The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS).

OBJECTIVE: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery. SUMMARY BACKGROUND DATA: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update. METHODS: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee. RESULTS: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee. CONCLUSIONS: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies.

Patterns of disease relapse and posttreatment follow-up of patients with resected pancreatic adenocarcinoma: A single-center analysis.

BACKGROUND AND OBJECTIVES: To describe the patterns of disease relapse and follow-up of patients with resected pancreatic adenocarcinoma. Additionally, we looked at patients' characteristics at relapse and survival. METHODS: We included patients with potentially resectable pancreatic adenocarcinoma diagnosed from 2008 to 2018 who were submitted to resection with clear macroscopic margins and started posttreatment surveillance. RESULTS: The study population consists of 73 patients. The median interval between imaging studies was 3.2 months during the first 2 years of follow-up and 5.1 months thereafter. Forty-eight patients (65.8%) experienced disease relapse. The most frequent single site of relapse was locoregional (N = 21; 43.8%). At relapse, 31 patients (64.6%) were symptomatic and forty-two patients (87.6%) had Eastern Cooperative Oncology Group performance status 0 or 1. Most patients were able to undergo additional anticancer therapy (N = 41; 85.4%). Patients with asymptomatic relapses experienced longer median postrelapse survival (25.4 vs. 11.3 months; p = 0.015). CONCLUSIONS: A follow-up protocol that included imaging studies every 3 months in the first 2 years and every 6 months thereafter is able to diagnose disease relapse when patients have adequate performance status and are still able to undergo additional anticancer treatment.

Cancer risk-reducing surgery: Brazilian Society of Surgical Oncology Guideline Part 2 (Gastrointestinal and thyroid).

BACKGROUND: Risk-reducing operations are an important part of the management of hereditary predisposition to cancer. In selected cases, they can considerably reduce the morbidity and mortality associated with cancer in this population. OBJECTIVES: The Brazilian Society of Surgical Oncology (BSSO) developed this guideline to establish national benchmarks for cancer risk-reducing operations. METHODS: The guideline was prepared from May to December 2021 by a multidisciplinary team of experts to discuss the surgical management of cancer predisposition syndromes. Eleven questions were defined and assigned to expert groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments, classified the level of evidence, and voted on the recommendations. RESULTS: For all questions including risk-reducing colectomy, gastrectomy, and thyroidectomy, a major agreement was achieved by the participants, always using accessible alternatives. CONCLUSION: This and its accompanying article represent the first guideline in cancer risk reduction surgery developed by the BSSO and it should serve as an important reference for the management of families with cancer predisposition.

Surgery or active surveillance for pNETs < 2 cm: Preliminary results from a single center Brazilian cohort.

BACKGROUND AND OBJECTIVES: Incidence of pancreatic neuroendocrine tumors (pNETS) seems to be rising over the years, with many cases incidentally diagnosed. Surgery and active surveillance are current treatment modalities for small pNETS. We review our institutional series and compare outcomes for small asymptomatic and nonfunctioning tumors. METHODS: This retrospective cohort study included patients with 2 cm or less and well differentiated pNETS at a single Brazilian Cancer Center. From 2002 to 2020, patients received active surveillance or surgery as a treatment strategy. Short and long-term results were compared. RESULTS: Sixty-four patients were included, 41 in surgical strategy and 23 in the active surveillance approach. Baseline group characteristics were comparable. More patients on active surveillance underwent abdominal magnetic resonance imaging (MRI) and had tumors located in the pancreatic head (41% vs. 17%, p = 0.038). Minimally invasive procedure was chosen in 80.1% of the surgical patients. No patient died after surgery. Median follow-up period was 38.6 and 46.4 months for active surveillance and surgery cohorts, respectively. No difference in disease progression rate was observed. CONCLUSION: Both approaches seem to be safe for small pNETs. Long-term outcome and quality of life should be considered when discussing such options with patients.

Consumption of processed and ultra-processed foods by patients with stomach adenocarcinoma: a multicentric case-control study in the Amazon and southeast regions of Brazil.

