Sympathetic nerve blocks for persistent pain in adults with inoperable abdominopelvic cancer.

BACKGROUND: Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition. OBJECTIVES: To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks. SEARCH METHODS: We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo. DATA COLLECTION AND ANALYSIS: We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system. MAIN RESULTS: We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome. AUTHORS' CONCLUSIONS: There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.

Efficacy and Safety of Celiac Plexus Neurolysis Versus Splanchnic Nerve Neurolysis in the Management of Abdominal Cancer Pain: A Meta-analysis of 359 Patients.

BACKGROUND: Splanchnic nerve neurolysis (SNN) is commonly used as an alternative pain control technique to celiac plexus neurolysis (CPN) in patients with distortion of anatomy, but the analgesic effect and relative risks of the 2 procedures remain controversial in general condition. OBJECTIVES: The aim of this study was to evaluate the pain condition, safety, and symptom burden of SNN compared with CPN. STUDY DESIGN: A systematic review and meta-analysis of neurolysis therapy for intractable cancer-related abdominal pain. METHODS: A systematic search was performed for randomized controlled trials comparing SNN and CPN using the PubMed, Medline, Cochrane Library, Web of Science, Google Scholar, and China National Knowledge Infrastructure databases. Meta-analysis was performed using Stata Version 15.0. Outcomes included pain condition, opioid consumption, adverse effects, quality of life (QOL), and survival rate. Standardized mean difference (SMD) was calculated for continuous outcomes with its corresponding 95% CI. LIMITATIONS: Study limitations include challenges to make subgroup analysis by intervention measures and addressing inevitable heterogeneity. Larger studies are needed for survival rates and further insights. RESULTS: Seven studies involving 359 patients were included. No significant difference was found in pain condition at 2 weeks [SMD = 0.75, 95% CI (-0.25, 1.74), P > 0.05], 2 months [SMD = 1.10, 95% CI (-0.21, 2.40), P > 0.05] and 6 months [SMD = 0.53, 95% CI (-0.02, 1.08), P > 0.05] between SNN and CPN. Opioid consumption was comparable at 2 weeks [SMD = 0.57, 95% CI (-1.21, 2.34), P > 0.05] and one month [SMD = 0.37, 95% CI (-1.33, 2.07), P > 0.05]. However, SNN was associated with a statistically significant reduction in the opioid consumption at 2 months postoperatively [SMD = 0.99, 95% CI (0.68, 1.30), P < 0.05]. A systematic review was performed for adverse effects and QOL. CONCLUSIONS: Our evidence supports that the analgesic effect of SNN is equivalent to that of CPN, independent of changes in the anatomical structure of the abdominal nerve plexus. SNN requires less use of opioids at 2 months and does not show greater improvement in pain burden compared to CPN.

Celiac plexus block combined with 125I seeds for refractory epigastric pain from abdominal malignancies: a retrospective case-control study.

PURPOSE: To evaluate the clinical efficacy of celiac plexus block (CPB) combined with 125I seeds implantation (ISI) for refractory epigastric pain from abdominal malignancies. METHODS: The data of 81 patients with refractory epigastric pain [visual analog scale (VAS) score ≥ 4] from abdominal malignancies were collected in this retrospective case-control study. Group A (n = 40) was treated with CPB alone, while Group B (n = 41) underwent CPB combined with ISI. The primary study endpoints were the VAS score, quality of life (QoL), and local tumor control (LTC) rate. The secondary endpoints were complications, progression-free survival (PFS), and overall survival (OS). RESULTS: The VAS scores at week 2 (T2), week 4 (T4), week 8 (T8), and week 12 (T12) in both groups were significantly lower compared with the pretreatment values (all P < 0.01). VAS scores in Group B showed a sustained decrease, especially for "mild pain" and "moderate pain," while the VAS scores in Group A rebounded at T8 and T12 (both P < 0.01). The QoL in Group B improved significantly from T4 until T12, which better than that at T12 in Group A (all P < 0.01). The LTC rates at T8 were 35.0% and 92.7% in Groups A and B, respectively, with a significant difference (P < 0.01). Group B had a slightly lower complication rate and a slightly longer median PFS/OS than group A, but neither was statistically different (P = 0.09 and P = 0.99, respectively). CONCLUSION: CPB combined with ISI performs more sustained pain relief (up to 12 weeks) compared to CPB alone, and ultimately improves the patients' QoL.

