Regional Lymph Node Metastases in Groin Sarcomas: A Diagnostic and Therapeutic Challenge.

INTRODUCTION: The evaluation of lymph nodes and the role of groin dissection for groin sarcomas has been controversial where there have not been previous studies or guidelines published. In this study, we aim to first formulate a clinical approach in the evaluation of regional lymph nodal metastases. Second, we aim to also evaluate the role of regional lymphadenectomy in the setting of pathologically involved regional lymph nodes for groin sarcomas. MATERIALS AND METHODS: In total, 43 consecutive patients with groin sarcomas underwent treatment at the National Cancer Centre Singapore between 2002 and 2015. Univariate comparisons were performed using the log-rank test. A Cox multivariate analysis was performed for disease-specific survival to identify independent prognostic factors. RESULTS: The median disease-free survival was 18 months (range, 1 to 180 mo). The median overall survival (OS) was 28 months (range, 3 to 180 mo). In total, 28 patients underwent a groin dissection. Of the 28 patients who underwent groin dissections, 15 had negative lymph node involvement, 7 had positive lymph node involvement and 6 had lymphovascular invasion.On univariate analysis, grade (P=0.047) and clinical and/or radiological involvement (P=0.039) were significant for regional lymph nodal metastases.The 5-year OS for patients with positive lymph nodes was 31%. CONCLUSIONS: Our study suggests that the evaluation of lymph nodes via groin dissections in groin sarcomas in the Asian population should be based primarily on clinical and radiologic evidence. Regional lymph node dissection seems to confer OS benefit in patients with these high-risk tumors and can improve local control of disease.

The Approach to Solitary Fibrous Tumors: Are Clinicopathological Features and Nomograms Accurate in the Prediction of Prognosis?

INTRODUCTION: Currently, factors such as size, mitotic rate, and degree of necrosis have been shown to influence survival in patients with solitary fibrous tumors (SFTs); however, there remains no consensus regarding the associations between tumor characteristics and the malignant nature of these tumors. The aim of this article was to identify factors that would help in prognosticating SFTs and to validate the MD Anderson Cancer Center (MDACC) SFT nomogram in the largest known series of SFTs treated in an Asian population. METHODS: A retrospective review of all patients with a diagnosis of SFT treated surgically in our institution between 2005 and 2015 was carried out. Basic demographics, clinicopathological, and surgical factors were analyzed for association with clinical outcomes. Factors that predicted for distant recurrence (DR) and poor survival were identified as high-risk features. The MDACC nomogram was validated by assessing the extent of discrimination, quantified using Harrell's concordance index (C-index). RESULTS: Fifty-nine patients were included in analysis. Significant univariate associations for DR were found for mitotic rate ( P = .05) and presence of necrosis ( P = .04). Significant univariate associations for overall survival were found for presence of recurrence ( P = .035), presence of necrosis ( P = .072), and mitotic rate ( P = .033). The C-index associated with the nomogram was 0.75. CONCLUSION: There is a negative association for DR and overall survival, with the mitotic rate and presence of necrosis. We propose that SFTs with these features should be regarded as high risk. The MDACC nomogram generally predicts well for patients in an Asian population.

Surgical Management of Metastatic Colorectal Cancer: A Single-Centre Experience on Oncological Outcomes of Pulmonary Resection vs Cytoreductive Surgery and HIPEC.

PURPOSE: Metastasectomy is accepted as standard of care for selected patients with colorectal pulmonary metastases (CLM); however, the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases (CPM) is not universally accepted. We aim to compare oncological outcomes of patients with CLM and CPM after pulmonary resection and CRS-HIPEC, respectively, by comparing overall survival (OS) and disease-free survival (DFS). METHODS: A retrospective review of 49 CLM patients who underwent pulmonary resection, and 52 CPM patients who underwent CRS-HIPEC in a single institution from January 2003 to March 2015, was performed. RESULTS: The 5-year OS for CLM patients and CPM patients were 59.6 and 40.5%, respectively (p = 0.100), while the 5-year DFS were 24.0 and 14.2%, respectively (p = 0.173). CPM patients had longer median operative time (8.38 vs. 1.75 h, p < 0.001), median hospital stay (13 vs. 5 days, p < 0.001), a higher rate of intensive care unit (ICU) admissions (67.3 vs. 8.2%, p < 0.001), and a higher rate of high-grade complications (17.3 vs. 4.1%, p < 0.001). Multivariate analysis demonstrated that recurrent lung metastasis after metastasectomy was an independent prognostic factor for OS of CLM patients (OR = 0.045, 95%, CL 0.003-0.622, p = 0.021). There were no independent prognostic factors for OS in CPM patients by multivariate analysis. There were no independent prognostic factors for DFS in CLM patients by multivariate analysis, but peritoneal cancer index score, bladder involvement, and higher nodal stage at presentation of the initial malignancy were independent prognostic factors for DFS in CPM patients. CONCLUSIONS: OS and DFS for CPM patients after CRS and HIPEC are comparable to CLM patients after lung resection, although morbidity appears higher. The prognostic factors affecting survival after surgery are different between CPM and CLM patients and must be considered when selecting patients for metastasectomy.

