Survival outcomes of patients with pathological stage I gastric cancer using the competing risks survival method.

BACKGROUND: Patients with stage I gastric cancer are considered to have an exquisite prognosis. Nonetheless, the fact that some patients experience disease relapse highlights that a subgroup might benefit from multimodality treatment. We aimed to evaluate the survival of patients with stage I gastric cancer and look for harbingers of gastric cancer recurrence. METHODS: We looked for patients with stage I gastric cancer treated exclusively with surgery from 1996 to 2015. The competing risks survival method was used to allow for concurrent causes of mortality. Also, we calculated subdistribution hazards (SH) to reveal factors associated with cancer recurrence and death from unrelated causes. RESULTS: A total of 185 patients constitute the study population. Thirty-seven patients had pT2N0 tumors. Most patients (80.5%) were treated with D2 lymphadenectomy. The probability of relapse at 5 years was 3.0% and 8.6% in the study population and the pT2N0 subgroup, respectively. Among all 26 deaths, only six were related to gastric cancer. In multivariate analysis, perineural invasion (PNI) was associated with increased risk of gastric cancer recurrence. CONCLUSIONS: The prognosis of stage I gastric cancer treated with D2 lymphadenectomy is excellent. PNI may indicate higher likelihood of recurrence. Further work in this field should account for the higher risk of death from unrelated causes.

Role of staging laparoscopy in the management of Pancreatic Duct Carcinoma (PDAC): Single-center experience from a tertiary hospital in Brazil.

BACKGROUND: Proper staging is critical to the management of pancreatic ductal carcinoma (PDAC). Laparoscopy has been used to stage patients without gross metastatic disease with variable success. OBJECTIVES: We aimed to identify the frequency of patients diagnosed by laparoscopy with occult metastatic disease. Also, we looked for variables related to a higher chance of occult metastasis. METHODS: Patients with PDAC submitted to staging laparoscopy either immediately before pancreatectomy or as a separate procedure between January 2010 and December 2016 were included. None presented gross metastatic disease at initial staging. We used logistic regression to search for variables associated with metastatic disease. RESULTS: The study population consisted of 63 patients. Among all patients, nine (16.7%) had occult metastases at laparoscopy. Unresectable tumor (Odds ratio = 18.0, P = 0.03), increasing tumor size (Odds ratio = 1.36, P = 0.01), and abdominal pain (Odds ratio = 5.6, P = 0.04) significantly predicted the risk of occult metastases in univariate analysis. In multivariate analysis, only tumor size predicted the risk of occult metastases. CONCLUSION: Laparoscopy remains a valuable tool in PDAC staging. Patients with either large or unresectable tumors, or presenting with abdominal pain present the highest risk for occult intra-abdominal metastases.

Minimally invasive surgery for gastric cancer in Brazil: current status and perspectives-a report from the Brazilian Laparoscopic Oncologic Gastrectomy Group (BLOGG).