[A Case of Intra-Abdominal Testicular Cancer Occurring from an Overlooked Intra-Abdominal Testis in Undescended Testicular Surgery].

Here, we report an adult case of intra-abdominal testicular cancer after surgical treatment of an undescended testis in infancy. A 36-year-old male patient was accidentally diagnosed with a tumor in the pelvic cavity by ultrasonographic examination. He had hematuria and the human chorionic gonadotropin beta subunit level was slightly elevated. T2-weighedmagnetic resonance imaging revealed a well-defined and highly intense mass. Since these findings suggested intra-abdominal testicular cancer, laparoscopic surgery was performed to remove the mass. Laparoscopy revealed an intra-abdominal tumor accompanied by a looping vas deferens entering the left inguinal canal. The distal part of the looping vas had already been removed from the external inguinal ring. The pathological findings revealed a pT1 seminoma. The patient has been recurrence-free for 12 months. The present case implies the importance of careful investigation and treatment for intra-abdominal testicular cancer, since intra-abdominal testis might have been overlooked at the time of surgery for undescended testis.

Risk factors indicating the need for surgical therapy in patients with pyogenic liver abscesses.

BACKGROUND: Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST. METHODS: We reviewed the medical charts of all of our institution's adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed. RESULTS: The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST. CONCLUSIONS: There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD.

Lateralized overgrowth as a guiding sign of abdominal neoplasms for pediatric orthopedic surgeons.

OBJECTIVES: This study aims to increase the awareness of the association between lateralized overgrowth (LO) and abdominal tumor among the pediatric orthopedic community and to evaluate its incidence in our center. PATIENTS AND METHODS: Between January 1997 and December 2021, a total of 166 patients with Wilms tumors and hepatoblastomas were retrospectively analyzed. Data including age, sex, initial clinical signs (hematuria, abdominal mass with or without general discomfort), type of asymmetric regional body overgrowth (isolated or in relation with any syndrome), and tumor stage at diagnosis were recorded. In addition, age at which asymmetric regional body overgrowth was described and age at the time of tumor diagnosis were noted. RESULTS: Of a total of 166 patients, 133 were diagnosed with Wilms tumors (nephroblastomas) and 33 were diagnosed with hepatoblastomas. In 94% of the cases, the initial clinical signs were an abdominal mass and/or hematuria. Overall, five (3%) patients presented with LO. Four patients with Wilms tumor presented it at the initial clinical examinations. In three of these cases (2.3%), we found it isolated and, in the remaining patient (0.75%), it was associated with Beckwith-Wiedemann spectrum. Only one patient affected from hepatoblastoma (3%) presented with an isolated LO at the time of tumor diagnosis. CONCLUSION: Our study results show an incidence of LO in relation to intra-abdominal tumors of 3%. The latest updates recommend genetic testing to identify subgroups with a higher risk for tumor development that are more likely to benefit from tumor protocol surveillance.

Abdominal tumors in patients with neurofibromatosis type I: Genotype-phenotype relationships.

