Perioperative and long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision: a retrospective study of 672 patients.

Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18-138) and for L-TME, it was 60 months (range 14-140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5 year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5 year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.

Robotic and laparoscopic sphincter-saving resections have similar peri-operative, oncological and functional outcomes in female patients with rectal cancer.

BACKGROUND: This study aimed to compare perioperative, long-term oncological, and anorectal functional outcomes of robotic total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) sphincter-saving total mesorectal excision in female patients with rectal cancer. METHODS: Retrospective analysis of prospectively maintained database was performed. Sixty-eight cases (L-TME, n = 34; R-TME, n = 34) were performed by a single surgeon (January 2014-January 2019). Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups. RESULTS: Clinical characteristics did not differ between the groups. Mean operating time was longer in R-TME (165.50 ± 95.50 vs. 124.50 ± 82.60 min, p < 0.001). There was no conversion to open surgery in both groups. Mesorectal integrity was complete in both groups (100%). Length of distal and circumferential resection margins (CRM) did not differ between groups. CRM involvement was observed in 1 (2.8%) and 1 (2.8%) in L-TME and R-TME patients, respectively. Incidence of anastomotic leakage was 5.8% (n = 2) in L-TME and 8.8% (n = 3) in R-TME, respectively. Mean length of follow-up was 62.5 (36-102) months for R-TME and 63 (36-103) months for L-TME. Five-year overall survival rates were 92.8% in L-TME and 89.6% in R-TME. Disease-free survival rates were 87.5% in L-TME and 89.6% in R-TME. Local recurrence rates were 3.0% for both groups. Mean Wexner score for L-TME and R-TME patients was: 9.42 ± 8.23 and 9.22 ± 3.64 (p = 0.685), respectively. Daily stool frequency was similar between groups. CONCLUSION: Robotic total mesorectal excision (R-TME) and laparoscopic TME (L-TME) have similar perioperative, oncological, and anorectal functional results in female patients with rectal cancer. The robotic approach for rectal cancers in female patients could be not as critical as for male patients.

Robotic male and laparoscopic female sphincter-preserving total mesorectal excision of mid-low rectal cancer share similar specimen quality, complication rates and long-term oncological outcomes.

The aim of this study was to compare perioperative and long-term oncological outcomes between laparoscopic sphincter-preserving total mesorectal excision in female patients (F-Lap-TME) and robotic sphincter-preserving total mesorectal excision in male patients (M-Rob-TME) with mid-low rectal cancer (RC). A retrospective analysis of a prospectively maintained database was performed. 170 cases (F-Lap-TME: 60 patients; M-Rob-TME: 110 patients) were performed by a single surgeon (January 2011-January 2020). Clinical characteristics did not differ significantly between the two groups. Operating time was longer in M-Rob-TME than in F-Lap-TME group (185.3 ± 28.4 vs 124.5 ± 35.8 min, p < 0.001). There was no conversion to open surgery in both groups. Quality of mesorectum was complete/near-complete in 58 (96.7%) and 107 (97.3%) patients of F-Lap-TME and M-Rob-TME (p = 0.508), respectively. Circumferential radial margin involvement was observed in 2 (3.3%) and 3 (2.9%) in F-Lap-TME and M-Rob-TME patients (p = 0.210), respectively. Median length of follow-up was 62 (24-108) months in the F-Lap-TME and 64 (24-108) months in the M-Rob-TME group. Five-year overall survival rates were 90.5% in the F-Lap-TME and 89.6% in the M-Rob-TME groups (p = 0.120). Disease-free survival rates in F-Lap-TME and M-Rob-TME groups were 87.5% and 86.5% (p = 0.145), respectively. Local recurrence rates were 5% (n = 3) and 5.5% (n = 6) (p = 0.210), in the F-Lap-TME and M-Rob-TME groups, respectively. The robotic technique can potentially overcome some technical challenges related to the pelvic anatomical difference between sex compared to laparoscopy. Laparoscopic and robotic approach, respectively in female and male patients provide similar surgical specimen quality, perioperative outcomes, and long-term oncological results.

Chemoradiation and consolidation chemotherapy for rectal cancer provides a high rate of organ preservation with a very good long-term oncological outcome: a single-center cohort series.

