Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

The Charlson age comorbidity index predicts prognosis in patients with resected pancreatic cancer.

BACKGROUND: The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. METHOD: A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI<4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. RESULTS: The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P < 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P < 0.0001). CONCLUSIONS: The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.

Clinical impact of sarcopenia on prognosis in pancreatic ductal adenocarcinoma: A retrospective cohort study.

OBJECTIVES: To investigate the impact of the body composition such as skeletal muscle, visceral fat and body mass index (BMI) on patients with resected pancreatic ductal adenocarcinoma (PDAC). METHODS: A total of 265 patients who underwent curative surgery for PDAC were examined in this study. The total skeletal muscle and fat tissue areas were evaluated in a single image obtained at the third lumber vertebra during a preoperative computed tomography (CT) scan. The patients were assigned to either the sarcopenia or non-sarcopenia group based on their skeletal muscle index (SMI) and classified into high visceral fat area (H-VFA) or low VFA (L-VFA) groups. The association of clinicopathological features and prognosis with the body composition were statistically analyzed. RESULTS: There were 170 patients (64.2%) with sarcopenia. The median survival time (MST) was 23.7 months for sarcopenia patients and 25.8 months for patients without sarcopenia. The MST was 24.4 months for H-VFA patients and 25.8 months for L-VFA patients. However, sarcopenia patients with BMI ≥22 exhibited significantly poorer survival than patients without sarcopenia (MST: 19.2 vs. 35.4 months, P = 0.025). There was a significant difference between patients with and without sarcopenia who did not receive chemotherapy (5-year survival rate: 0% vs. 68.3%, P = 0.003). The multivariate analysis revealed that tumor size, positive dissected peripancreatic tissue margin, and sarcopenia were independent prognostic factors. CONCLUSIONS: Sarcopenia is an independent prognostic factor in PDAC patients with a BMI ≥22. Therefore, evaluating skeletal muscle mass may be a simple and useful approach for predicting patient prognosis.

The significance of relative dose intensity in adjuvant chemotherapy of pancreatic ductal adenocarcinoma-including the analysis of clinicopathological factors influencing relative dose intensity.

Recently, it has been reported that the relative dose intensity (RDI) of adjuvant chemotherapy (AC) influences survival in various cancers, but there are very few reports about RDI in pancreatic ductal adenocarcinoma (PDAC). The optimal timing for initiation of AC for PDAC also remains unknown. The aim of this study was to identify the significance of RDI and the time interval between surgery and initiation of AC on survival of patients with PDAC. Clinicopathological factors that affect RDI were also investigated.A total of 311 consecutive PDAC patients who underwent curative resection between May 2005 and January 2015 were enrolled. Patients who underwent neoadjuvant chemoradiation, had UICC stage IV disease, or had early recurrences within 6 months were excluded, and the remaining 168 cases were analyzed.Patients with RDIs ≥80% (n = 79) showed significantly better overall survival (OS) compared to patients with RDIs <80% (n = 55) (median survival time (MST): 45.6 months, 26.0 months, P < 0.001). Patients with no AC (n = 34) showed the worst OS (MST: 20.8 months). Whether the AC was initiated earlier or later than 8 weeks after surgery did not influence survival, either in patients with RDIs ≥80% (P = 0.79) or in those with <80% (P = 0.73). Patients in the S-1 monotherapy group (n = 49) showed significantly better OS than patients in the gemcitabine monotherapy group (n = 51) (MST: 95.0 months, 26.0 months, respectively; P = 0.001). Univariate analysis conducted after adjusting for the chemotherapeutic drug used identified several prognostic factors; male gender (P = 0.01), intraoperative blood transfusion (P = 0.005), lymph node metastasis (P = 0.03), and postoperative WBC count (P = 0.03). Multivariate analysis identified intra-plus postoperative blood transfusion (P = 0.002) and high postoperative platelet-to-lymphocyte ratios (PLR) (P = 0.04) as independent predictors of poor RDI.Efforts to maintain RDI had a greater impact on survival than the struggle to start AC early after surgery. Intra-plus postoperative blood transfusion and a high postoperative PLR could be predictive markers of reduced RDI in AC of PDAC patients. Avoidance of perioperative blood transfusions where possible and nutritional support during the perioperative period could maintain adequate RDI and may lead to improved long-term outcome.

Adverse impact of low skeletal muscle index on the prognosis of hepatocellular carcinoma after hepatic resection.

BACKGROUND: Skeletal muscle depletion predicts poor prognosis of patients with certain cancers. However, the correlation between low skeletal muscle index (SMI) and the prognosis of hepatocellular carcinoma (HCC) is not well understood. METHODS: To determine their influence on prognosis, skeletal muscle index (SMI) and visceral fat area (VFA) were measured using computed tomography at the level of the third lumbar vertebra of 195 patients who underwent primary hepatectomy for hepatocellular carcinoma (HCC). We defined sarcopenia using cutoff values for SMI as 43.75 cm(2)/m(2) and 41.10 cm(2)/m(2) for males and females, respectively. RESULTS: Sarcopenia was present in 89 of 195 (45.6%) patients and correlated significantly (P < 0.001) with female sex, low body mass index (BMI), low subcutaneous fat area, low VFA, and low serum albumin levels. There was a trend indicating the association of sarcopenia with poor cumulative recurrence rate (CRR) (P = 0.13). In patients with BMI ≥22, CRR was significantly different between patients with or without sarcopenia (19.0 or 35.2 months, respectively, P = 0.03). In contrast, there was no significant difference in patients with BMI ≥22 as a function of VFA (P = 0.47). When the cohort was limited to patients with BMI ≥22, multivariate analysis showed that sarcopenia was a significant independent risk factor for recurrence (hazard ratio = 1.6; 95% confidence interval, 1.1-2.5; P = 0.02). CONCLUSIONS: Low-SMI was an independent adverse prognostic factor for CRR in patients with BMI ≥22. Therefore, preventing muscle wasting may improve the CRR of patients with HCC.