BACKGROUND: Gastrointestinal stromal tumors have been detected in 25% of the necropsies performed on NF1 patients, but have been reported only in 7% of NF1 patients in the largest series. Such data imply an important gap between the true presence of tumors and those diagnosed. Few genotype-phenotype relationships have been described but to date none referring to abdominal tumors. OBJECTIVES: Evaluate retrospectively the efficacy of a regular and proactive follow-up of NF1 patients to early diagnose abdominal tumors and report their mutations. METHODS: Cohort study performed between 2010 and 2020, with 43 NF1 adult patients followed at our Dermatology department. RESULTS: Eight abdominal tumors were diagnosed in six patients, meaning that 14% of the followed patients developed an abdominal tumor. Five patients (83%) were asymptomatic. Five (83.3%) had a family history of NF1 with abdominal tumors (patients 1,2 and 3,4,5 were relatives). CONCLUSIONS: Although currently gastrointestinal routine screening investigations for asymptomatic patients are not recommended in the guidelines, the family aggregation in our series suggests it should be considered a close follow-up of the relatives of a patient with an NF1-related abdominal tumor. Also, for the first time, two mutations [c.2041C > T (p.Arg681Ter) and c.4537C > T (p.Arg1513*)] have been associated with family aggregation of abdominal tumors in NF1 patients.

DYNAMICS OF CHANGES IN 2,3 DIPHOSPHOGLYCERATE AND COGNITIVE DYSFUNCTION IN THE POSTOPERATIVE PERIOD IN PATIENTS WITH ABDOMINAL NEOPLASMS.

The problem of analysis of clinical - diagnostic and biochemical criteria of postoperative cognitive dysfunction in abdominal oncosurgery, depending on the degree and structure of disorders, remains unresolved, which determines its relevance. The role of 2, 3-diphosphoglycerate is essential, because its increase in the concentration of red blood cells in hypoxic conditions is one of the adaptive mechanisms that improve oxygen transport to tissues. Purpose. The influence of the dynamics of 2,3 diphosphoglycerate content, as the main indicator of hypoxia, on the occurrence of cognitive dysfunction in the postoperative period in patients with neoplasms of the abdominal cavity. The study was conducted on the basis of departments for patients of the surgical profile of the municipal institution "Kharkiv City Clinical Hospital of Ambulance and Emergency Care named after Professor OI Meshchaninov ". To achieve this goal, we examined 80 patients with abdominal neoplasms who underwent surgery under general anesthesia using propofol and fentanyl. All patients were divided into 2 groups depending on the age of patients on the WHO scale, who underwent surgery using general anesthesia: Group 1 (n = 39) - middle-aged patients (50-59 years); Group 2 (n = 41) - elderly and senile patients (60-80 years). The control points of the examination were the day before the operation and the 1st, 7th, 30th day from the moment of the operation. The state of cognitive function in these patients was determined by conducting neuropsychological tests. To assess the state of cognitive function of patients, neuropsychological tests were used: MMSE scale (Mini-Mental State Examination, MMSE), the method of memorizing 10 words AR Luria, frontal dysfunction battery (FAB), Schulte technique. To assess the state of energy metabolism in patients, the level of erythrocytes and hemoglobin in the blood analysis was determined by well-known methods, the level of 2,3 diphosphoglycerate in erythrocytes and its ratio to hemoglobin. Anemia in the first week after surgery in patients of group 1 contributes to the development of a hypoxic state, in erythrocytes there is an increase in the content of 2,3 41 diphosphoglycerate, which promotes the transport of oxygen to tissues. During the week there is an increase in the intensity of the formation of 2,3 diphosphoglycerate, as evidenced by the ratio of 2,3 diphosphoglycerate to hemoglobin. In patients of group 2, the changes are more pronounced: anemia with a significant decrease in erythrocytes and hemoglobin in the blood, a decrease in 2.3 diphosphoglycerate in erythrocytes, reflects changes in erythrocyte metabolism, namely a decrease in biosynthesis of important organophosphorus compounds, in particular 2,3 diphosphogly by reducing the basic enzymes of glycolysis. Decreased energy metabolism in the elderly contributes to impaired cell function. With age, the content of adenosine triphosphate, 2,3 diphosphoglycerate decreases, thus increasing the affinity of hemoglobin for oxygen, impaired transport of oxygen to tissues, which leads to the development of hypoxia. According to the results of neuropsychological tests, we found postoperative cognitive dysfunction in patients with neoplasms of the abdominal cavity. Disruption of energy metabolism and changes in the activity of glycolysis enzymes in erythrocytes contributes to a decrease in the concentration of 2, 3 diphosphoglycerate, increase the affinity of hemoglobin for oxygen and the development of tissue hypoxia. The obtained results indicate the interdependence of these processes and allow continuing research in this direction with the development of appropriate clinical and diagnostic measures and areas of intensive care to improve the condition of patients with abdominal tumors and their quality of life after surgery.