AIM: To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC). METHOD: Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50-83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE). RESULTS: Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. Five-year OS and DFS were 94.9% (95% CI: 88-100%) and 80% (95% CI: 55.2-100%), respectively, in the RG group. For all patients (n=60), 5-year TME-free DFS was 57.3% (95% CI: 44.3-70.2%) and organ preservation-adapted DFS was 77.5% (95% CI: 66.4-88.4%). For the WW group (n=39), 5-year TME-free DFS was 77.5% (95% CI: 63.2-91.8%) and organ preservation-adapted DFS was 85.0% (95% CI: 72.3-97.8%). CONCLUSION: CRT-CNCT provides cCR as high as 2/3 of LARC patients. Regrowths, developed during follow-up, can be successfully salvaged without causing oncological disadvantage if strict surveillance is performed.

Intramural Component of Venous, Lymphatic, and Perineural Invasion in Colon Cancer: A Threat or an Illusion?

Background: Extramural venous invasion is an independent predictor of poor outcome in colorectal cancer, whereas the significance of the intramural component of venous and lymphatic and perineural invasion is unclear. Aims: To evaluate the prognostic impact of intramural components for venous, lymphatic, and perineural invasions and the relation of these invasion patterns with clinicopathological features in patients with colon cancer. Study Design: A retrospective cross-sectional study. Methods: The analysis included 626 patients with colon cancer in stages II and III. All patients were divided into four categories (no invasion, intramural invasion only, extramural invasion only, or both intramural and extramural invasions) for vascular invasion, lymphatic invasion and perineural invasion. The primary outcomes were 5-year disease-free and overall survival. Results: Right-sided (for vascular invasion, 24.7% vs. 33.9%, p = 0.007; for perineural invasion, 34.5% vs. 41.5%, p = 0.034) and dMMR tumors (for vascular invasion, 13.5% vs. 33.5, p < 0.001; for perineural invasion, 25% vs. 41.4%, p = 0.004) exhibited less venous and perineural invasion. Compared with no invasion, presence of intramural invasion only, did not exert any effect on disease-free or overall survival for vascular invasion, lymphatic invasion, and perineural invasion. Multivariate analyses revealed that the presence of both intramural and extramural invasion was independently associated with poor disease-free and overall survival for venous (hazard ratios: 2.39, p = 0.001; hazard ratios: 2.46, p = 0.001), lymphatic (hazard ratios: 2.456, p < 0.001; hazard ratios: 2.13, p = 0.02) and perineural invasion (hazard ratios: 2.99, p < 0.001; hazard ratios: 2.68, p < 0.001), respectively. Conclusion: Our data strongly advocates the importance of reporting intramural and extramural components of invasion since the presence of intramural invasion alone may not be considered as a high-risk factor for systemic recurrence.

Robotic vs. laparoscopic intersphincteric resection for low rectal cancer: a case matched study reporting a median of 7-year long-term oncological and functional outcomes.

Aim of this study was to compare operative, long-term oncological and functional outcomes of laparoscopic (LISR) and robotic (RISR) intersphincteric resection in low-lying rectal cancer. Retrospective analysis of prospectively maintained database was performed. 115 cases (LISR, n = 55; RISR, n = 60) were performed by a single surgeon (January 2011-January 2020). Clinical characteristics did not differ between the groups. Operating time was longer in RISR (160.0 ± 45.7 vs. 205.0 ± 36.5 min, p = 0.035). There was no conversion in RISR, whereas in LISR, two patients (3.6%) converted to open surgery. Complete mesorectum was 61.8% and 83.3% for LISR and RISR (p = 0.046), respectively. Circumferential radial margin involvement was 10.9% and 8.3% in LISR and RISR (p = 0.365), respectively. Median follow-up was 82.8 (30-138) months for LISR and 83.6 (30-138) months for RISR. Three-, five-, and seven-year overall survival rates (OS) for LISR and RISR were: 88.6%, 80.4%, 73.4% and 90.4%, 86.3%, 76.9%, respectively. Three-, five-, and seven-year disease-free survival (DFS) rates for LISR and RISR were 80.5%, 75.2%, 70.4% and 84.4%, 81.4%, 79.8% (p = 0.328), respectively. Three-, five-, and seven-year local recurrence-free survival rates in LISR and RISR were: 96.1%, 92.6%, 88.4% and 96.7%, 94.2%, 90.4% (p = 0.573), respectively. Mean Wexner score for LISR (n = 32) and RISR (n = 40) was: 10.5 ± 4.7 and 9.8 ± 4.2 (p = 0.782), respectively. Colostomy-free survival in LISR and RISR was: 3 years 94.5%/95.2%, 5 years 89.1%/91.7%, and 7 years 83.6%/85.0%. RISR is associated with better mesorectal integrity, no conversion, and lower postoperative complication rate. RISR has longer operation time. Oncological and anorectal functional outcomes are similar in both groups.