PURPOSE: There is limited information about the dietary habits associated with stomach adenocarcinoma in the Brazilian population, so our purpose is to analyze the consumption of processed and ultra-processed foods by patients with stomach adenocarcinoma in Brazil. METHODS: A multicentric hospital-based case-control study was conducted in São Paulo (southeastern region) and Belém (Amazon region) of Brazil with 1,045 individuals, both sexes, between 18 and 75 years old. In São Paulo, there were 214 cases with stomach adenocarcinoma and 150 controls patients submitted to stomach endoscopy named as Group I (without any pre-malignant gastric disease) and the Healthy Controls (Group 2) comprised 401 individuals matched by age and sex from the prevention unit at A.C .Camargo Cancer Center. In Belém, it has two groups one are cases 140 and second 140 hospital controls, recruited in outpatient clinics. Lifestyle and food frequency questionnaires (FFQ) were administered in cases and controls in both places. Univariate and multivariable binomial logistic regression analyses were performed. RESULTS: In São Paulo, cases reported two times greater consumption of processed meat (adjusted OR 2.56, 95% CI 1.32-4.96) and of sweets (≥ 80 g/day) than Group 1 (endoscopic controls) (adjusted OR 2.25, 95% CI 1.21-4.18). Compared with Group 2, processed food consumption (≥ 44 g/day) as well as ≥ 44 g/day of salted bread increased the odds of having stomach adenocarcinoma (adjusted OR 2.96, 95% CI 1.82-4.81 and adjusted OR 2.03, 95% CI 1.30-3.18), respectively. In Belém, individuals who reported consuming ≥ 166 g/day of fried and roasted meat and fish were more likely to have stomach adenocarcinoma (adjusted OR 2.21, 95% CI 1.13-4.30). CONCLUSIONS: In both cities, consumption of processed and ultra-processed foods, especially salted bread, yellow cheese, fried and roasted meats, fish fried, processed meat, and sweets, was independently associated with the chance of having stomach adenocarcinoma.

Evaluation of Bacteria and Fungi DNA Abundance in Human Tissues.

Whereas targeted and shotgun sequencing approaches are both powerful in allowing the study of tissue-associated microbiota, the human: microorganism abundance ratios in tissues of interest will ultimately determine the most suitable sequencing approach. In addition, it is possible that the knowledge of the relative abundance of bacteria and fungi during a treatment course or in pathological conditions can be relevant in many medical conditions. Here, we present a qPCR-targeted approach to determine the absolute and relative amounts of bacteria and fungi and demonstrate their relative DNA abundance in nine different human tissue types for a total of 87 samples. In these tissues, fungi genomes are more abundant in stool and skin samples but have much lower levels in other tissues. Bacteria genomes prevail in stool, skin, oral swabs, saliva, and gastric fluids. These findings were confirmed by shotgun sequencing for stool and gastric fluids. This approach may contribute to a more comprehensive view of the human microbiota in targeted studies for assessing the abundance levels of microorganisms during disease treatment/progression and to indicate the most informative methods for studying microbial composition (shotgun versus targeted sequencing) for various samples types.

Symptomatic Recurrence and Survival Outcomes After Curative Treatment of Gastric Cancer: Does Intensive Follow-up Evaluation Improve Survival?