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience.

INTRODUCTION: Inferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. METHODS: In this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. RESULTS: Fourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. CONCLUSIONS: IVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

Comparison Between Two Volumes of 70% Alcohol in Single Injection Ultrasound-Guided Celiac Plexus Neurolysis: A Randomized Controlled Trial.

BACKGROUND: Pain due to inoperable upper abdominal malignancies is a challenging condition that needs a multimodal analgesic regimen to be managed properly. Celiac plexus alcohol neurolysis was proved to be effective in relieving such type of pain; however, there is no consistent data about the optimal volume to be used to maintain the balance between the neurolytic effect and the destructive effect of alcohol. OBJECTIVES: We aim to compare the analgesic effect of 2 different volumes of alcohol to improve the outcome of interventional management. STUDY DESIGN: This was a randomized controlled double-blinded interventional clinical trial. SETTING: Single university hospital. METHODS: Thirty-two patients who suffered from abdominal pain due to unresectable abdominal malignancies were randomly allocated to receive in a single injection ultrasound-guided celiac plexus neurolysis (CPN) with injection of either 20 mL 70% alcohol (CPN20 group) or 40 mL 70% alcohol (CPN40 group). The primary outcome was the post-procedure pain score, while the secondary outcomes included the post-procedure total daily opioid consumption and quality of life (QOL). RESULTS: There was no statistically significant difference between both groups regarding visual analog scale (VAS) scores at all time points (P-value > 0.05); however, comparisons in each group revealed significantly reduced VAS scores at all time points following the intervention when compared to the baseline. Daily morphine equivalent consumption doses showed statistically significant differences between the baseline and each time point in both groups (P value < 0.05), with no significant difference between both groups at each time point (P value > 0.05). There was no statistically significant difference between the study groups regarding all domains in quality of life assessment at all time points (P value > 0.05). The scores of most time points in all domains were different significantly when compared to the baseline readings in both groups, with a tendency to decline over time in both groups approaching the baseline values. LIMITATIONS: This was a single-center study with a relatively small sample size. Further prospective, multicenter, randomized, and controlled studies with a larger sample size are required to confirm the effects in this study. CONCLUSIONS: During ultrasound-guided CPN for patients with inoperable upper abdominal cancers who failed medical management, a volume of 20 mL is as effective as 40 mL of 70% alcohol regarding pain control, opioid consumption, quality of life, and procedure-related complications.

PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL).

BACKGROUND: Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients' fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs. METHODS: This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs. DISCUSSION: The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery. TRIAL REGISTRATION: This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry ( ACTRN12621000617864 ) on 24th May 2021.

Intra-abdominal cancer risk with abdominal pain: a prospective cohort primary care study.