Is robotic da Vinci Xi® superior to the da Vinci Si® for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients.

The aim of this study was to determine the superiority between the robotic da Vinci Si® (Si group) and da Vinci Xi® (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 ± 31.8 min in Si group vs 123.6 ± 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.

Watch and Wait Strategy for Rectal Cancer: How Long Should We Wait for a Clinical Complete Response?

BACKGROUND: The objective of this study was to determine how long to wait in locally advanced rectal tumor (LARC) patients who receive total neoadjuvant therapy (TNT) and achieve a clinical complete response (cCR), and to identify the clinical parameters that affect the waiting period for the watch-and-wait strategy (W &W). MATERIALS AND METHODS: The data of patients who achieved cCR between February 2015 and June 2020 were examined retrospectively. The week in which patients with cCR at the end of TNT achieved clearance was determined by reanalyzing recorded endoscopy video images. In the assessment at the time of the initial diagnosis, tumor characteristics, such as digital rectal examination findings, MRI stage, location with respect to the puborectalis muscle, annularity, and tumor size, were recorded prospectively. RESULTS: A total of 54 patients were included in this study. According to the MRI-T stage, 14 cases were cT3a, 22 were cT3b, and 18 were cT3c-T4. Forty-four percent of the cases achieved cCR at 8-10 weeks, 19% at 12-16 weeks, 20% at 16-22 weeks, and 17% at 20-26 weeks. Patients with tumors that were early MRI-T stage (cT3a), negative clinical circumferential resection margin, mobile, small (≤4 cm), located above the puborectalis muscle and showed <180 degrees annularity achieved cCR significantly earlier than those with other tumors (p<0.05). CONCLUSION: In this study, cCR was achieved in less than half (44%) of the cases during the 8-10 week waiting period. In the W&W strategy, the initial assessment for cCR seems insufficient, and we may need to wait up to 26-30 weeks, especially in patients with advanced-stage tumors.

Intersphincteric Resection for Low Rectal Cancer: Parameters Affecting Functional Outcomes and Survival Rates.

INTRODUCTION: The development of new surgical techniques and devices, as well as the improvements in neoadjuvant chemoradiotherapy enabled intersphincteric resection (ISR), has reduced permanent colostomy usage. The aim of this study was to assess the long-term oncological and functional outcomes of patients who underwent partial ISR for rectal cancer located less than 5cm from the anal verge. MATERIALS AND METHODS: A series of 106 consecutive patients with very low rectal cancer underwent curative partial ISR from January 2006 to September 2019 were retrospectively evaluated. One-hundred-three (97%) of 106 patients received neoadjuvant chemo-radiotherapy. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) rates were calculated using Kaplan-Meier methods. The Wexner incontinence score and Kirwan classification were used to evaluate patients' functional results. RESULTS: The median follow up was 60 months (range, 18-174). The estimated five-year overall and disease-free survival rates were 89% and 81.6%, respectively. Five-year local recurrence and distant metastasis rates were 6.6% and 10.4%, respectively. There was no in-hospital and 30-day mortality. The median Wexner score was 9 (range, 0-20) for 72 patients. Age (<65 years, p=0.027) and gender (male, p=0.019) had a positive effect on functional outcomes after surgery. One and five years colostomy-free survival rates were 96% and 89%, respectively. CONCLUSION: Intersphincteric resection techniques are feasible for patients with very low rectal cancer, providing good oncological and functional outcomes.

Acute Ischemic Gangrene of the Rectosigmoid Colon in a Patient With Rectal Cancer in the "Watch-and-Wait" Protocol.