BACKGROUND: Intensive surveillance after treatment of gastric cancer patients with curative intent may lead to an earlier diagnosis of disease recurrence, but its impact on survival is uncertain. This study aimed to evaluate whether early diagnosis of disease recurrence among asymptomatic patients was associated with long-term survival. METHODS: This retrospective study analyzed patients with stages 1 to 3C gastric adenocarcinoma treated between 1999 and 2018. All recurrence events were classified as symptomatic or asymptomatic (detected by follow-up tests), and their clinicopathologic characteristics, patterns of recurrence, and survival were analyzed. RESULTS: The cohort consisted of 669 patients treated with a total gastrectomy in 48.6% and a D2-lymphadenectomy in 88.8% of the cases. Most of the tumors were pT3-4 (46.5%), with 45.5% involving lymph node metastases and 42.3% manifesting a diffuse histology. During a median follow-up period of 80.1 months (95% confidence interval [CI], 75.3-84.8 months), 166 patients had recurrences (24.8%), 65.7% of which were symptomatic. The peritoneum was the main site of recurrence (37.2%), and peritoneal recurrence was associated with worse overall survival (OS) (hazard ratio, 1.69; 95%CI, 1.2-2.37). The median disease-free, post-recurrence survival, and OS periods in the asymptomatic and symptomatic groups were respectively 13.4 versus 17.2 months (p = 0.04), 11.9 versus 4.7 months (p < 0.001), and 29.9 versus 26.4 months (p = 0.21). When OS was analyzed among the patients with non-peritoneal recurrence, no difference was observed between the two groups (31.3 vs 31.1 months; p = 0.46). CONCLUSION: Early diagnosis of asymptomatic disease recurrence did not affect the OS of the gastric cancer patients treated with curative intent. The use of intensive surveillance strategies in this scenario still requires further evidence.

Brazilian Group of Gastrointestinal Tumours' consensus guidelines for the management of oesophageal cancer.

Oesophageal cancer is among the ten most common types of cancer worldwide. More than 80% of the cases and deaths related to the disease occur in developing countries. Local socio-economic, epidemiologic and healthcare particularities led us to create a Brazilian guideline for the management of oesophageal and oesophagogastric junction (OGJ) carcinomas. The Brazilian Group of Gastrointestinal Tumours invited 50 physicians with different backgrounds, including radiology, pathology, endoscopy, nuclear medicine, genetics, oncological surgery, radiotherapy and clinical oncology, to collaborate. This document was prepared based on an extensive review of topics related to heredity, diagnosis, staging, pathology, endoscopy, surgery, radiation, systemic therapy (including checkpoint inhibitors) and follow-up, which was followed by presentation, discussion and voting by the panel members. It provides updated evidence-based recommendations to guide clinical management of oesophageal and OGJ carcinomas in several scenarios and clinical settings.

Early postoperative outcomes among patients with delayed surgeries after preoperative positive test for SARS-CoV-2: A case-control study from a single institution.

BACKGROUND: There are limited data on surgical complications for patients that have delayed surgery after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to analyze the surgical outcomes of patients submitted to surgery after recovery from SARS-CoV-2 infection. METHODS: Asymptomatic patients that had surgery delayed after preoperative reverse-transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 were matched in a 1:2 ratio for age, type of surgery and American Society of Anesthesiologists to patients with negative RT-PCR for SARS-CoV-2. RESULTS: About 1253 patients underwent surgical procedures and were subjected to screening for SARS-CoV-2. Forty-nine cases with a delayed surgery were included in the coronavirus disease (COVID) recovery (COVID-rec) group and were matched to 98 patients included in the COVID negative (COVID-neg) group. Overall, 22 (15%) patients had 30-days postoperative complications, but there was no statistically difference between groups -16.3% for COVID-rec and 14.3% for COVID-neg, respectively (odds ratio [OR] 1.17:95% confidence interval [CI] 0.45-3.0; p = .74). Moreover, we did not find difference regarding grades more than or equal to 3 complication rates - 8.2% for COVID-rec and 6.1% for COVID-neg (OR 1.36:95%CI 0.36-5.0; p = .64). There were no pulmonary complications or SARS-CoV-2 related infection and no deaths within the 30-days after surgery. CONCLUSIONS: Our study suggests that patients with delayed elective surgeries due to asymptomatic preoperative positive SARS-CoV-2 test are not at higher risk of postoperative complications.

Brazilian Group of Gastrointestinal Tumours' consensus guidelines for the management of gastric cancer.

