Quadruple therapies show a higher eradication rate compared to standard triple therapy for Helicobacter pylori infection within the LEGACy consortium. A multicenter observational study in European and Latin American countries.

INTRODUCTION: Gastric cancer (GC) is one of the most lethal malignancies worldwide. Helicobacter pylori is the primary cause of GC; therefore, its eradication reduces the risk of developing this neoplasia. There is extensive evidence regarding quadruple therapy with relevance to the European population. However, in Latin America, data are scarce. Furthermore, there is limited information about the eradication rates achieved by antibiotic schemes in European and Latin American populations. OBJECTIVE: To compare the effectiveness of standard triple therapy (STT), quadruple concomitant therapy (QCT), and bismuth quadruple therapy (QBT) in six centers in Europe and Latin America. METHODS: A retrospective study was carried out based on the LEGACy registry from 2017 to 2022. Data from adult patients recruited in Portugal, Spain, Chile, Mexico, and Paraguay with confirmed H. pylori infection who received eradication therapy and confirmatory tests at least 1 month apart were included. Treatment success by each scheme was compared using a mixed multilevel Poisson regression, adjusting for patient sex and age, together with country-specific variables, including prevalence of H. pylori antibiotic resistance (clarithromycin, metronidazole, and amoxicillin), and CYP2C19 polymorphisms. RESULTS: 772 patients were incorporated (64.64% females; mean age of 52.93 years). The total H. pylori eradication rates were 75.20% (255/339) with STT, 88.70% (159/178) with QCT, and 91.30% (191/209) with QBT. Both quadruple therapies (QCT-QBT) showed significantly higher eradication rates compared with STT, with an adjusted incidence risk ratio (IRR) of 1.25 (p: <0.05); and 1.24 (p: <0.05), respectively. The antibiotic-resistance prevalence by country, but not the prevalence of CYP2C19 polymorphism, showed a statistically significant impact on eradication success. CONCLUSIONS: Both QCT and QBT are superior to STT for H. pylori eradication when adjusted for country-specific antibiotic resistance and CYP2C19 polymorphism in a sample of individuals residing in five countries within two continents.

Latin American young patients with gastric adenocarcinoma: worst prognosis and outcomes.

Background: Incidence of young patients (aged 40 years or younger) diagnosed with gastric carcinoma has increased worldwide. Young GC diagnosis, have clinicopathological features that differ from elderly, and is correlated with bad prognosis factors. The purpose of this work is to describe the prevalence, clinic-pathological features, and prognosis of overall survival (OS) of young Latin-American patients with GC. Methods: Retrospective, observational study. Included patients treated at the National Cancer Institute [2004-2020]. Statistical analysis: χ2 and t-test, Kaplan-Meier, Log-Rank and Cox-Regression. Statistical significance differences were assessed when P was bilaterally <0.05. Results: A total of 2,543 patients fulfilled the inclusion criteria. Young-patients were predominantly female (54%), with diffuse-type adenocarcinoma (68%), signet-ring-cell (72%), poor-differentiation (90%), and metastatic (79%). In OS analysis, patients with metastatic disease, showed differences regarding age, young patients reported a median-OS of 8 versus 13 months for elderly patients (P=0.001). Among young patients, differences were also observed regarding gender, young-female patients had a median-OS of 5 versus 11 months for young-man (P=0.001). Conclusions: This is one of the pioneer studies correlating age with gender and the prognostic features of bad prognosis in Latin-American population. Besides, supports the idea that a global effort is required to improve awareness, prevention, and early diagnosis of GC.

Recurrence rate and survival implications of surgical margins in patients with acral melanoma. Is a wide margin necessary?