The minimally invasive surgery for gastric cancer in Brazil has begun about two years after the first laparoscopic gastrectomy (LG) performed by Kitano in Japan, in 1991. Although the report of first surgeries shows the year of 1993, there was no dissemination of the technique until the years 2010. At that time with the improvement of optical devices, laparoscopic instruments and with the publications coming from Asia, several Brazilian surgeons felt encouraged to go to Korea and Japan to learn the standardization of the LG. After that there was a significant increase in that type of surgery, especially after the IRCAD opened a branch in Brazil. The growing interest for the subject led some services to begin their own experience with the LG and, since the beginning, the results were similar with those found in the open surgery. Nevertheless, there were some differences with the papers published initially in Japan and Korea. In those countries, the surgeries were laparoscopic assisted, meaning that, in the majority of cases, the anastomoses were done through a mini-incision in the end of the procedure. In Brazil since the beginning it was performed completely through laparoscopic approach due to the skills acquired by Brazilian surgeons in bariatric surgeries. Another difference was the stage. While in the east the majority of cases were done in T1 patients, in Brazil, probably due to the lack of early cases, the surgeries were done also in advanced cases. The initial experience of Zilberstein et al. revealed low rates of morbidity without mortality. Comparing laparoscopic and open surgery, the group from Barretos/IRCAD showed shorter surgical time (216×255 minutes), earlier oral or enteral feeding and earlier hospital discharge, with a smaller number of harvested lymph nodes (28 in laparoscopic against 33 in open surgery). There was no significant difference regarding morbidity, mortality and reoperation rate. In the first efforts to publish a multicentric study the Brazilian Gastric Cancer Association (BGCA) collected data from three institutions analyzing 148 patients operated from 2006 to 2016. There were 98 subtotal, 48 total and 2 proximal gastrectomies. The anastomoses were totally laparoscopic in 105, laparoscopic assisted in 21, cervical in 2, and 20 open (after conversion). The reconstruction methods were: 142 Roux-en-Y, two Billroth I, and three other types. The conversion rate was 13.5% (20/148). The D2 dissection was performed in 139 patients. The mean number of harvested lymph nodes was 34.4. If we take only the D2 cases the mean number was 39.5. The morbidity rate was 22.3%. The mortality was 2.7%. The stages were: IA-59, IB-14, IIA-11, IIB-15, IIIA-9, IIIB-19, IIIC-11 and stage IV-three cases. Four patients died from the disease and 10 are alive with disease. The participating services have already begun the robotic gastrectomy with satisfactory results. The intention of this group is to begin now a prospective multicentric study to confirm the data already obtained with the retrospective studies.

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION / I CONSENSO BRASILEIRO DE TRATAMENTO MULTIDISCIPLINAR DE METÁSTASE HEPÁTICA COLORRETAIS. MÓDULO 1: AVALIAÇÃO PRÉ-TRATAMENTO

Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors. Aim : In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established. Method: Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy. Results : The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent. Conclusion : Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

Racional : As metástases hepáticas de câncer colorretal são evento frequente e potencialmente fatal na evolução de pacientes com estas neoplasias. Objetivo : Neste módulo procurou-se contextualizar esta situação clínica, bem como parametrizar dados epidemiológicos e de resultados das diversas modalidades de tratamento estabelecidas. Método : Foi realizada discussão sobre como detectar e estadiar o câncer colorretal metastático, bem como o emprego dos métodos de imagem na avaliação de resposta ao tratamento sistêmico instituído. Resultado : Fundamentou na definição de quais pacientes teriam suas metástases consideradas ressecáveis e de como se poderia ampliar a gama de pacientes submetidos às modalidades de tratamento ditas de intuito curativo. Conclusão : Foram apresentados os fatores prognósticos clínicos, patológicos e moleculares com validação para serem levados em consideração na prática clínica.

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION.

BACKGROUND: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors. AIM: In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established. METHOD: Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy. RESULTS: The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent. CONCLUSION: Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

Percutaneous use of ePTFE/FEP-covered metallic stent for palliation of malignant biliary obstruction.

INTRODUCTION: Placement of self-expanding metallic stents has been a standard palliative treatment for patients with inoperable biliary malignancy, aiming at improving quality of life via a minimally invasive procedure. This study aimed to evaluate the efficacy of percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents for palliation of inoperable biliary malignancy. MATERIAL AND METHODS: Between February 2012 and April 2013, 11 patients with inoperable malignant biliary obstruction were treated with stent implantation. Serum bilirubin and liver enzyme levels were measured before/immediately after stent placement and at one, three, and six months. Patient survival and stent patency were calculated using Kaplan-Meier analysis. RESULTS: No migration occurred. Patients showed clinical improvement immediately and one month after stent placement, with a significant reduction in mean serum bilirubin level (p < 0.05). At six months, bilirubin levels were <1.5 mg/dL in all cases. One patient developed acute liver failure four days after stent implantation, leading to death. Survival rates were 90% at three months and 70% at six months. Primary patency rates were 100%, 100%, and 90% at one, three, and six months, respectively. CONCLUSION: Percutaneous placement of expanded polytetrafluoroethylene/fluorinated ethylene propylene-covered metallic stents offered an effective palliative therapy for patients with inoperable biliary malignancy.