Acute rectal ischemia is a rare entity because the rectum has abundant blood supply from the inferior mesenteric, internal iliac, internal pudendal, and marginal artery with rich collaterals. We present a case of an acute ischemic proctosigmoiditis with a history of rectal cancer who completely recovered after total neoadjuvant treatment and was in the "watch-and-wait" protocol. Urgent laparoscopic low anterior resection and protective ileostomy were performed. Causes of acute rectosigmoid ischemia include old age, diabetes, atherosclerosis, previous aortic surgery due to aneurysm, vasculitis, and radiotherapy. Ischemia may be present as only involving the mucosa, which can be managed conservatively, but full-thickness necrosis requires urgent surgical intervention. Endoscopic examination is the gold standard in initial diagnosis. Ischemic gangrene of the rectosigmoid colon is a rare condition and can be life-threatening unless an urgent surgical intervention is performed.

Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer.

INTRODUCTION: Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic system may help to overcome some of the limitations. The aim of our study was to compare long-term oncological outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision in male patients with mid-low rectal cancer. MATERIALS AND METHODS: The study was conducted as a retrospective review of a prospectively maintained database. One-hundred-three robotic and 84 laparoscopic sphincter-saving total mesorectal excisions were performed by a single surgeon between January 2011 and January 2020. Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups. RESULTS: The patients' characteristics did not differ significantly between the two groups. Median operating time was longer in the robotic than in the laparoscopic group (180 minutes versus 140 minutes, p=0.033). Macroscopic grading of the specimen in the robotic group was complete in 96 (93.20%), near complete in four (3.88%) and incomplete in three (2.91%) patients. In the laparoscopic group, grading was complete in 37 (44.04%), near complete in 40 (47.61%) and incomplete in seven (8.33%) patients (p=0.03). The median length of follow up was 48 (9-102) months in the robotic, and 75.6 (11-113) months in the laparoscopic group. Overall, five-year survival was 87% in the robotic and 85.3% in the laparoscopic groups. Local recurrence rates were 3.8% and 7.14%, respectively, in the robotic and laparoscopic groups (p<0.05). CONCLUSION: Sphincter-saving robotic total mesorectal excision is a safe and feasible tool, which provides good mesorectal integrity and better local control in male patients with mid-low rectal cancer.

Robotic Sphincter-Saving Total Mesorectal Excision for Rectal Cancer Treatment: A Single-Surgeon Experience in 103 Consecutive Male Patients.

BACKGROUND: A robotic surgical approach provides advantages compared to laparoscopy in male patients with mid- and low-lying rectal cancer located in the narrow pelvic space. The aim of this report is to present a single-surgeon experience with robotic sphincter-saving total mesorectal excision of rectal cancer in male patients. METHODS: A series of 103 consecutive male patients who underwent robotic rectal surgery between January 2012 and June 2019 were analyzed retrospectively in terms of demographics, histopathological data, and surgical and oncological outcomes. RESULTS: All of the patients underwent robotic sphincter-saving resection: 76 (73.8%) underwent low-anterior resection and 27 (26.2%) underwent intersphincteric resection with colo-anal anastomosis. There was no conversion. The median distal resection margin of the operative specimen was 3 (0.2-7) cm. The circumferential resection margin was positive in 3 (2.91%) cases. The median number of retrieved lymph nodes was 22 (18-42). The median hospital stay was 4 (3-16) days. Whereas the overall morbidity was 13%, there was no in-hospital or 30-day mortality. The median length of follow-up was 48 (9-80) months. The 5-year overall survival rate was 87%. The 5-year disease-free survival rate was 84%. Local and distant recurrence rates were 3.8% and 5.82%, respectively. CONCLUSIONS: In male patients with rectal cancer, a robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.

The impact of total neo-adjuvant treatment on nonoperative management in patients with locally advanced rectal cancer: The evaluation of 66 cases.