INTRODUCTION: Appropriate size of resection margins in acral melanoma is not clearly established. OBJECTIVE: To investigate whether narrow-margin excision is appropriate for thick acral melanoma. METHODS: Three-hundred and six patients with acral melanoma were examined. Factors associated with recurrence and survival were analyzed according to surgical margin size (1 to 2 cm and > 2 cm). RESULTS: Out of 306 patients, 183 were women (59.8%). Median Breslow thickness was 6 mm; 224 cases (73.2%) were ulcerated, 154 patients (50.3%) had clinical stage III disease, while 137 were at stage II (44.8%) and 15 at stage IV (4.9%). All cases had negative margins, with a median of 31.5 mm. A Breslow thickness of 7 mm (p = 0.001) and clinical stage III (p = 0.031) were associated with recurrence; the factors associated with survival were Breslow index (p = 0.047), ulceration (p = 0.003), advanced clinical stage (p < 0.001), and use of adjuvant therapy (p = 0.003). CONCLUSION: A resection margin of 1 to 2 cm did not affect tumor recurrence or survival in patients with acral melanoma.

INTRODUCCIÓN: La extensión apropiada de los márgenes de resección en el melanoma acral no está claramente establecida. OBJETIVO: Investigar si la escisión con margen estrecho es adecuada en el melanoma acral grueso. MÉTODOS: Se estudiaron 306 pacientes con melanoma acral. Conforme a la extensión del margen quirúrgico (de 1 a 2 cm y > 2 cm), se analizaron los factores asociados a la recurrencia y la supervivencia. RESULTADOS: De 306 pacientes, 183 fueron mujeres (59.8 %). La mediana del grosor de Breslow fue 6 mm; 224 casos (73.2 %) fueron de tipo ulcerados, 154 pacientes (50.3 %) tenían enfermedad en estadio clínico III, 137 en II (44.8 %) y 15 en IV (4.9 %). Todos los casos presentaron margen negativo, con una mediana de 31.5 mm. Un grosor de Breslow de 7 mm (p = 0.001) y la etapa clínica III (p = 0.031) se asociaron a recurrencia; los factores asociados a la supervivencia fueron el índice de Breslow (p = 0.047), la ulceración (p = 0.003), la etapa clínica avanzada (p < 0.001) y el uso de adyuvancia (p = 0.003). CONCLUSIÓN: Un margen de resección de 1 a 2 cm no afectó la recurrencia tumoral ni la supervivencia en los pacientes con melanoma acral.

Tasa de recurrencia e implicación del margen quirúrgico en la supervivencia del paciente con melanoma acral. ¿Es necesario un margen amplio? / Recurrence rate and survival implications of surgical margins in patients with acral melanoma. Is a wide margin necessary?

Resumen Introducción: La extensión apropiada de los márgenes de resección en el melanoma acral no está claramente establecida. Objetivo: Investigar si la escisión con margen estrecho es adecuada en el melanoma acral grueso. Métodos: Se estudiaron 306 pacientes con melanoma acral. Conforme a la extensión del margen quirúrgico (de 1 a 2 cm y > 2 cm), se analizaron los factores asociados a la recurrencia y la supervivencia. Resultados: De 306 pacientes, 183 fueron mujeres (59.8 %). La mediana del grosor de Breslow fue 6 mm; 224 casos (73.2 %) fueron de tipo ulcerados, 154 pacientes (50.3 %) tenían enfermedad en estadio clínico III, 137 en II (44.8 %) y 15 en IV (4.9 %). Todos los casos presentaron margen negativo, con una mediana de 31.5 mm. Un grosor de Breslow de 7 mm (p = 0.001) y la etapa clínica III (p = 0.031) se asociaron a recurrencia; los factores asociados a la supervivencia fueron el índice de Breslow (p = 0.047), la ulceración (p = 0.003), la etapa clínica avanzada (p < 0.001) y el uso de adyuvancia (p = 0.003). Conclusión: Un margen de resección de 1 a 2 cm no afectó la recurrencia tumoral ni la supervivencia en los pacientes con melanoma acral.