Evaluation of nrratio in selecting patients foradjuvant chemoradiotherapy afteer d2-gastrectomy / Avaliacao do N-Ratio para a selecao de pacientes candidatos a quimioradioterapia adjuvante apos gastrectomia D2

Context Whether adjuvant chemoradiotherapy may contribute to improve survival outcomes after D2-gastrectomy remains controvertial. Objective To explore the clinical utility of N-Ratio in selecting gastric cancer patients for adjuvant chemoradiotherapy after D2-gastrectomy. Methods A retrospective cohort study was carried out on gastric cancer patients who underwent D2-gastrectomy alone or D2-gastrectomy plus adjuvant chemoradiotherapy (INT-0116 protocol) at the Hospital A. C. Camargo from September 1998 to December 2008. Statistical analysis were performed using multiple conventional methods, such as c-statistic, adjusted Cox's regression and stratified survival analysis. Results Our analysis involved 128 patients. According to c-statistic, the N-Ratio (i.e., as a continuous variable) presented “area under ROC curve” (AUC) of 0.713, while the number of metastatic nodes presented AUC of 0.705. After categorization, the cut-offs provide by Marchet et al. displayed the highest discriminating power – AUC value of 0.702. This N-Ratio categorization was confirmed as an independent predictor of survival using multivariate analyses. There also was a trend of better survival by adding of adjuvant chemoradiotherapy only for patients with milder degrees of lymphatic spread – 5-year survival of 23.1% vs 66.9%, respectively (HR = 0.426, 95% CI 0.150–1.202; P = 0.092). Conclusions This study confirms the N-Ratio as a tool to improve the lymph node metastasis staging in gastric cancer and suggests the cut-offs provided by Marchet et al. as the best way for its categorization after a D2-gastrectomy. In these settings, the N-Ratio appears a useful tool to select patients for adjuvant chemoradiotherapy, and the benefit of adding this type of adjuvancy to D2-gastrectomy is suggested to be limited to patients with milder degrees of lymphatic spread (i.e., NR2, 10%–25%). .

Contexto A utilização de quimiorradioterapia adjuvante permanece controversa após a realização de gastrectomia D2. Objetivo Explorar a utilidade clínica do N-Ratio para a seleção de pacientes com câncer gástrico candidatos à quimiorradioterapia adjuvante após gastrectomia D2. Métodos Realizou-se estudo de coorte retrospectivo incluindo pacientes com câncer gástrico submetidos a gastrectomia D2, isoladamente ou associada à quimiorradioterapia adjuvante (protocolo INT-0116), no Hospital A.C. Camargo, de setembro de 1998 a dezembro de 2008. As análises estatísticas foram realizadas utilizando-se diversos métodos, tais como análise de área sob curvas ROC, regressão de Cox's ajustada e análise estratificada da sobrevivência. Resultados A análise envolveu 128 pacientes. Por análise das áreas sob curvas ROC, o N-Ratio apresentou AUC de 0,713 como variável contínua, enquanto o número total de linfonodos metastáticos apresentou AUC de 0,705. Na análise categorizada, os pontos-de-corte propostos por Marchet et al. apresentaram o maior poder de discriminação, com valor de AUC de 0,702. A categorização N-Ratio segundo estes autores foi confirmada como um preditor independente de sobrevivência, utilizando-se análises multivariadas. Observou-se tendência de melhor sobrevivência acrescentando-se quimiorradioterapia adjuvante apenas para pacientes com moderado grau de disseminação linfática (NR2, 10%-25%), entre os quais a sobrevivência em 5 anos foi de 23,1% vs 66,9%, respectivamente (HR = 0,426, IC 95% 0,150-1,202, P = 0,092). Conclusões Este estudo confirma o N-Ratio como uma medida para melhorar o estadiamento linfonodal no câncer gástrico e sugere que os pontos-de-corte descritos por Marchet et al. sejam a ...