Gastric cancer is among the ten most common types of cancer worldwide. Most cases and deaths related to the disease occur in developing countries. Local socio-economic, epidemiologic and healthcare particularities led us to create a Brazilian guideline for the management of gastric carcinomas. The Brazilian Group of Gastrointestinal Tumors (GTG) invited 50 physicians with different backgrounds, including radiology, pathology, endoscopy, nuclear medicine, genetics, oncological surgery, radiotherapy and clinical oncology, to collaborate. This document was prepared based on an extensive review of topics related to heredity, diagnosis, staging, pathology, endoscopy, surgery, radiation, systemic therapy and follow-up, which was followed by presentation, discussion, and voting by the panel members. It provides updated evidence-based recommendations to guide clinical management of gastric carcinomas in several scenarios and clinical settings.

Surgical cancer care in the COVID-19 era: front line views and consensus.

OBJECTIVE: to suggest a script for surgical oncology assistance in COVID-19 pandemic in Brazil. METHOD: a narrative review and a "brainstorming" consensus were carried out after discussion with more than 350 Brazilian specialists and renowned surgeons from Portugal, France, Italy and United States of America. RESULTS: consensus on testing for COVID-19: 1- All patients to be operated should be tested between 24 and 48 before the procedure; 2- The team that has contact with sick or symptomatic patients should be tested; 3 - Chest tomography was suggested to investigate pulmonary changes. Consensus on protection of care teams: 1 - Use of surgical masks inside the hospitals. Use of N95 masks for all professionals in the operating room; 2 - Selection of cases for minimally invasive surgery and maximum pneumoperitoneal aspiration before removal of the surgical specimen; 2 - Optimization of the number of people in teams, with a minimum number of professionals, reducing their occupational exposure, the consumption of protective equipment and the circulation of people in the hospital environment; 3 - Isolation of contaminated patients. Priority consensus: 1- Construction of service priorities; 2 - Interdisciplinary discussion on minimally invasive or conventional pathways. CONCLUSION: the Brazilian Society of Surgical Oncology (BSSO) suggests a script for coping with oncological treatment, remembering that the impoundment in the assistance of these cases, can configure a new wave of overload in health systems.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort.

BACKGROUND: Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments. METHODS: We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012. RESULTS: To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive. CONCLUSIONS: Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection.

OBJECTIVE: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Short-term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center.

INTRODUCTION: Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes. MATERIALS AND METHODS: Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database. RESULTS: Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34-81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications. CONCLUSION: Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision-making process for extended resections.

Safe implementation of minimally invasive pancreas resection: a systematic review.

BACKGROUND: Minimally invasive pancreas resection (MIPR) has been expanding in the past decade. Excellent outcomes have been reported, however, safety concerns exist. The aim of this study was to define prerequisites for performing MIPR with the objective to guide safe implementation of MIPR into clinical practice. METHODS: This systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). PubMed, Embase and Cochrane databases were searched for literature concerning the implementation of MIPR between 1946 and November 2018. Quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). RESULTS: Overall, 1150 studies were screened, of which 32 studies with 8519 patients were included in this systematic review. Training programs for minimally invasive distal pancreatectomy, laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy have been described with acceptable outcomes during the learning curve and improved outcomes after training. Learning curve studies have revealed an association between growing experience and improving perioperative outcomes. In addition, the association between higher center volume and lower mortality and morbidity has been reported by several studies. CONCLUSION: When embarking on MIPR, it is recommended to participate in a dedicated training program, to assure a sufficient volume, especially when implementing minimally invasive pancreatoduodenectomy, (20 procedures recommended annually), and prospectively collect and closely monitor outcomes for continuous quality assessment, this can be achieved through institutional databases and participation in national or international registries.