BACKGROUND: Quantifying cancer risk in primary care patients with abdominal pain informs diagnostic strategies. AIM: To quantify oesophagogastric, colorectal, liver, pancreatic, ovarian, uterine, kidney, and bladder cancer risks associated with newly reported abdominal pain with or without other symptoms, signs, or abnormal blood tests (that is, features) indicative of possible cancer. DESIGN AND SETTING: This was an observational prospective cohort study using Clinical Practice Research Datalink records with English cancer registry linkage. METHOD: The authors studied 125 793 patients aged ≥40 years with newly reported abdominal pain in primary care between 1 January 2009 and 31 December 2013. The 1-year cumulative incidence of cancer, and the composite 1-year cumulative incidence of cancers with shared additional features, stratified by age and sex are reported. RESULTS: With abdominal pain, overall risk was greater in men and increased with age, reaching 3.4% (95% confidence interval [CI] = 3.0 to 3.7, predominantly colorectal cancer 1.9%, 95% CI = 1.6 to 2.1) in men ≥70 years, compared with their expected incidence of 0.88% (95% CI = 0.87 to 0.89). Additional features increased cancer risk; for example, for men, colorectal or pancreatic cancer risk with abdominal pain plus diarrhoea at 60-69 years of age was 3.1% (95% CI = 1.9 to 4.9) predominantly colorectal cancer (2.2%, 95% CI = 1.2 to 3.8). CONCLUSION: Abdominal pain increases intra-abdominal cancer risk nearly fourfold in men aged ≥70 years, exceeding the 3% threshold warranting investigation. This threshold is surpassed for the >60 years age group only with additional features. These results will help direct appropriate referral and testing strategies for patients based on their demographic profile and reporting features. The authors suggest non-invasive strategies first, such as faecal immunochemical testing, with safety-netting in a shared decision-making framework.

Desnutrição e desfechos clínicos e nutricionais de pacientes oncológicos atendidos em um ambulatório de nutrição: um estudo transversal / Malnutrition and clinical and nutritional outcomes in patients with cancer treated at an outpatient nutrition clinic: a cross-sectional study

Introdução: O câncer causa alterações metabólicas e disfunções imunológicas e nutricionais significativas que podem acarretar desnutrição e síndrome de anorexia-caquexia. O objetivo do presente estudo foi avaliar a associação entre a Avaliação Subjetiva Global produzida pelo paciente e os desfechos clínicos e nutricionais.Métodos: Foi realizado um estudo transversal, com coletas de dados retrospectivos, de pacientes atendidos em Ambulatório de Nutrição e Oncologia de um hospital público no Rio Grande do Sul, entre Janeiro de 2018 a Janeiro de 2020. Foram incluídos adultos com diagnóstico de câncer hematológico ou tumor sólido. Os dados demográficos e clínicos foram coletados a partir de prontuário eletrônico e os dados nutricionais e sintomas coletados através da ficha de anamnese. A relação entre variáveis categóricas foi avaliada pelos testes do qui-quadrado ou exato de Fischer, e de variáveis contínuas através dos testes de Pearson ou correlação de Spearman. O nível de significância utilizado foi de 5%.Resultados: Foram avaliados 260 pacientes, sendo 51,5% do sexo feminino, a maioria de raça branca (84,2%), com idade média de 59 anos. Em relação ao diagnóstico nutricional, observou-se que 41,5% dos pacientes eram bem nutridos, 39,6% apresentavam suspeita de desnutrição ou desnutrição moderada e 18,8% eram desnutridos graves. Observou-se associação significativa entre pacientes com desnutrição (ASGPPP B e/ou C) e os seguintes desfechos: idade, óbito, tipo de câncer, em especial, esôfago, pulmão e cólon, presença de diabetes melito, tipo de tratamento clínico e via alimentar. Também foi observada associação significativa com os sintomas de disfagia, odinofagia, saciedade precoce, alteração do paladar, xerostomia e inapetência quando comparado os pacientes desnutridos com os classificados como bem nutrido.Conclusão: Observou-se associação entre os pacientes com algum grau de desnutrição e diversos sintomas que influenciam negativamente no consumo alimentar. Além disso, foi associada à localização do câncer e seu tratamento.