BACKGROUND: The study aimed to assess if adherence to a total-neoadjuvant-treatment (TNT) protocol followed by observation(watch-and-wait) led to the successful nonoperative-management of low-rectal-cancer. METHODS: In this study, patients with primary, resectable-T3-T4, N0-N1 distal-rectal-adenocarcinoma underwent-chemoradiotherapy + consolidation-chemotherapy (TNT). During the-TNT-period, endoscopy, MRI, and FDG-PET/CT were performed. We allocated patients with complete-clinical-tumor-regression, who underwent endoscopy every two months, MRI every-four-months, and PET/CT every-six-months-after-treatment, to the observation-group(OG). All other patients were referred for surgery. The OG was followed-up. The primary endpoint was local tumor-ecurrence after allocation to the OG. RESULTS: Between 2015 and 2018, we enrolled 66-patients. Of 60-patients who were eligible to participate, 39 had complete-clinical-response(cCR) and were allocated to the OG, six underwent local-excision (LE), and 15 underwent total-mesorectal-excision (TME). The median follow-up duration was 22 (9-42) months. The local-recurrence-rate in the OG was 15.3%, and the LE and TME rates were 16.6% and 0%, respectively. All recurrence cases were salvaged through either LE or TME. The-distant-metastasis rate was 5.1%, 16.6%, and 12.5% in the OG, LE, and TME groups, respectively. The endoscopic negative-predictive-value(NPV) was 50%, and the positive-predictive-value(PPV) was 76.9% in the surgery group (LE + TME). MRI; NPV-50%, PPV-76.9%. PET/CT; NPV-100%, PPV-93.3%. Six patients(28.57%) from surgery group achieved complete pathological response (cPR). CONCLUSION: Our results indicated a high proportion of selected-rectal-cancers with-cCR after neo-adjuvant-therapy could potentially be managed non-operatively, and major surgery may be avoided.

The long-term oncological outcomes of the 140 robotic sphincter-saving total mesorectal excision for rectal cancer: a single surgeon experience.

Robotic surgery became more popularly in the colorectal surgical field. The aim of the study was to evaluate of the oncological outcomes which patients who underwent the robotic total mesorectal excision for rectal cancer. A series of 140 consecutive patients who underwent robotic rectal surgery between January 2012 and June 2019 was analyzed retrospectively in terms of demographics, pathological data, and surgical and oncological outcomes. There were 104 (74.28%) male and 36 (25.71%) female patients. The tumor was located in the lower rectum in 84 (60%) cases, in the mid rectum in 38 (27.14%) cases, and in the upper rectum in 18 (12.85%) cases. Ninety-eight (70%) of the patients has received neoadjuvant chemoradiotherapy. All the patients underwent robotic sphincter-preserving surgery, 101 (72.14%) patients low-anterior resection, and 39 (27.85%) patients underwent intersphincteric resection with colo-anal anastomosis. There were no conversions. The circumferential resection margin was positive in five (3.57%) patients. The median distal resection margin of the operative specimen was 3.2 (0.2-7) cm. The median number of retrieved lymph nodes was 22 (16-42). TME quality in the in our study was rated as complete in 88.57% (n124) of patients, nearly complete in 7.14% (n10) of patients; and 4.28% (n6) of incomplete. The median hospital stay was 3.5 (3-12) days. In-hospital and 1-month mortality was zero. The median length of follow-up was 40 (2-80) months. The 5-year overall survival rate was 92.78%. The 5-year disease-free survival rate was 90%. Locally recurrence and distance recurrence rate was 3.57% (n5/140) and 2.85% (n4/140), respectively. Robotic rectal cancer surgery has a good oncological outcomes and feasible tool in the field of the rectal surgery, but required a steep learning curve.

En-Bloc Excision of the High-ligated Inferior Mesenteric Vein Pedicle With the Specimen in Patients Undergoing Minimally Invasive and Open Sphincter Saving Rectal Resections for Cancer.

Although high-ligated pedicle of the inferior mesenteric artery is usually kept in the resected specimens, the value of preserving high-ligated pedicle of the inferior mesenteric vein within the resected specimens of the sphincter saving rectal resections for cancer is not well defined. In the current study, patients undergoing open, laparoscopic, and robotic sphincter saving rectal resection for cancer were prospectively included. Lymph node invasion and presence of lymph nodes along the IMV pedicles were analyzed. In total 100 patients were included. There were lymph nodes in 63 patients at the IMV and 71 patients at the IMA pedicles. En-bloc removal of the high-ligated IMV pedicle with the resected specimen significantly increased the number of harvested lymph nodes(P<0.001) regardless of surgical modality (P=0.36). Although it increases the number of harvested lymph nodes with acceptable operative morbidity, no oncological benefits were found related to preservation of high-ligated pedicle of the inferior mesenteric vein within the resected specimen of the rectum.

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the Istanbul Group.

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.

Immunohistochemical and genetic features of mucinous and signet-ring cell carcinomas of the stomach, colon and rectum: a comparative study.

