Robotic versus laparoscopic gastrectomy for gastric cancer: A Western propensity score matched analysis.

BACKGROUND: Robot-assisted gastrectomy (RG) has been shown to be safe and feasible in the treatment of gastric cancer (GC). However, it is unclear whether RG is equivalent to laparoscopic gastrectomy (LG), especially in the Western world. Our objective was to compare the outcomes of RG and LG in GC patients. METHODS: We reviewed all gastric adenocarcinoma patients who underwent curative gastrectomy by minimally invasive approach in our institution from 2009 to 2022. Propensity score matching (PSM) analysis was conducted to reduce selection bias. DaVinci Si platform was used for RG. RESULTS: A total of 156 patients were eligible for inclusion (48 RG and 108 LG). Total gastrectomy was performed in 21.3% and 25% of cases in LG and RG, respectively. The frequency of stage pTNM II/III was 48.1%, and 54.2% in the LG and RG groups (p = 0.488). After PSM, 48 patients were matched in each group. LG and RG had a similar number of dissected lymph nodes (p = 0.759), operative time (p = 0.421), and hospital stay (p = 0.353). Blood loss was lower in the RG group (p = 0.042). The major postoperative complications rate was 16.7% for LG and 6.2% for RG (p = 0.109). The 30-day mortality rate was 2.1% and 0% for LG and RG, respectively (p = 1.0). There was no significant difference between the LG and RG groups for disease-free survival (79.6% vs. 61.2%, respectively; p = 0.155) and overall survival (75.9% vs. 65.7%, respectively; p = 0.422). CONCLUSION: RG had similar surgical and long-term outcomes compared to LG, with less blood loss observed in RG.

Prognostic implications of tumor-infiltrating lymphocytes within the tumor microenvironment in gastric cancer.

BACKGROUND: Tumor-infiltrating lymphocytes (TILs) play a regulatory role in the tumor-associated immune response and are important in the prognosis and treatment response of several cancers. However, because of its heterogeneity, the prognostic value of TILs in gastric cancer (GC) is still controversial. Thus, this study aimed to investigate the association between the density of TILs and patients' outcomes in GC. METHODS: Patients with gastric adenocarcinoma who underwent curative intent gastrectomy were retrospectively investigated. The groups for analysis were determined on the basis of TIL intensity and percentage of CD3+ T-cell infiltration by immunohistochemical. Furthermore, Epstein-Barr virus (EBV), microsatellite instability (MSI), T-cell ratio of CD4 to CD8, and programmed death protein ligand 1 (PD-L1) status were evaluated. RESULTS: A total of 345 patients were enrolled: 124 patients with GCs (35.9%) were classified as the low-CD3+ TIL group, and 221 patients with GCs (64.1%) were classified as the high-CD3+ TIL group. Poorly differentiated histology (P = .014), EBV-positive status (P < .001), PD-L1-positive status (P = .001), and CD4 < CD8 (P < .001) were associated with high-CD3+ GC. There was no difference regarding MSI status, the degree of tumor invasion (pT), the presence of lymph node metastasis, and pTNM stage between low- and high-CD3+ groups. In survival analysis, the high-CD3+ group had better disease-free survival and overall survival rates than had the low-CD3+ group (P = .055 and P = .041, respectively). In the multivariate analysis, total gastrectomy, lymph node metastasis, advanced pT stage, and low CD3+ levels were independent factors related to worse survival. CONCLUSION: High CD3+ TILs levels were significantly associated with improved survival and could serve as prognostic biomarkers in GC. In addition, CD3+ T-cell infiltration was related to both EBV-positive and PD-L1-positive GC and may assist in the investigation of targets in immunotherapy.

Pancreatoduodenectomy with Venous Resection or Palliative Therapy? A Meta-Analysis.