Abstract Introduction: Appropriate size of resection margins in acral melanoma is not clearly established. Objective: To investigate whether narrow-margin excision is appropriate for thick acral melanoma. Methods: Three-hundred and six patients with acral melanoma were examined. Factors associated with recurrence and survival were analyzed according to surgical margin size (1 to 2 cm and > 2 cm). Results: Out of 306 patients, 183 were women (59.8%). Median Breslow thickness was 6 mm; 224 cases (73.2%) were ulcerated, 154 patients (50.3%) had clinical stage III disease, while 137 were at stage II (44.8%) and 15 at stage IV (4.9%). All cases had negative margins, with a median of 31.5 mm. A Breslow thickness of 7 mm (p = 0.001) and clinical stage III (p = 0.031) were associated with recurrence; the factors associated with survival were Breslow index (p = 0.047), ulceration (p = 0.003), advanced clinical stage (p < 0.001), and use of adjuvant therapy (p = 0.003). Conclusion: A resection margin of 1 to 2 cm did not affect tumor recurrence or survival in patients with acral melanoma.

Lymph node retrieval in radical gastrectomy: the pathologist alone or the surgeon-pathologist team?

INTRODUCTION: Lymph node (LN) dissection is an important prognostic factor in gastric cancer. There is little information comparing the LN count depending on whether they are dissected in the operating room or in the pathology laboratory. AIM: To establish if the LN count is greater in either of them. MATERIAL AND METHODS: From 2015 to 2017 all consecutive gastrectomies with D2 dissection were prospectively evaluated based in either of 2 protocols: One started in the operating room where the surgeon separated the LN levels and then submitted the entire adipose tissue with LNs (undissected) to pathology in separate containers; the pathologist dissected the LNs from the specimens. The second protocol consisted of sending the tissue/LNs to pathology as usual (adipose tissue and LN attached to the stomach). RESULTS: A total of 83 patients were analysed. The mean age was 58.4 years. The median number of LNs dissected in the protocol starting in the operating room was 56 (IQR: 37-74), whereas the pathology laboratory dissected a median of 39 LNs (IQR 26-53) (p = 0.005). The survival of cases dissected by both protocols were comparable (median survival of 48 and 43 months, p = 0.316). CONCLUSIONS: The LN final count is significantly higher when LN levels are separated beforehand in the operating room compared to dissection only in pathology; however, this does not impact survival, perhaps because the number of dissected nodes in both groups is high and the quality of the surgery is good.

Role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of gastric cancer.

Patients with peritoneal carcinomatosis (PC) of gastric origin have a poor prognosis of life with an average survival of 1-3 months. Systemic chemotherapy has improved the survival of those patients with gastric metastatic cancer at 7-10 months. However, this benefit could not be reproduced in those patients with PC. The current literature for the use of hyperthermic intraperitoneal chemotherapy (HIPEC) for gastric PC has significant variation related to patient selection, treatment intent (palliative vs. attempt at curative treatment), surgical technique, intraperitoneal chemotherapy agent utilized, and systemic chemotherapy administered adjuvantly. From the perspective of patient selection for cytoreduction and HIPEC, patients with extensive PC are not candidates. In addition, unresectable location would make a patient a poor candidate for cytoreduction and HIPEC. Optimally, those with positive peritoneal cytology alone could benefit most. However, the role of cytoreductive surgery and HIPEC in patients with PC of gastric origin has not yet been clarified.

Los pacientes con carcinomatosis peritoneal (CP) de origen gástrico tienen un mal pronóstico de vida, con una supervivencia media de 1 a 3 meses. La quimioterapia sistémica ha mejorado la supervivencia de los pacientes con cáncer gástrico metastásico a los 7-10 meses. Sin embargo, este beneficio no se ha podido reproducir en los pacientes con CP. En cuanto a lo relacionado con la literatura actual para el uso de HIPEC (hyperthermic intraperitoneal chemotherapy) en la CP de origen gástrico, existe una variación significativa en la selección de pacientes, la intención de tratamiento (paliativo frente a intento de tratamiento curativo), la técnica quirúrgica, el agente quimioterapéutico intraperitoneal utilizado y la quimioterapia sistémica adyuvante administrada. Desde la perspectiva de la selección de pacientes para citorreducción y tratamiento con HIPEC, los pacientes con CP extensa no son candidatos. Además, lesiones irresecables por su localización harían al paciente un pobre candidato para citorreducción y tratamiento con HIPEC. De manera óptima, aquellos pacientes con citología peritoneal positiva en ausencia de CP son quienes más podrían beneficiarse. Sin embargo, el papel de la cirugía citorreductora y del tratamiento con HIPEC en los pacientes con CP de origen gástrico aún no ha sido esclarecido.

