective early diagnosis and management of NAFLD is urgent, considering the galloping incidence of the obesity and the fact that liver cirrhosis and HCC due to NAFLD will become the first indication for liver transplantation in foreseeable future.

Neoadjuvant chemotherapy for gastric cancer. Has the time to decelerate the enthusiasm passed us by?

Neoadjuvant therapy for locally advanced gastric cancer is a treatment option well recognized in international guidelines. However, neither completed randomized trials nor ongoing studies (will) offer definitive answers about the efficacy of neoadjuvant therapy. With extensive experience confirming the safety and some efficacy for this approach most current studies are focused on identifying the best preoperative treatment regimen. We try to clarify if is really the time to slow down the enthusiasm about neoadjuvant approach.

Sentinel Node Navigation in Gastric Cancer: Where Do We Stand?

BACKGROUND: Early gastric cancer (EGC) is more common nowadays and is related a to low percentage of lymph node metastasis. For this reason, there is enormous interest to implicate minimally invasive approaches. Recently, special efforts have been made towards a potential intraoperative (real-time) lymph node metastasis (LNM) assessment, as nodal disease status could not be identified with precision before or during surgery. In this direction, accurate prediction of the LNM status through sentinel LN mapping has been attempted, as an approach to the intraoperative detection of sentinel lymph nodes (SLNs). A careful literature search was conducted in order to clarify the potential clinical application of SN biopsy in the gastric cancer field. CONCLUSION: The real clinical application of SN biopsy in gastric cancer treatment has been more than challenging due to the "complicated" nature of gastric lymphatic drainage and the high possibility of "skip" metastasis phenomenon. Notably, sophisticated technical aspects, such as the preferred tracer used and the potential "ideal" method to verify the presence of metastases in the resected SLNs, made SN biopsy application in gastric cancer field extremely demanding. Assessing the potential role of SN navigation for gastric cancer treatment in the era of advanced technology, where the minimally invasive surgical approaches are in the top of the scientific interest, it has to be highlighted that SN navigation for gastric cancer is a topic that remains highly controversial, and the need for future clinical trials on this topic is obvious.

Perioperative Use of Anti-TNFa Biological Agents in Open and Laparoscopic Surgery for Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) consists of two disorders: Crohn's disease (CD) and ulcerative colitis (UC). Over the past few decades, a great body of knowledge has accumulated regarding the pathogenesis of IBD, and effective pharmaceutical agents, such as inhibitors of tumor necrosis factor (anti-TNF), have been introduced. Although these agents have dramatically improved the outcome of IBD, up to 70% of patients with CD and 10-30% of those with UC still undergo surgery within 10 years from diagnosis. Because of their young age and high recurrence rates, these patients are appropriate candidates for laparoscopic surgery as an alternative to laparotomy. Recently, considerable attention has been focused on perioperative outcomes of patients who are receiving anti-TNF agents and require surgery. The aim of this narrative review is to discuss the current evidence regarding the impact of perioperative anti-TNF treatment on post-operative complication rates with a special focus on laparoscopic surgery.