Clinical Implication of Inflammation-Based Prognostic Score in Pancreatic Cancer: Glasgow Prognostic Score Is the Most Reliable Parameter.

A variety of systemic inflammation-based prognostic scores have been explored; however, there has been no study to clarify which score could best reflect survival in resected pancreatic cancer patients.Between 2002 and 2014, 379 consecutive patients who underwent curative resection of pancreatic cancer were enrolled. The Glasgow Prognostic Score (GPS), modified GPS (mGPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic index (PI), and prognostic nutritional index (PNI) scores for each patient were calculated. Survival of each score was evaluated, and correlations between the score selected on the basis of the prognostic significance and various clinicopathological factors were analyzed.In the analysis of the GPS, the median survival time (MST) was 28.1 months for score 0, 25.6 for score 1, and 17.0 for score 2. As for mGPS, the MST was 25.8 months for score 0, 27.7 for score 1, and 17.0 for score 2. Both scores were found to be significant. On the contrary, there were no statistical differences in MST between various scores obtained using the NLR, PLR, PI, or PNI. Multivariate analysis revealed that lymph node metastasis, positive peritoneal washing cytology, and a GPS score of 2 were significant prognostic factors. There was also statistically significant correlation between the GPS score and tumor location (head), tumor size (≥2.0 cm), bile duct invasion, and duodenal invasion.Our study demonstrated that the GPS could be an independent predictive marker and was superior to other inflammation-based prognostic scores in patients with resected pancreatic cancer.

A vascular endothelial growth factor gene polymorphism predicts malignant potential in intraductal papillary mucinous neoplasm.

OBJECTIVES: The aim of this study was to evaluate the clinical relevance of vascular endothelial growth factor (VEGF) single nucleotide polymorphisms (SNPs) in intraductal papillary mucinous neoplasms (IPMNs). METHODS: A total of 169 IPMN and 108 pancreatic ductal adenocarcinoma patients who underwent curative resection were enrolled, and VEGF +405G/C and -460C/T SNPs were investigated. RESULTS: Vascular endothelial growth factor +405C/C was found more frequently in malignant IPMNs compared with +405G/G (odds ratio [OR], 2.7; P = 0.04), and +405C allele was associated with malignant IPMNs compared with +405G (P = 0.055). In branch duct IPMNs, VEGF +405C/C was significantly associated with malignant transformation (CC vs GG: OR, 4.0; P = 0.03; CC vs CG + GG: OR, 3.3; P = 0.04), and there was a trend of VEGF +405C/C associated with malignant transformation of gastric-type IPMNs (CC vs GG: OR, 3.0; P = 0.07). When the survival outcomes were analyzed based on VEGF +405G/C SNPs, however, there was no relationship between VEGF SNPs and overall survival in patients with both IPMNs and pancreatic ductal adenocarcinomas. CONCLUSIONS: Vascular endothelial growth factor +405G/C SNP was significantly associated with malignant transformation in IPMNs, especially branch duct and gastric-type IPMNs. Vascular endothelial growth factor +405G/C SNP might be helpful in predicting clinical course in pancreatic disease with potential for malignant transformation.

Clinical significance of zinc-finger E-box binding homeobox 1 mRNA levels in peritoneal washing for gastric cancer.

Zinc-finger E-box binding homeobox 1 (ZEB1) is an important regulator of epithelial-to-mesenchymal transition and is associated with various types of metastasis. Gastric cancer patients often develop peritoneal carcinomatosis, of which the detection of free cancer cells in the peritoneal washes is an important predictor. We analyzed the correlation of ZEB1 mRNA levels in the peritoneal washing (pZEB1) with clinicopathological variables and survival in 107 gastric cancer patients who underwent surgery and peritoneal washing cytology. Reverse transcription-polymerase chain reaction was performed to quantify pZEB1. The patients were classified into the pZEB1High (n=27) and the pZEB1Low (n=80) groups based on their pZEB1 expression. pZEB1 was statistically correlated with pathological T stage (P=0.03) and vascular involvement (P=0.03). At 5 years, the disease-specific survival was 36.4% for the pZEB1High group and 64.7% for the pZEB1Low group (P=0.02), whereas the disease-free survival rate was 46.9% for the pZEB1High group and 83.0% for the pZEB1Low group (P=0.03). When subclassified into 4 categories based on washing cytology and pZEB1, survival was significantly lower in the pZEB1High compared to the pZEB1Low group (cytology -negative group, P=0.01; cytology -positive group, P=0.13). Therefore, pZEB1 may add valuable information to conventional peritoneal washing cytology as a prognostic determinant in gastric cancer.