This review evaluated the risks and survival benefits of pancreatoduodenectomy associated with venous resection compared with palliative surgery. A systematic review with meta-analysis was performed. Higher overall survival was observed in the pancreatic resection group (HR = 4.000; 95% CI 2.800 to 5.200). However, the palliative group had fewer complications (RD = -0.170; 95% CI -0.260 to -0.070). There was no significant difference in the mortality rates (RD = 0.000; 95% CI -0.030 to 0.030). In centres with experience in pancreatic surgery, resection may be considered for locally advanced cancer and major venous invasion. Pancreaticoduodenectomy with vascular resection may improve survival for periampullary tumours compared with palliation therapy. However, pancreaticoduodenectomy with major venous resection has potentially higher morbidity than palliation therapy. Key Words: Pancreatoduodenectomy, Pancreatic neoplasms, Vascular surgical procedures.

FAILURE TO RESCUE AFTER GASTRECTOMY: A NEW INDICATOR OF SURGICAL QUALITY.

BACKGROUND: The main treatment modality for gastric cancer is surgical resection with lymphadenectomy. Despite advances in perioperative care, major surgical complications can occur in up to 20% of cases. To determine the quality of surgical care employed, a new indicator called failure to rescue (FTR) was proposed, which assesses the percentage of patients who die after complications occur. AIMS: To assess the rate of FTR after gastrectomy and factors associated with its occurrence. METHODS: Patients with gastric cancer who underwent gastrectomy with curative intent were retrospectively evaluated. According to the occurrence of postoperative complications, patients were divided into FTR group (grade V complications) and rescued group (grade III/IV complications). RESULTS: Among the 731 patients, 114 had major complications. Of these patients, 76 (66.7%) were successfully treated for the complication (rescued group), while 38 (33.3%) died (FTR group). Patients in the FTR group were older (p=0.008; p<0.05), had lower levels of hemoglobin (p=0.021; p<0.05) and albumin (p=0.002; p<0.05), and a higher frequency of ASA III/IV (p=0.033; p<0.05). There were no differences between the groups regarding surgical and pathological characteristics. Clinical complications had a higher mortality rate (40.0% vs 30.4%), with pulmonary complications (50.2%) and infections (46.2%) being the most lethal. Patients with major complications grade III/IV had worse survival than those without complications. CONCLUSIONS: The FTR rate was 33.3%. Advanced age, worse performance, and nutritional parameters were associated with FTR.

Preoperative albumin-bilirubin score is a prognostic factor for gastric cancer patients after curative gastrectomy.

BACKGROUND: Albumin-bilirubin (ALBI) score is an indicator of liver dysfunction and is useful for predicting prognosis of hepatocellular carcinomas. Currently, this liver function index has been used to predict prognosis in other neoplasms. However, the significance of ALBI score in gastric cancer (GC) after radical resection has not been elucidated. AIM: To evaluate the prognostic value of the preoperative ALBI status in patients with GC who received curative treatment. METHODS: Patients with GC who underwent curative intended gastrectomy were retrospectively evaluated from our prospective database. ALBI score was calculated as follows: (log10 bilirubin × 0.660) + (albumin × -0.085). The receiver operating characteristic curve with area under the curve (AUC) was plotted to evaluate the ability of ALBI score in predicting recurrence or death. The optimal cutoff value was determined by maximizing Youden's index, and patients were divided into low and high-ALBI groups. The Kaplan-Meier curve was used to analyze the survival, and the log-rank test was used for comparison between groups. RESULTS: A total of 361 patients (235 males) were enrolled. The median ALBI value for the entire cohort was -2.89 (IQR -3.13; -2.59). The AUC for ALBI score was 0.617 (95%CI: 0.556-0.673, P < 0.001), and the cutoff value was -2.82. Accordingly, 211 (58.4%) patients were classified as low-ALBI group and 150 (41.6%) as high-ALBI group. Older age (P = 0.005), lower hemoglobin level (P < 0.001), American Society of Anesthesiologists classification III/IV (P = 0.001), and D1 lymphadenectomy P = 0.003) were more frequent in the high-ALBI group. There was no difference between both groups in terms of Lauren histological type, depth of tumor invasion (pT), presence of lymph node metastasis (pN), and pathologic (pTNM) stage. Major postoperative complication, and mortality at 30 and 90 days were higher in the high-ALBI patients. In the survival analysis, the high-ALBI group had worse disease-free survival (DFS) and overall survival (OS) compared to those with low-ALBI (P < 0.001). When stratified by pTNM, the difference between ALBI groups was maintained in stage I/II and stage III CG for DFS (P < 0.001 and P = 0.021, respectively); and for OS (P < 0.001 and P = 0.063, respectively). In multivariate analysis, total gastrectomy, advanced pT stage, presence of lymph node metastasis and high-ALBI were independent factors associated with worse survival. CONCLUSION: The preoperative ALBI score is able to predict the outcomes of patients with GC, where high-ALBI patients have worse prognosis. Also, ALBI score allows risk stratification of patients within the same pTNM stages, and represents an independent risk factor associated with survival.