Evaluation of N-ratio in selecting patients for adjuvant chemoradiotherapy after d2-gastrectomy.

CONTEXT: Whether adjuvant chemoradiotherapy may contribute to improve survival outcomes after D2-gastrectomy remains controversial. OBJECTIVE: To explore the clinical utility of N-Ratio in selecting gastric cancer patients for adjuvant chemoradiotherapy after D2-gastrectomy. METHODS: A retrospective cohort study was carried out on gastric cancer patients who underwent D2-gastrectomy alone or D2-gastrectomy plus adjuvant chemoradiotherapy (INT-0116 protocol) at the Hospital A. C. Camargo from September 1998 to December 2008. Statistical analysis were performed using multiple conventional methods, such as c-statistic, adjusted Cox's regression and stratified survival analysis. RESULTS: Our analysis involved 128 patients. According to c-statistic, the N-Ratio (i.e., as a continuous variable) presented "area under ROC curve" (AUC) of 0.713, while the number of metastatic nodes presented AUC of 0.705. After categorization, the cut-offs provide by Marchet et al. displayed the highest discriminating power - AUC value of 0.702. This N-Ratio categorization was confirmed as an independent predictor of survival using multivariate analyses. There also was a trend of better survival by adding of adjuvant chemoradiotherapy only for patients with milder degrees of lymphatic spread - 5-year survival of 23.1% vs 66.9%, respectively (HR = 0.426, 95% CI 0.150-1.202; P = 0.092). CONCLUSIONS: This study confirms the N-Ratio as a tool to improve the lymph node metastasis staging in gastric cancer and suggests the cut-offs provided by Marchet et al. as the best way for its categorization after a D2-gastrectomy. In these settings, the N-Ratio appears a useful tool to select patients for adjuvant chemoradiotherapy, and the benefit of adding this type of adjuvancy to D2-gastrectomy is suggested to be limited to patients with milder degrees of lymphatic spread (i.e., NR2, 10%-25%).

Prognostic factors for survival in patients with colorectal liver metastases: experience of a single brazilian cancer center / Fatores prognósticos de sobrevida em pacientes com metástases hepáticas colorretais

CONTEXT: Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for 2/3 of deaths from this disease. There is considerable controversy among the data in the literature regarding the results of surgical treatment and prognostic factors of survival, and no analysis have been done in a large cohort of patients in Brazil. OBJECTIVES: To characterize the results of surgical treatment of patients with colorectal liver metastases, and to establish prognostic factors of survival in a Brazilian population. METHOD: This was a retrospective study of patients undergoing liver resection for colorectal metastases in a tertiary cancer hospital from 1998 to 2009. We analyzed epidemiologic variables and the clinical characteristics of primary tumors, metastatic disease and its treatment, surgical procedures and follow-up, and survival results. Survival analyzes were done by the Kaplan-Meier method and the log-rank test was applied to determine the influence of variables on overall and disease-free survival. All variables associated with survival with P<0.20 in univariate analysis, were included in multivariate analysis using a Cox proportional hazard regression model. RESULTS: During the period analyzed, 209 procedures were performed on 170 patients. Postope-rative mortality in 90 days was 2.9% and 5-year overall survival was 64.9%. Its independent prognostic factors were the presence of extrahepatic disease at diagnosis of liver metastases, bilateral nodules and the occurrence of major complications after liver surgery. The estimated 5-year disease-free survival was 39.1% and its prognostic factors included R1 resection, extrahepatic disease, bilateral nodules, lymph node involvement in the primary tumor and primary tumors located in the rectum. CONCLUSION: Liver resection for colorectal metastases is safe and effective and the analysis of prognostic factors of survival in a large cohort of Brazilian patients showed similar results to those pointed in international series. The occurrence of major postoperative complications appears to be able to compromise overall survival and further investigation in needed in this topic.