Surgical cancer care in the COVID-19 era: front line views and consensus / A assistência cirúrgica oncológica na era COVID-19: opiniões e consenso do campo de batalha

ABSTRACT Objective: to suggest a script for surgical oncology assistance in COVID-19 pandemic in Brazil. Method: a narrative review and a "brainstorming" consensus were carried out after discussion with more than 350 Brazilian specialists and renowned surgeons from Portugal, France, Italy and United States of America. Results: consensus on testing for COVID-19: 1- All patients to be operated should be tested between 24 and 48 before the procedure; 2- The team that has contact with sick or symptomatic patients should be tested; 3 - Chest tomography was suggested to investigate pulmonary changes. Consensus on protection of care teams: 1 - Use of surgical masks inside the hospitals. Use of N95 masks for all professionals in the operating room; 2 - Selection of cases for minimally invasive surgery and maximum pneumoperitoneal aspiration before removal of the surgical specimen; 2 - Optimization of the number of people in teams, with a minimum number of professionals, reducing their occupational exposure, the consumption of protective equipment and the circulation of people in the hospital environment; 3 - Isolation of contaminated patients. Priority consensus: 1- Construction of service priorities; 2 - Interdisciplinary discussion on minimally invasive or conventional pathways. Conclusion: the Brazilian Society of Surgical Oncology (BSSO) suggests a script for coping with oncological treatment, remembering that the impoundment in the assistance of these cases, can configure a new wave of overload in health systems.

RESUMO Objetivo: sugerir roteiro de assistência oncológica cirúrgica em meio à pandemia COVID-19 no Brasil. Método: foi realizada revisão narrativa da literatura e consenso tipo "brainstorming" após discussão com mais de 350 especialistas brasileiros e cirurgiões renomados de Portugal, França, Itália e Estados Unidos da América. Resultados: consenso sobre testagem para COVID-19: 1-Todos os pacientes a serem operados devem ser testados entre 24 e 48 antes do procedimento; 2-Equipe que tenha contato com doentes ou sintomáticos deve ser testada; 3-Tomografia de tórax foi sugerida para pesquisa de alterações pulmonares. Consenso sobre proteção das equipes de assistência: 1-Uso de máscaras cirúrgicas dentro de hospitais. Uso de máscaras N95 para todos os profissionais na sala cirúrgica; 2-Seleção dos casos para cirurgia minimamente invasiva e aspiração máxima do pneumoperitônio antes da retirada da peça cirúrgica; 2-Otimização das equipes, com número mínimo de profissionais, reduzindo a exposição ocupacional, o consumo de equipamento de proteção e a circulação de pessoas no ambiente hospitalar; 3 -Isolamento de pacientes contaminados. Consenso sobre priorizações: 1-Construção de prioridades de atendimento; 2- Discussão interdisciplinar sobre via minimamente invasiva ou convencional. Conclusão: a Sociedade Brasileira de Cirurgia Oncológica (SBCO) sugere roteiro de enfrentamento para o tratamento oncológico, lembrando que o represamento na assistência desses casos, pode configurar uma nova onda de sobrecarga em sistemas de saúde.

Predicting overall and major postoperative morbidity in gastric cancer patients.

BACKGROUND: Postoperative complications after gastric cancer resection vary in different series and they might have a significant impact in long-term outcomes. Our aim was to build a prediction rule on gastric cancer patients' overall and major morbidity risks. METHODS: This retrospective study included 1223 patients from a single center who were resected between 1992 and 2016. Overall and major morbidity predictors were identified through multiple logistic regression. Models' performances were assessed through discrimination, calibration, and cross-validation, and nomograms were constructed. RESULTS: The mean age was 61.3-year old and the male gender was more frequent (60%). The most common comorbidities were hypertension (HTN), diabetes, and chronic obstructive pulmonary disease (COPD). A D2-distal gastrectomy was the most frequent procedure and 87% of all lesions were located in the middle or distal third. Age, COPD, coronary heart disease, chronic liver disease, pancreatic resection, and operative time were independent predictors of overall and major morbidity. The extent of resection and splenectomy was associated with overall events and HTN with major ones. Both models were very effective in predicting events among patients at higher risk. CONCLUSIONS: The overall and major morbidity models and nomograms included clinical- and surgical-related data that were very effective in predicting events, especially for high-risk patients.

The Potential Clinical Implications of Circulating Tumor Cells and Circulating Tumor Microemboli in Gastric Cancer.