[Resultados quirúrgicos de histerectomía radical laparoscópica en pacientes con cáncer de cérvix en etapa temprana: experiencia inicial en Instituto de Cáncer]. / Surgical outcomes of laparoscopic radical hysterectomy for patients with early cervical cancer: Initial experience in Cancer Institute.

ANTECEDENTES: La histerectomía radical abierta con linfadenectomía pélvica bilateral es el tratamiento estándar para el cáncer de cérvix uterino (CACU) en etapas temprana (1A2-1B1); la histerectomía radical por laparoscopia (HRL) es una opción segura y viable. OBJETIVO: Evaluar la seguridad y la factibilidad de la HRL en un centro hospitalario de atención de cáncer. MÉTODO: Estudio retrospectivo que incluyó 17 pacientes con CACU en etapa temprana intervenidas con HRL entre abril de 2013 y noviembre de 2016 en el Instituto Nacional de Cancerología de México. RESULTADOS: Las 17 pacientes se encontraban en etapa clínica IB1, en 10 (58.8%) fue subtipo epidermoide, en 4 (23.5%) adenocarcinoma y en 3 (17.6%) adenoescamoso. La media de edad fue de 42 ± 8 años. El tamaño del tumor fue de 2.3 ± 0.9 cm, y en el 94.1% los márgenes quirúrgicos estaban libres de enfermedad. El promedio de tiempo operatorio fue de 341 ± 65 minutos, con una pérdida sanguínea de 107 ± 64 ml, no requirieron trasfusión sanguínea y no hubo conversión a cirugía abierta. La media de estancia hospitalaria fue de 2.7 días (rango: 2-7 días). No se presentaron complicaciones intraoperatorias ni posoperatorias. CONCLUSIONES: La HRL es una alternativa segura y confiable para el tratamiento del CACU en etapa temprana. BACKGROUND: Open radical hysterectomy with bilateral pelvic lymphadenectomy is the standard treatment in early stages (1A2-1B1) of uterine cervical cancer (UCC); laparoscopic radical hysterectomy (LRH) is a safe and viable option. OBJECTIVE: To evaluate the safety and feasibility of LRH in a hospital cancer care center. METHOD: Retrospective study that included the first 17 patients with UCC in an early stage operated with LRH in the period from April 2013 to November 2016 at the National Cancer Institute of Mexico. RESULTS: The 17 patients were stage IB1 clinical, of which 10 (58.8%) was epidermoid subtype, 4 (23.5%) adenocarcinoma and 3 (17.6%) adenoescamoso. The mean age was 42 ± 8 years. The tumor size was 2.3 ± 0.9 cm, and in 94.1% the surgical margins were free of disease. The average operative time was 341 ± 65 minutes and blood loss of 107 ± 64 ml, no patient required blood transfusion and there was no case of conversion to open surgery. The average length of hospital stay was 2.7 days (range: 2-7 days). There were no intraoperative or postoperative complications. CONCLUSIONS: LRH is a safe and reliable alternative for the treatment of early stage UCC.

Prognosis of Signet Ring Cell Carcinoma of the Colon and Rectum and their Distinction of Mucinous Adenocarcinoma with Signet Ring Cells. A Comparative Study.