INTRAPERITONEAL CHEMOTHERAPY FOR GASTRIC CANCER WITH PERITONEAL CARCINOMATOSIS: STUDY PROTOCOL OF A PHASE II TRIAL.

BACKGROUND: Peritoneal carcinomatosis in gastric cancer is considered a fatal disease, without expectation of definitive cure. As systemic chemotherapy is not sufficient to contain the disease, a multimodal approach associating intraperitoneal chemotherapy with surgery may represent an alternative for these cases. AIMS: The aim of this study was to investigate the role of intraperitoneal chemotherapy in stage IV gastric cancer patients with peritoneal metastasis. METHODS: This study is a single institutional single-arm prospective clinical trial phase II (NCT05541146). Patients with the following inclusion criteria undergo implantation of a peritoneal catheter for intraperitoneal chemotherapy: Stage IV gastric adenocarcinoma; age 18-75 years; Peritoneal carcinomatosis with peritoneal cancer index<12; Eastern Cooperative Oncology Group 0/1; good clinical status; and lab exams within normal limits. The study protocol consists of four cycles of intraperitoneal chemotherapy with paclitaxel associated with systemic chemotherapy. After treatment, patients with peritoneal response assessed by staging laparoscopy undergo conversion gastrectomy. RESULTS: The primary outcome is the rate of complete peritoneal response. Progression-free and overall survivals are other outcomes evaluated. The study started in July 2022, and patients will be screened for inclusion until 30 are enrolled. CONCLUSIONS: Therapies for advanced gastric cancer patients have been evaluated in clinical trials but without success in patients with peritoneal metastasis. The treatment proposed in this trial can be promising, with easy catheter implantation and ambulatory intraperitoneal chemotherapy regime. Verifying the efficacy and safety of paclitaxel with systemic chemotherapy is an important progress that this study intends to investigate.

Gastroduodenal Perforation in Cancer Patients: Association with Chemotherapy and Prognosis.

BACKGROUND: Gastroduodenal perforation stands out as one of the complications in cancer patients. Despite its high mortality, its characteristics are still poorly described. This study aimed to evaluate the characteristics and outcomes of cancer patients who had gastroduodenal perforation, and the influence of chemotherapy (CMT) in these cases. METHOD: A retrospective analysis of patients who underwent emergency surgery with an intraoperative finding of gastroduodenal perforation. Patients who performed CMT within 60 days before perforation were considered as the CMT group. RESULTS: Among 45 patients included, 16 (35.5%) were classified as the CMT group and the remaining 29 (64.5%) patients as the non-CMT group. There was no difference between the groups regarding sex, age, BMI, comorbidity, and laboratory exams. ECOG 2-3 was significantly more frequent in the CMT group (68.8% vs. 34.5% p = 0.027). Major postoperative complications were similar between both groups (75% vs. 58.6%, p = 0.272). The sepsis of abdominal focus was the main postoperative complication. The 30-day mortality was 55.6%, with no difference between non-CMT and CMT groups (62.5% vs. 51.7%, respectively; p = 0.486). A multivariate analysis of risk factors showed that only an age of ≥65 years was related to 30-day mortality. CONCLUSIONS: Patients with gastroduodenal perforation and oncologic treatment present high mortality, regardless of receiving recent CMT.

STAGING LAPAROSCOPY IS STILL A VALUABLE TOOL FOR OPTIMAL GASTRIC CANCER MANAGEMENT.