Introduction: Cancer causes metabolic changes and relevant immune and nutritional disorders, which can lead to malnutrition and anorexia-cachexia syndrome. The aim of the present study was to evaluate the association between the Patient-Generated Subjective Global Assessment and clinical and nutritional outcomes.Methods: This was a cross-sectional, retrospective study of patients treated at the Outpatient Nutrition and Oncology Clinic of a public hospital in Rio Grande do Sul, Brazil, between January 2018 and January 2020. Adults with a diagnosis of hematologic cancer or solid tumor were included. Demographic and clinical data were collected from electronic medical records, and nutritional data and symptoms were collected using a medical history form. The relationship between categorical variables was assessed using the chi-square test or Fischer's exact test, and continuous variables were assessed using Pearson's or Spearman's correlation. The significance level was set at 5%.Results: A total of 260 patients were evaluated, 51.5% of whom were women, mostly white (84.2%), with a mean age of 59 years. In relation to the nutritional diagnosis, 41.5% of patients were well nourished, 39.6% had suspected malnutrition or moderate malnutrition, and 18.8% were severely malnourished. There was a significant association between patients with malnutrition and the following outcomes: age, death, type of cancer (especially esophageal, lung, and colon), presence of diabetes, type of clinical treatment, and diet. Patients with malnutrition were also significantly associated with symptoms of dysphagia, odynophagia, early satiety, altered taste, dry mouth, and lack of appetite.Conclusion: Patients with some degree of malnutrition were associated with several symptoms that negatively affect food consumption, as well as with cancer site and cancer treatment.

A single-centre ten-year retrospective cohort study of malignant small bowel obstruction.

INTRODUCTION: Management of malignant small bowel obstruction (mSBO) is challenging. The decision to perform an operation evaluates the perceived chance of success against a patient's fitness for operation. The aim of this study was to characterise the mSBO patient population in a tertiary UK centre and assess the patient's treatment pathway including use and effects of palliative surgery, total parenteral nutrition (TPN), Gastrografin and dexamethasone as well as preoperative stratification. METHODS: Patients were included if they had mSBO confirmed on computed tomography imaging due to a primary or metastatic neoplasm. Data were collected on pathway and management, and Cox proportional hazard methods were utilised to observe effects on survival. RESULTS: Ninety-four patients were included, with 104 inpatient episodes. Mean age was 67.4 (SD 13.7), with 57 (60.6%) females. Most (89.4%) had only one admission for mSBO. Eighty-four (89.4%) patients died over the ten-year period, 18 (17.3%) within 30 days of admission. Fifty patients (53.1%) underwent operative management: 70% bypass, 24% stoma formation and 6% open-close laparotomies. Log rank testing of survival probability analysis was significant (p = 0.00018), with 50% survival probability at 107.32 days for operative management and 47.87 days for non-operative. DISCUSSION AND CONCLUSION: Operative management forms part of the treatment pathway for a significant proportion of patients with mSBO, offering a survival benefit, though quality of survival is not known. Case selection is good, with few open-close laparotomies. Trials of non-operative interventions such as Gastrografin and dexamethasone are not utilised fully.

Imaging for Staging of Pediatric Abdominal Tumors: An Update, From the AJR Special Series on Cancer Staging.

The three most common pediatric solid tumors of the abdomen are neuroblastoma, Wilms tumor, and hepatoblastoma. These embryonal tumors most commonly present in the first decade of life. Each tumor has unique imaging findings, including locoregional presentation and patterns of distant spread. Neuroblastoma, Wilms tumor, and hepatoblastoma have unique staging systems that rely heavily on imaging and influence surgical and oncologic management. The staging systems include image-defined risk factors for neuroblastoma, the Children's Oncology Group staging system for Wilms tumor, and the pretreatment extent of tumor system (PRETEXT) for hepatoblastoma. It is important for radiologists to be aware of these staging systems to optimize image acquisition and interpretation. This article provides a practical and clinically oriented approach to the role of imaging in the staging of these common embryonal tumors of childhood. The selection among imaging modalities, key findings for determining tumor stage, and the role of imaging in posttreatment response evaluation and surveillance are discussed. Recent updates to the relevant staging systems are highlighted with attention to imaging findings of particular prognostic importance. The information presented will help radiologists tailor the imaging approach to the individual patient and guide optimal oncologic management.

[Treatment of Concomitant Intra-abdominal Malignancy and Abdominal Aortic Aneurysm].

