A systematic review of minimal length of lroximal margin in gastric adenocarcinoma resection.

For early distal gastric cancers, a proximal margin (PM) > 2-3 cm might probably be sufficient. For advanced tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length. INTRODUCTION: In gastric cancer surgery, microscopic positive margin is a poor prognostic factor whereas complete resection with tumor-free margins remains a challenging issue. European guidelines recommended a macroscopic margin of 5 or even 8 cm for diffuse-type cancers to achieve R0 resection. However, it is unclear if the length of negative proximal margin (PM) could have a prognostic impact on survival. We aimed to perform a systematic review of the literature analyzing PM length and its prognostic impact in gastric adenocarcinoma. MATERIAL AND METHODS: Pubmed and Embase databases were searched for "gastric cancer" or "gastric adenocarcinoma," combined with "proximal margin," between January 1990 and June 2021. English-written studies that specified PM length were included. Survival data, in relation to PM, were extracted. RESULTS: Twelve retrospective studies, with a total number of 10,067 patients, met inclusion criteria and were analyzed. Mean length of proximal margin on the whole population varied from 2.6 to 5.29 cm. Three studies found minimal PM cut-off to improve overall survival in univariate analysis. Concerning recurrence-free survival analysis, only 2 series showed better results with PM > 2 or > 3 cm, using Kaplan-Meier method. Multivariate analysis demonstrated an independent impact of PM on overall survival in 2 studies. CONCLUSION: For early distal gastric cancers, a PM > 2-3 cm might probably be sufficient. For advanced or proximal tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

Strategies for Managing Intraoperative Discovery of Limited Colorectal Peritoneal Metastases.

BACKGROUND: Management of limited synchronous colorectal peritoneal metastases (CRPM) is critical to outcome. Resection of the primary tumor and CRPM can be performed concurrently, followed by hyperthermic intraperitoneal chemotherapy (HIPEC) either immediately, during the same procedure (one-stage), or during a systematic second-stage procedure (two-stage). OBJECTIVE: The aim of this study was to compare these two strategies for morbidity, mortality, and survival. METHODS: All patients presenting with limited (initial Peritoneal Cancer Index [PCI] ≤ 10) synchronous CRPM who had undergone complete cytoreductive surgery plus HIPEC between 2000 and 2016 were selected from a prospectively maintained institutional database. RESULTS: Overall, 74 patients were included-31 in the one-stage group and 43 in the two-stage group. During second-stage surgery, a peritoneal recurrence was diagnosed in 37 (86%) patients, 12 of whom had a PCI > 10 (28%) and 2 of whom had unresectable disease (5%). Among the one-stage group, peritoneal recurrence occurred in 29% of patients after a median delay of 23 months. Overall survival at 1, 3, and 5 years was similar between the two groups, i.e. 96%, 59%, and 51% for the one-stage group, and 98%, 77%, and 61% for the two-stage group. A PCI > 10 at the time of HIPEC, as well as liver metastases, were independent negative prognostic factors. CONCLUSIONS: For incidental limited CRPM diagnosed during primary tumor resection, one-stage curative treatment is preferable, avoiding a supplementary surgical procedure. Given the critical issues associated with completeness of resection, patients should be referred to centers specialized in peritoneal surgery.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent.

BACKGROUND: The mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown. METHODS: From January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51 %) and the median age was 44 years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59 %), strong acids in 36 patients (25 %), and bleach in 23 patients (16 %). Emergency and long-term outcomes were compared according to the nature of the ingested agent. RESULTS: Four patients died (3 %) and 40 patients (28 %) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13 %, p =0.042) and duodenal (9 vs. 0 %, p = 0.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12 %, p = 0.98). No significant differences were recorded between emergency mortality (9 vs. 1 %, p = 0.15), morbidity (33 vs. 33 %, p = 0.92), the need for esophageal reconstruction (25 vs. 20 %, p = 0.88), and functional success rates (76 vs. 84 %, p = 0.31) after acid and alkali ingestion, respectively. CONCLUSION: Bleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

New developments and standard of care in the management of advanced gastric cancer.

Advanced gastric adenocarcinoma is a common disease with a poor prognosis whose treatment has for decades been based on cytotoxic chemotherapy, including platinum salts in first-line, and taxane or irinotecan in second or later line. Recent years have seen the emergence of new drugs that have improved patient survival, such as trastuzumab in first-line for HER2-positive tumors, ramucirumab alone or in combination with paclitaxel in second-line, and trifluridine-tipiracil beyond the second-line treatment. More recently, two monoclonal antibodies have demonstrated their efficacy in combination with oxaliplatin-based first-line chemotherapy, nivolumab (anti-PD1) for PD-L1 CPS ≥5 tumors, and zolbetuximab for tumors overexpressing Claudin 18.2. In addition, regorafenib has been also showed effective in phase 3 trial for heavily pretreated patients. Based on phase 2 studies, trastuzumab-deruxtecan was approved in 2022 by the EMA for HER2-positive pretreated patients. This agent is currently evaluated in phase 3 study (DESTINY-Gastric04 trial), as are several other anti-HER2 (zanidatamab, margetuximab, tucatinib), immune checkpoint inhibitors, or targeted therapies (anti-FGFR2b).

Peritoneal Tumour DNA in Peritoneal Fluid: Emerging Tool for Peritoneal Metastasis Detection.

The prognostic significance of positive peritoneal cytology still varied between cancer types and geographical origin. However, because of the lack of sensitivity of this biomarker, conventional cytology is not routinely performed in every country. Here, we wanted to test a new biomarker, peritoneal tumour DNA, using NGS technique, in order to compare it with the historical one, in patients having peritoneal metastases of gastrointestinal or ovarian cancer.

Peritoneal and extraperitoneal relapse after previous curative treatment of peritoneal metastases from colorectal cancer: What survival can we expect?

INTRODUCTION: Over the last 20 years, complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) dramatically increased the survival of patients with colorectal peritoneal metastases (CRPM). However, despite better knowledge of the disease, around 70% of patients relapse after CRS with HIPEC. This study was designed to analyse the pattern of recurrence and the outcomes of different treatment modalities. METHODS: Patients relapsing after CRS plus HIPEC for CRPM were selected from a prospective database. The impact of iterative curative-intent treatments was analysed using Kaplan-Meier estimates and multivariate Cox regression models. RESULTS: Between April 1993 and December 2014, 190 of 274 (69%) patients previously treated by CRS plus HIPEC developed relapse, as an isolated peritoneal recurrence (31%), isolated distant recurrence (35%), or multisite recurrence (34%). The curative-intent treatment rate was 48% for isolated peritoneal recurrences, 49% for isolated distant recurrences and 22% for multisite recurrences (p = 0.002). From the diagnosis of relapse, 3- and 5-year overall survival were 77% and 46% after curative-intent treatment and 14% and 4.7% after non-curative treatment, with median survival of 59.7 and 18.3 months (log-rank p < 0.0001), respectively. Regression analysis identified the initial extent of CRPM (hazard ratio [HR]: 2.25; p < 0.0001), iterative curative-intent treatment (HR: 0.22; p < 0.0001) and disease-free interval (HR: 1.77; p = 0.01) as independent predictors of prolonged survival. CONCLUSIONS: Iterative curative-intent treatment can be performed in up to 40% of patients with relapse after CRS and HIPEC for CRPM, and is associated with prolonged survival in selected patients.

Ischaemic colitis: indications, extent, and results of standardized emergency surgery.

BACKGROUND: Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management. METHODS: 191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively. RESULTS: Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure. CONCLUSION: An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.