BACKGROUND: Gastric adenocarcinoma (GAC) is the third deadliest malignant neoplasm worldwide, mostly because of late disease diagnosis, low chemotherapy response rates, and an overall lack of tumor biology understanding. Therefore, tools for prognosis and prediction of treatment response are needed. Quantification of circulating tumor cells (CTCs) and circulating tumor microemboli (CTM) and their expression of biomarkers has potential clinical relevance. Our aim was to evaluate CTCs and CTM and their expression of HER2 and plakoglobin in patients with nonmetastatic GAC, correlating the findings to clinicopathological data. MATERIALS AND METHODS: CTC enrichment was performed with isolation by size of epithelial tumor cells, and the analysis was performed with immunocytochemistry and microscopy. Two collections were made: one at diagnosis (55 samples before neoadjuvant treatment) and one after surgery and before adjuvant therapy (33 samples). RESULTS: A high detection rate of CTCs (90%) was observed at baseline. We evaluated HER2 expression in 45/55 biopsy samples and in 42/55 CTC samples, with an overlap of 36 subjects. Besides the good agreement observed for HER2 expression in primary tumors and paired CTCs for 36 cases (69.4%; κ = 0.272), the analysis of HER2 in CTCs showed higher positivity (43%) compared with primary tumors (11%); 3/5 patients with disease progression had HER2-negative primary tumors but HER2-positive CTCs. A significant CTC count drop in follow-up was seen for CTC-HER2-positive cases (4.45 to 1.0 CTCs per mL) compared with CTC-HER2-negative cases (2.6 to 1.0 CTCs per mL). The same was observed for CTC-plakoglobin-positive cases (2.9 to 1.25 CTCs per mL). CONCLUSION: CTC analysis, including their levels, plakoglobin, and HER2 expression, appears to be a promising tool in the understanding the biology and prognosis of GAC. IMPLICATIONS FOR PRACTICE: The analysis of circulating tumor cell levels from the blood of patients with gastric adenocarcinoma, before and after neoadjuvant treatment, is useful to better understand the behavior of the disease as well as the patients more likely to respond to treatment.

Identification of DNA mutations in gastric washes from gastric adenocarcinoma patients: Possible implications for liquid biopsies and patient follow-up.

Whereas cancer patients have benefited from liquid biopsies, the scenario for gastric adenocarcinoma (GAC) is still dismal. We used next-generation deep sequencing of TP53-a highly mutated and informative gene in GAC-to assess mutations in tumor biopsies, plasma (PL) and stomach fluids (gastric wash-GW). We evaluated their potential to reveal tumor-derived mutations, useful for monitoring mutational dynamics at diagnosis, progression and treatment. Exon-capture libraries were constructed from 46 patients including tumor biopsies, GW and PL pre and post-treatment (196 samples), with high vertical coverage >8,000×. At diagnosis, we detected TP53 mutations in 15/46 biopsies (32.6%), 7/46 GW- (15.2%) and 6/46 PL-samples (13%). Biopsies and GW were concordant in 38/46 cases (82.6%) for the presence/absence of mutations and, furthermore, four GW-exclusive mutations were identified, suggesting tumor heterogeneity. Considering the combined analysis of GW and PL, TP53 mutations found in biopsies were also identified in 9/15 (60%) of cases, the highest detection level reported for GAC. Our study indicates that GW could be useful to track DNA alterations, especially if anchored to a comprehensive gene-panel designed for this malignancy.

Genomics and epidemiology for gastric adenocarcinomas (GE4GAC): a Brazilian initiative to study gastric cancer

Gastric cancer (GC) is the fifth most common type of cancer worldwide with high incidences in Asia, Central, and South American countries. This patchy distribution means that GC studies are neglected by large research centers from developed countries. The need for further understanding of this complex disease, including the local importance of epidemiological factors and the rich ancestral admixture found in Brazil, stimulated the implementation of the GE4GAC project. GE4GAC aims to embrace epidemiological, clinical, molecular and microbiological data from Brazilian controls and patients with malignant and pre-malignant gastric disease. In this letter, we summarize the main goals of the project, including subject and sample accrual and current findings