Objective To explore the outcomes in patients who receive the endovascular abdominal aortic aneurysm repair(EVAR)and have concomitant intra-abdominal malignancy.Methods Between January 2014 and December 2019,all the patients who underwent surgery for malignancy and/or EVAR were retrospectively reviewed.Results Twenty-eight abdominal aortic aneurysm(AAA)patients with concomitant intra-abdominal malignancy were included.The patients were treated by two-stage operation and the priority was given for EVAR in 21 patients.There was no perioperative death or major complications.In the follow-up,one patient developed graft thrombosis and one had type Ⅱ endoleak.There was no AAA-associated death.Conclusions It is preferred that EVAR should come first followed by operation for malignancy.Details of treatment strategy still need further investigation.

Treatment of infantile fibrosarcoma associated to an abdominal aortic aneurysm with larotrectinib: a case report.

Infantile fibrosarcoma (IFS) is a rare pediatric tumor which often presents the ETV6-NTRK3 gene fusion. NTRK3 encodes the neurotrophin-3 growth factor receptor tyrosine kinase, a druggable therapeutic target. Selective tropomyosin receptor kinase (TRK) inhibitors, such as larotrectinib, have shown efficacy and safety in the treatment of IFS. We report a case of an abdominal IFS diagnosed in a newborn associated with an aortic aneurysm that was successfully treated with larotrectinib without relevant adverse effects.

Cardiopulmonary Exercise Testing Versus Frailty, Measured by the Clinical Frailty Score, in Predicting Morbidity in Patients Undergoing Major Abdominal Cancer Surgery.

BACKGROUND: The primary outcome of this study is to investigate the association between the cardiopulmonary exercise testing (CPET) variables: anaerobic threshold (AT), peak oxygen uptake (VO2 peak), peak work rate (WR), ventilatory equivalence of CO2 (VE/VCO2) at the anaerobic threshold (AT) with frailty, measured by the clinical frailty scale (CFS) in patients planned to undergo major abdominal cancer surgery. The secondary outcome is to compare the CPET variables (VO2 peak, peak WR, VE/VCO2 at AT) with frailty measured by the CFS in predicting postoperative surgical morbidity in patients following major abdominal cancer surgery. METHODS: This study was a single-centre prospective cohort analysis of consecutive adult patients undergoing CPET and CFS scoring as part of their pre-operative work-up for major abdominal cancer surgery. RESULTS: A total of n = 317 patients underwent CPET and CFS assessment ahead of planned abdominal oncological surgery. Negative correlations were observed between the CPET variables: AT - 0.42 p < 0.01; VO2 peak - 0.53 p < 0.01; peak WR - 0.54 p < 0.01 with CFS scores and a positive correlation between CFS scores and VE/VCO2 0.29 p < 0.01. Only CFS remained statistically significant in a multivariate model OR 2.11 (1.42-3.15) 95% CI associated with Clavien-Dindo (CD) ≥ 1 defined morbidity including the significant univariate variables (VO2 peak, peak WR and CFS scores). No variables were associated with CD ≥ 3 morbidity. CONCLUSIONS: In patients scheduled to have major abdominal cancer surgery there was a weak association between poor performance on CPET and increasing frailty measured by the CFS. The CFS score unlike CPET was associated with all post-operative morbidity, but not major complications alone, in these patients. This suggests that CFS may be used as a less expensive alternative to CPET for predicting any postoperative morbidity in major abdominal cancer surgery.

Assessment of Secondary Sarcomas Among Patients With Cancer of the Abdomen or Pelvis Who Received Combinations of Surgery, Radiation, and Chemotherapy vs Surgery Alone.