Is the Memorial Sloan Kettering Cancer Centre (MSKCC) sarcoma nomogram useful in an Asian population?

AIM: A nomogram for prediction of 12-year sarcoma-specific survival has been developed based on patients with soft tissue sarcomas treated in Memorial Sloan Kettering Cancer Centre (MSKCC). We aim to evaluate the predictive accuracy of the MSKCC sarcoma nomogram in a cohort of patients treated at an Asian institution. This has not been validated in an Asian population and thus its universal applicability remains unproven. MATERIALS AND METHODS: Between 1990 and 2013, 840 adult patients underwent treatment for primary soft tissue sarcoma (STS) at the National Cancer Centre Singapore. Patients who presented with locally recurrent or metastatic disease were excluded from the analysis. The variables included in the MSKCC nomogram included age at diagnosis, tumor size, histologic grade, histologic subtype, depth and site. A total of 399 patients were left for analysis. The nomogram was validated by assessing its extent of discrimination and level of calibration. RESULTS: All patients had deep tumors. Disease occurred most commonly in the lower extremity (n = 149 [37.3%]), the most common histologic subtype was "Others" (angiosarcoma, ewing's sarcoma, endometrial stromal sarcoma, sarcoma NOS [not otherwise specified] and rhabdomyosarcoma). Sixty-four percent of all patients had high-grade tumors while 36% had low-grade tumors. The median patient age at diagnosis was 54 years (range: 17-88 years). The median follow up time for all patients and surviving patients were 29 (range: 1-174) and 33 (range: 1-157) months, respectively. The observed 5- and 10-year sarcoma-specific survival were 55% and 33%, respectively. The concordance index was 0.71. For level of calibration, the observed correspondence between predicted and actual outcomes suggest that the MSKCC nomogram generally predicts well for patients with higher survival probability, but consistently overpredicts survival for the other groups, in our cohort of patients. CONCLUSION: The MSKCC sarcoma nomogram was found to be accurate in terms of extent of discrimination. In terms of level of calibration, it generally predicts well for patients with higher survival probability, but consistently overpredicts survival for the other groups in our population.

Tumor biology remains the main determinant of prognosis in retroperitoneal sarcomas: a 14-year single-center experience.

AIM: To review our experience in the management of retroperitoneal sarcomas (RPSs) in a single institution, with a predominantly Asian population, and identify associated prognostic factors for overall survival (OS), disease-free survival (DFS) and local recurrence. MATERIALS AND METHODS: All RPSs diagnosed and managed at our center between January 2000 and March 2014 were included. Exclusion criteria included patients whose medical records were untraceable and patients who underwent biopsy but did not undergo resection. The variables studied were age, gender, histological subtype, tumor size, tumor grade, surgical margins, type of presentation of tumor (primary or recurrent) and presence of contiguous organ resection. The primary outcome measured was OS. RESULTS: Eighty-five patients underwent resection of RPS with curative intent. Eight patients underwent adjuvant chemotherapy and 15 patients underwent radiotherapy. The median DFS was 21 months (range: 0-146) and median OS was 45 months (range: 1-233). On univariate analysis, resection margin (P = 0.04), tumor grade (P = 0.011) and type of presentation of tumor (P = 0.007) were found to significantly affect OS. Patients with tumor adherent to contiguous organs had a greater OS as compared to patients with tumor invasive into the contiguous organs (P = 0.02). CONCLUSION: An aggressive surgical approach in primary and recurrent RPS is associated with good OS. Complete resection, with contiguous organ resection if necessary should be performed to achieve microscopically negative surgical margins to allow for long-term survival. However, tumor biology remains the main determinant for OS.

Malignancy arising in a 41-year-old colonic interposition graft.

The colon can be used for esophageal reconstruction after an esophagectomy. The development of a malignancy in the colonic interposition graft is rare, with less than 15 cases reported in the literature. We present a case of a 60-year-old male with high-grade dysplasia of the colonic interposition graft used for reconstruction of the esophagus, which developed 41 years after the esophageal reconstruction. The long-term complication of the development of a malignancy must be considered when using the colon for reconstruction especially when the esophageal reconstruction is performed for a benign cause.

Metachronous cholangiocarcinoma 13 years post resection of choledochal cyst-is long-term follow-up useful?: a case study and review of the literature.