CONTEXTO: As metástases hepáticas são evento comum na evolução clínica de pacientes com câncer colorretal e são responsáveis por 2/3 dos óbitos por esta doença. Há grande controvérsia entre os dados publicados na literatura quanto a resultados de tratamento cirúrgico e seus fatores prognósticos e não há análise, em casuísticas maiores, destes aspectos em uma grande coorte de pacientes no Brasil. OBJETIVOS: Caracterizar os resultados do tratamento cirúrgico de pacientes com metástases hepáticas de tumores colorretais e estabelecer os fatores prognósticos de sobrevida em uma população. MÉTODO: Estudo retrospectivo de pacientes submetidos a ressecção hepática de metástases colorretais em hospital oncológico terciário, de 1998 a 2009. Foram analisadas variáveis epidemiológicas e dos tumores primários da doença metastática e seu tratamento, dos procedimentos cirúrgicos e do seguimento e os resultados de sobrevidas. Para as análises de sobrevida foram utilizadas as curvas de Kaplan-Meyer e o teste de log-rank foi aplicado para determinar a influência das variáveis estudadas nas sobrevidas global e livre de doença. Aquelas variáveis em que este teste apresentou P<0,20 em análise univariada, foram incluídas em análise multivariada pelo modelo de regressão de Cox. RESULTADOS: No período analisado, 209 procedimentos foram realizados em 170 pacientes. A mortalidade em 90 foi de 2,9%. A sobrevida global em 5 anos foi de 64,9%. Os fatores prognósticos independentes de sobrevida global foram a presença de doença extra-hepática no momento do diagnóstico das metástases hepáticas, de nódulos em ambos os lobos hepáticos e a ocorrência de complicações maiores após a cirurgia. A sobrevida livre de doença estimada em 5 anos foi de 39,1% e seus fatores prognósticos incluíram a ressecção R1, a presença de doença extra-hepática, doença bilobar, a presença de acometimento linfonodal no tumor primário e tumores primários localizados no reto. CONCLUSÃO: A ressecção de metástases hepáticas de câncer colorretal se demonstrou segura e eficaz em nosso meio, com resultados semelhantes aos apresentados por outras grandes séries internacionais. A ocorrência de complicações pós-operatórias parece poder comprometer os resultados de sobrevida global obtidos e investigação mais aprofundada se faz necessária neste sentido.

Prognostic factors for survival in patients with colorectal liver metastases: experience of a single brazilian cancer center.

CONTEXT: Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for 2/3 of deaths from this disease. There is considerable controversy among the data in the literature regarding the results of surgical treatment and prognostic factors of survival, and no analysis have been done in a large cohort of patients in Brazil. OBJECTIVES: To characterize the results of surgical treatment of patients with colorectal liver metastases, and to establish prognostic factors of survival in a Brazilian population. METHOD: This was a retrospective study of patients undergoing liver resection for colorectal metastases in a tertiary cancer hospital from 1998 to 2009. We analyzed epidemiologic variables and the clinical characteristics of primary tumors, metastatic disease and its treatment, surgical procedures and follow-up, and survival results. Survival analyzes were done by the Kaplan-Meier method and the log-rank test was applied to determine the influence of variables on overall and disease-free survival. All variables associated with survival with P<0.20 in univariate analysis, were included in multivariate analysis using a Cox proportional hazard regression model. RESULTS: During the period analyzed, 209 procedures were performed on 170 patients. Postope-rative mortality in 90 days was 2.9% and 5-year overall survival was 64.9%. Its independent prognostic factors were the presence of extrahepatic disease at diagnosis of liver metastases, bilateral nodules and the occurrence of major complications after liver surgery. The estimated 5-year disease-free survival was 39.1% and its prognostic factors included R1 resection, extrahepatic disease, bilateral nodules, lymph node involvement in the primary tumor and primary tumors located in the rectum. CONCLUSION: Liver resection for colorectal metastases is safe and effective and the analysis of prognostic factors of survival in a large cohort of Brazilian patients showed similar results to those pointed in international series. The occurrence of major postoperative complications appears to be able to compromise overall survival and further investigation in needed in this topic.

Advances in surgical treatment of colorectal liver metastases.