Importance: The association of radiation and chemotherapy with the development of secondary sarcoma is known, but the contemporary risk has not been well characterized for patients with cancers of the abdomen and pelvis. Objective: To compare the risk of secondary sarcoma among patients treated with combinations of surgery, radiation, or chemotherapy with patients treated with surgery alone and the general population. Design, Setting, and Participants: This population-based cohort study included 173 580 patients in Ontario, Canada, with nonmetastatic cancer of the prostate, bladder, colon, rectum or anus, cervix, uterus, or testis. Patients were enrolled from January 1, 2002, to January 31, 2017. Data analysis was conducted from March 1, 2019, to January 31, 2020. Exposures: Treatment combinations of radiation, chemotherapy, and surgery. Main Outcome and Measures: Diagnosis of sarcoma based on histologic codes from the Ontario Cancer Registry. Time to sarcoma was compared using a cause-specific proportional hazard model. Results: Of 173 580 patients, most were men (125 080 [72.1%]), and the largest group was aged between 60 and 69 years (58 346 [33.6%]). Most patients had genitourinary cancer (86 235 [51.4%]) or colorectal cancer (69 241 [39.9%]). Overall, 64 301 (37.1%) received surgery alone, 51 220 (29.5%) received radiation alone, 15 624 (9.0%) were treated with radiation and chemotherapy, 15 252 (8.8%) received radiation with surgery, and 11 822 (6.8%) received all 3 treatments. A total of 332 patients (0.2%) had sarcomas develop during a median (interquartile range) follow-up of 5.7 (2.2-8.9) years. The incidence of sarcoma was 0.3% among those who underwent radiation alone (138 of 51 220) and radiation with chemotherapy (40 of 15 624), 0.2% among those who received radiation and surgery (36 of 15 252) and all 3 modalities (25 of 11 822), and 0.1% among those who received surgery with chemotherapy (13 of 14 861) and surgery alone (80 of 64 801). Compared with a reference group of patients who had surgery alone, the greatest risk of sarcoma was found among patients who underwent a combination of radiation and chemotherapy (cause-specific relative hazard [csRH], 4.07; 95% CI, 2.75-6.01; P < .001), followed by patients who had radiation alone (csRH, 2.35; 95% CI, 1.77-3.12; P < .001), radiation with surgery (csRH, 2.33; 95% CI, 1.57-3.46; P < .001), and all 3 modalities (csRH, 2.27; 95% CI, 1.44-3.58; P < .001). In the general population, 7987 events occurred during 46 554 803 person-years (17.2 events per 100 000 person-years). The standardized incidence ratio for sarcoma among patients treated with radiation compared with the general population was 2.41 (95% CI, 1.57-3.69; 41.3 events per 100 000 person-years). The annual number of cases of sarcoma increased from 2009 (15 per 100 000 persons) to 2016 (32 per 100 000 persons), but the annual rate did not change during the study period. Conclusions and Relevance: In this cohort study, patients treated with radiation or chemotherapy for abdominopelvic cancers had an increased rate of sarcoma. Although the absolute rate is low, patients and physicians should be aware of this increased risk of developing sarcoma.

Does a selective surgical approach to malignant bowel obstruction help in palliative care patients?

BACKGROUND: Malignant bowel obstruction (MBO) is a condition secondary to intra-abdominal metastatic spread of advanced-stage tumors. There is no consensus for the treatment approach of MBO. This study aims to present the results of medical treatment and palliative surgery in patients diagnosed with MBO. METHODS: The patients who were treated for advanced-stage tumors between 2010 and 2017 and for whom consultation was requested from the surgical clinic for MBO symptoms were identified. A selective approach together with palliative care for the indication of surgery was instituted. The patients with surgical treatment and medical treatment were compared concerning survival, oral food intake and symptom relief. RESULTS: Seventy-six patients (30 female, 46 male) aged 60.5±12.8 years (range: 27-88) were included in this study. Forty-eight of the patients (64.9%) underwent surgical treatment, while 28 (35.1%) had medical treatment. Although the patients with surgery had longer duration of stay in the hospital (median 16 days vs. 4 days) (p<0.001) and higher complication rates (27.1% vs. 3.5%) compared to medically treated patients; the restoring oral food intake was better (97.9% vs. 78.6%) (p=0.005) and the survival was longer (105 days vs. 43 days). CONCLUSION: This study revealed that surgical treatment resulted in better outcomes for life quality parameters in highly selected patients with malignant bowel obstruction evaluated by multidisciplinary team, including palliative care.