Signet ring cell carcinoma (SRCC) of the colorectum is very rare, comprising between <1% and 2.4% cases of colorectal cancer. Patients' prognoses are poor. Several case reports had described as SRCC cases that are mucinous adenocarcinomas (MAC) with signet ring cells (SRC). In order to clearly delineate between MAC with SRC and SRCC, we performed a retrospective study at a national cancer referral center in which survival and clinicopathological characteristics between these two forms were compared and also SRCC were characterized by immunohistochemistry. We retrieved 32 cases that had been classified as either SRCC or MAC with SRC subtypes. It was noted that SRCC patients presented at older ages, demonstrated more advanced clinical stages, lymphovascular invasion, lymph node metastases, and higher carcinoembrionic levels than MAC with SRC patients. Regarding SRCC immunophenotype, 50% showed loss of CDX2 expression, 33% were CK20 negative, 41.7% were CK7 positive, and 25% were negative for both CK7 and CK20. For the MAC with SRC and SRCC groups, the median disease-specific survival (DSS) was 46.1 months (95% CI 36.9-55.25) and 22.4 months (95% CI 5.1-39.7 [p = 0.039]), respectively. The 3-year DSS was 80.7% and 28.6% (p = 0.017) for the MAC and SRCC patients, respectively. Univariate and multivariate analyses showed that SRCC was associated with decreased survival. SRCC had several clinicopathological features that permitted differentiation of MAC with SRC from SRCC patients, who had a poor DSS. A differential diagnosis for metastatic gastric cancer is only possible with a good clinicopathological correlation.

Outcome of young patients with rectal adenocarcinoma.

BACKGROUND: There is an increase in the incidence of rectal carcinoma (RC) in young patients. METHODS: We analyzed 175 patients with sporadic RC which were divided in two groups according their age: 24 patients ≤40 years and 151 patients >40 years and the two groups were compared in order to determine if the outcomes (especially overall 5-year survival) were different. RESULTS: Overall 5-year survival was similar between groups (67.1% for patients over 40 years and 70.4% for those under 40 years, P=0.803). The only differences found were in some clinicopathologic features: patients <40 years showed more dissected lymph nodes (LNs) (21 vs. 15, P=0.035) and more LN metastasis (54.2% vs. 39.1%, P=0.048). In multivariate analysis factors associated with worse survival were incomplete resection and no use of neoadjuvant therapy. Age did not demonstrate prognostic value (P=0.077). CONCLUSIONS: RC in people ≤40 years demonstrated greater number of LN harvested and LN metastases but oncologic outcomes, especially 5-year overall survival, were similar between groups.

Primary retroperitoneal Merkel cell carcinoma: Case report and literature review.

BACKGROUND: Merkel cell carcinoma (MCC) is an aggressive cutaneous neuroendocrine carcinoma that affects elderly patients and typically arises in sun-exposed skin. The disease is very rare and only few cases present with no apparent skin lesion. In the retroperitoneum there are only two cases reported in the literature. CASE PRESENTATION: We report a case of a 54-year-old Mexican male with MCC, which presented as a large retroperitoneal mass. Pathological and immunohistochemical analysis of the transabdominal CT-guided biopsy specimen revealed a MCC. The patient underwent preoperative chemotherapy followed by a laparotomy and the mass was successfully excised. DISCUSSION: There are two possible explanations for what occurred in our patient. The most plausible theory is the retroperitoneal mass could be a massively enlarged lymph node where precursor cells became neoplastic. This would be consistent with a presumptive diagnosis of primary nodal disease. Moreover, metastasis to the retroperitoneal lymph nodes has been reported as relatively common when compared to other sites such as liver, bone, brain and skin. The less probable theory is the non-described "regression" phenomena of a cutaneous MCC, but we are not found a primary skin lesion. CONCLUSION: Preoperative chemotherapy and excision of the primary tumor is the surgical treatment of choice for retroperitoneal MCC. We propose that further studies are needed to elucidate the true efficacy of chemotherapy in conventional and unconventional patients with MCC.