Colorectal cancer is the 3rd most common malignant neoplasm in the West. About 50% of patients develop liver metastases throughout the course of the disease. Those are responsible for at least two-thirds of deaths. Advances in surgical techniques and improvement in chemotherapy regimens have allowed offering treatment with curative intent to an increasing number of patients. This article reviews recent advances in the treatment of liver metastases, including strategies to increase resection (e.g., portal vein embolization, radiofrequency ablation, two-stage hepatectomy, conversion therapy and reverse treatment strategy) and hepatectomy in the presence of extrahepatic disease. Finally, the results of surgical treatment of liver metastases at the Hospital A.C. Camargo are briefly shown.

Avanços no tratamento cirúrgico das metástases hepáticas colorretais / Advances in surgical treatment of colorectal liver metastases

O câncer colorretal é o terceiro tumor mais frequente no ocidente. Cerca de 50 por cento dos pacientes desenvolvem metástases hepáticas na evolução da doença, as quais são responsáveis por, no mínimo, dois terços das mortes1-6. O avanço nas técnicas cirúrgicas e a melhora dos esquemas quimioterápicos têm permitido oferecer tratamento com intuito curativo a um número cada vez maior de pacientes. Neste artigo, fazemos uma revisão dos avanços recentes do tratamento das metástases hepáticas, incluindo estratégias para aumentar as ressecções (por exemplo: embolização da veia porta, ablação por radiofrequência, hepatectomia em dois tempos, quimioterapia de conversão e estratégia inversa de tratamento) e hepatectomias na presença de doença extra-hepática. Por fim, mostramos brevemente o resultado do tratamento cirúrgico de metástases hepáticas no Hospital A.C. Camargo.

Colorectal cancer is the 3rd most common malignant neoplasm in the West. About 50 percent of patients develop liver metastases throughout the course of the disease. Those are responsible for at least two-thirds of deaths. Advances in surgical techniques and improvement in chemotherapy regimens have allowed offering treatment with curative intent to an increasing number of patients. This article reviews recent advances in the treatment of liver metastases, including strategies to increase resection (e.g., portal vein embolization, radiofrequency ablation, two-stage hepatectomy, conversion therapy and reverse treatment strategy) and hepatectomy in the presence of extrahepatic disease. Finally, the results of surgical treatment of liver metastases at the Hospital A.C. Camargo are briefly shown.

Surgical management of symptomatic pericardial effusion in patients with solid malignancies.

BACKGROUND: Symptomatic pericardial effusion in patients with cancer may lead to a life-threatening event that requires diligent treatment, but the best surgical treatment is still controversial. The purpose of this study was to identify predictors of survival for patients with solid malignancies and symptomatic pericardial effusion, which might help to select the best surgical treatment for each patient. METHODS: We retrospectively analyzed 47 patients with solid malignancies concomitant with symptomatic pericardial effusion who underwent surgery between 1994 and 2004. Overall survival was calculated from date of surgery, and prognostic importance of clinical and pathological variables was assessed. RESULTS: The most common primary sites of disease were breast (46.8%) and lung (25.6%). Initial pericardiocentesis were performed in 29 patients; median volume of fluid drained was 480 mL. Median interval from the diagnosis of primary cancer to the development of pericardial effusion (pericardial effusion-free interval) was 34.8 months. Definitive surgical treatment was performed in 43 patients, as follows: subxiphoid pericardial window (n = 21); thoracotomy and pleuropericardial window (n = 10); pericardiodesis (n = 8); and videothoracoscopic pleuropericardial window (n = 4). Pericardiocentesis was the only procedure in four patients. Median follow-up was 2.9 months. Median overall survival was 3.7 months. Pericardial effusion-free interval longer than 35 months and more than 480 mL of fluid drained at initial pericardiocentesis were determinants of better survival. CONCLUSIONS: Pericardial window and pericardiodesis seem to be safe and efficacious in treating effusion of the pericardium. Pericardial effusion-free interval and volume drained at initial pericardiocentesis are determinants of outcome.