Gastric and colorectal cancers are prevalent and fatal cancers worldwide. Although mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRCC) are relatively uncommon, they are of critical importance because of poor prognosis. In Turkey, studies on MSI and other molecular characteristics in mucinous adenocarcinoma (MAC) and signet-ring cell carcinoma (SRCC) of stomach and colon have not been conducted. The present study aimed to investigate the similarities and differences between gastric/colorectal MACs and SRCCs. A total of 590 patients with gastric carcinoma and 1075 patients with colorectal carcinoma, in whom pathologic diagnosis was made within a period of 8 years in our hospital, were retrospectively evaluated. Tissue blocks and slides obtained from the pathology archive were used for immunohistochemical and genetic studies and for microscopic re-evaluation according to the WHO criteria. Data from a total of 135 patients, of whom 78 had been diagnosed with MAC and 57 had been diagnosed with SRCC, were analyzed. MAC patients were significantly older than those with SRCCs. While colorectal localization was more common among MACs, SRCC patients mostly showed gastric localization. Macroscopically, ulceroinfiltrative type was the most prevalent in both groups followed by fungating type in MAC and infiltrative type in SRCC. When compared with SRCC group, MAC group was associated with higher tumor invasion stage, lower rate of patients with infiltrative growth pattern and perineural invasion, and less frequent lymph node invasion. More effective approaches will be developed in the treatment and prevention of cancer along with more data about the incidence, pathogenesis, prognostic factors, and clinical course of cancers.

A comparison study of the reporting systems for salivary gland fine needle aspirations: Are they really different?

BACKGROUND: Recently a new system for reporting salivary gland fine-needle aspiration (FNA) cytology was proposed, the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC). Herein, we evaluated diagnostic accuracy of salivary gland FNA, comparing the system previously used in our hospital with the Milan system. METHODS: Salivary gland specimens obtained between 2011 and 2017 were reclassified according to MSRSGC. Risk of malignancy for each diagnostic category was determined. Diagnostic yield of both classifications was evaluated. RESULTS: The cases (n = 388) were classified according to the old system: nondiagnostic (n = 28), benign (n = 246), atypical (n = 36), neoplastic (n = 57), suspicious for malignancy (n = 7) and malignant (n = 14). The lesions were distributed according to the MSRSGC: nondiagnostic (n = 28), non-neoplastic (n = 89), atypia of undetermined significance (n = 39), benign neoplasm (n = 156), neoplasm of uncertain malignant potential (n = 55), suspicious for malignancy (n = 7) and malignant (n = 14). When considering only benign and malignant cases, both classifications showed the same sensitivity (62.5%), specificity (100%) and similar accuracy (95.8%). Comparison between the two systems showed no significant difference. CONCLUSIONS: Salivary gland FNA has high diagnostic accuracy and assists clinical management independently of the reporting system used, however, in some cases, the use of Milan system could be beneficial, since it allows an enhanced category stratification.

A Rare Case of Sunitinib-Induced Hyperammonemic Encephalopathy and Hypothyroidism in Metastatic Renal Cell Carcinoma.

Sunitinib has become a standard treatment agent for metastatic renal cell carcinoma (RCC) for several years. However, various adverse events have been reported. We present a rare adverse effect of hyperammonemic encephalopathy induced by sunitinib. A 66-year-old woman with metastatic RCC referred to the emergency department with confusion that developed 14 days after the initiation of 50 mg/d of sunitinib. Her serum ammonia and thyroid-stimulating hormone levels were markedly elevated (146 µg/dL and 27.27 µIU/mL, respectively). Sunitinib was discontinued, and an enema with lactulose and L-thyroxine were administered. Her mental status and neurologic symptoms were normalized 7 days after the treatment. Serum ammonia level decreased to 61 µg/dL and thyroid stimulating hormone level decreased 22.34 µIU/mL. The incidence of sunitinib-induced hyperammonemia is rarely reported. The relationship between sunitinib and the development of hyperammonemia is not well understood, and the mechanism is unclear. Sunitinib-induced hyperammonemia is very rare, and to the best of our knowledge, this is fourth case hyperammonemia and first case hyperammonemic encephalopathy with hypothyroidism as an adverse effect. Therefore, it is important for clinicians to be aware of hyperammonemia that can occur in several days after the initiation of sunitinib treatment in metastatic RCC.