BACKGROUND: Patients with congenital choledochal cyst are at risk of the development of hepatobiliary malignancy, with recommended treatment of choledochal cyst being surgical excision. The development of cholangiocarcinoma more than 10 years after excision of choledochal cysts is rare, with less than 21 cases reported in the literature from 1972 to 2014. This is the first reported case of metachronous recurrence after a previously excised adenocarcinoma within a choledochal cyst. CASE PRESENTATION: Herein, we review the case of a patient with cholangiocarcinoma arising 13 years post excision of a Todani type 1 choledochal cyst and discuss the theories of carcinogenesis and long-term management of patients with choledochal cysts. The long-term development of a malignancy must be considered in these patients. CONCLUSIONS: Reviewing all published cases to date, regular follow-up post resection did not improve on the resectability and long-term survival of these patients. Patients presenting with symptoms did not prejudice against resectability. Despite curative resection, median survival was dismal. Optimal long-term follow-up strategies for these patients remain to be elucidated.

Surgery for the palliation of intestinal perforation from secondary metastases in advanced malignancies.

AIM: This study aims to review patient and disease factors that predict survival after palliative surgery for intestinal perforation from metastases in advanced malignancies, with a goal to help decision-making in this clinical scenario. Secondary aims include validation of the UC Davis Cancer Centre nomogram to predict risk of 30-day morbidity and mortality for patients with disseminated malignancy undergoing surgical intervention. METHODS: The following factors were examined: age, preoperative albumin, total white blood cell count, creatinine, site of metastases, presence of ascites, presence of sepsis, steroid use, presence of dyspnea, presence of significant weight loss, preoperative chemotherapy, preoperative radiotherapy, type of operative procedure performed, Eastern Cooperative Oncology Group (ECOG) status, length of surgery, duration of inhospitalization and mortality. For univariate analysis, independent t-test and Fisher's exact test were used to analyze the association of continuous and categorical variables, respectively. For multivariate analysis, logistic regression using likelihood ratios was used. The nomogram was validated by assessing its extent of discrimination (c-index). RESULTS: Twenty palliative operations for intestinal perforation were performed during this period. On univariate analysis, presence of dyspnea, decreased preoperative levels of albumin and high ECOG status were significant predictors of increased mortality. On multivariate analysis, high ECOG status and decreased preoperative albumin were statistically significant. The concordance index in our data set was 0.64. CONCLUSION: Preoperative levels of albumin (>20 g/L) and low ECOG status (≤1) were independently associated with favorable postoperative outcomes. In patients with favorable prognostic factors such as absence of dyspnea, high preoperative levels of albumin and low ECOG status, surgical management should be considered. Conversely, in patients with unfavorable prognostic factors, medical management should be considered to avoid unnecessary surgery.

Role of pelvic exenteration in the management of locally advanced primary and recurrent rectal cancer.

AIM: A review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed. MATERIALS & METHODS: Patients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan-Meier Method (Fig. 1). RESULTS: Pelvic exenterations were performed in 13 patients with a median age of 59 (range 26-81). The rate of major post-operative complications was 8% (n = 1), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70%). The DFS was 19.4 and the OS was 22.5 months. CONCLUSION: An aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.

A case of portomesenteric venous gas found with extensive secondary pneumatosis intestinalis in the small bowel, stomach and distal oesophagus on radiographic images with an insidious presentation.

Portomesenteric gas together with pneumatosis intestinalis is a rare radiological finding and is usually associated with bowel ischaemia, extensive bowel necrosis and a high mortality rate. We report a case of portomesenteric venous gas found with extensive secondary pneumatosis intestinalis in the small bowel, stomach and distal oesophagus on radiographic images with an insidious presentation. Here we review the case and discuss the pathophysiology, diagnosis and management of portomesenteric gas associated with bowel ischaemia.

Surgical management of colorectal peritoneal metastases: treatment and outcomes compared with hepatic metastases.

PURPOSE: The liver and peritoneum are common sites of colorectal metastases. Hepatectomy for colorectal liver metastases (CLM) is considered gold standard treatment. We attempt to compare the survival outcomes for CLM patients after hepatectomy to that of patients with colorectal peritoneal metastases (CPM) who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: A retrospective review of patients with CPM and CLM who underwent surgery between January 2003 and May 2011 was performed. The overall (OS) and disease-free survivals (DFS) were compared. RESULTS: There were 22 patients with CPM who underwent CRS and HIPEC and 186 patients who underwent hepatectomy for CLM. Patients with CPM had a 3-year OS of 39 % and DFS of 27.7 %. CLM patients showed a 3-year OS of 58.5 % and a DFS of 28.8 %. Most recurrences for CPM occurred within 2 years, while CLM patients continue to develop systemic recurrences over 3 years, showing a gradual decline in DFS and OS during this period of time. CONCLUSION: Our results show that CRS and HIPEC for CPM confer good OS and DFS rates and that the DFS after CRS and HIPEC is comparable to that after hepatectomy for CLM.