BACKGROUND: Complete surgical resection is the main determining factor in the survival of advanced gastric cancer patients, but is not indicated in metastatic disease. The peritoneum is a common site of metastasis and preoperative imaging techniques still fail to detect it. AIM: The aim of this study was to evaluate the role of staging laparoscopy in the staging of advanced gastric cancer patients in a Western tertiary cancer center. METHODS: A total of 130 patients with gastric adenocarcinoma who underwent staging laparoscopy from 2009 to 2020 were evaluated from a prospective database. Clinicopathological characteristics were analyzed to identify factors associated with the presence of peritoneal metastasis and were also evaluated the accuracy and strength of agreement between computed tomography and staging laparoscopy in detecting peritoneal metastasis and the change in treatment strategy after the procedure. RESULTS: The peritoneal metastasis was identified in 66 (50.76%) patients. The sensitivity, specificity, and accuracy of computed tomography in detecting peritoneal metastasis were 51.5, 87.5, and 69.2%, respectively. According to the Kappa coefficient, the concordance between staging laparoscopy and computed tomography was 38.8%. In multivariate analysis, ascites (p=0.001) and suspected peritoneal metastasis on computed tomography (p=0.007) were statistically correlated with peritoneal metastasis. In 40 (30.8%) patients, staging and treatment plans changed after staging laparoscopy (32 patients avoided unnecessary laparotomy, and 8 patients, who were previously considered stage IVb by computed tomography, were referred to surgical treatment). CONCLUSION: The staging laparoscopy demonstrated an important role in the diagnosis of peritoneal metastasis, even with current advances in imaging techniques.

Intraperitoneal chemotherapy for gastric cancer with peritoneal carcinomatosis: study protocol of a phase ii trial / Quimioterapia intraperitoneal para o câncer gástrico com carcinomatose peritoneal: protocolo de estudo de um ensaio de fase ii

ABSTRACT BACKGROUND: Peritoneal carcinomatosis in gastric cancer is considered a fatal disease, without expectation of definitive cure. As systemic chemotherapy is not sufficient to contain the disease, a multimodal approach associating intraperitoneal chemotherapy with surgery may represent an alternative for these cases. AIMS: The aim of this study was to investigate the role of intraperitoneal chemotherapy in stage IV gastric cancer patients with peritoneal metastasis. METHODS: This study is a single institutional single-arm prospective clinical trial phase II (NCT05541146). Patients with the following inclusion criteria undergo implantation of a peritoneal catheter for intraperitoneal chemotherapy: Stage IV gastric adenocarcinoma; age 18-75 years; Peritoneal carcinomatosis with peritoneal cancer index<12; Eastern Cooperative Oncology Group 0/1; good clinical status; and lab exams within normal limits. The study protocol consists of four cycles of intraperitoneal chemotherapy with paclitaxel associated with systemic chemotherapy. After treatment, patients with peritoneal response assessed by staging laparoscopy undergo conversion gastrectomy. RESULTS: The primary outcome is the rate of complete peritoneal response. Progression-free and overall survivals are other outcomes evaluated. The study started in July 2022, and patients will be screened for inclusion until 30 are enrolled. CONCLUSIONS: Therapies for advanced gastric cancer patients have been evaluated in clinical trials but without success in patients with peritoneal metastasis. The treatment proposed in this trial can be promising, with easy catheter implantation and ambulatory intraperitoneal chemotherapy regime. Verifying the efficacy and safety of paclitaxel with systemic chemotherapy is an important progress that this study intends to investigate.

RESUMO RACIONAL: A carcinomatose peritoneal no câncer gástrico é considerada uma doença fatal, sem expectativa de cura definitiva. Como a quimioterapia sistêmica não é suficiente para conter a doença, uma abordagem multimodal associando a quimioterapia intraperitoneal à cirurgia pode representar uma alternativa para esses casos. OBJETIVOS: Investigar o papel da quimioterapia intraperitoneal em pacientes com câncer gástrico estágio IV com metástases peritoneais. MÉTODOS: Trata-se de um ensaio clínico prospectivo unicêntrico, braço único, fase II (NCT05541146). Pacientes com os seguintes critérios de inclusão serão submetidos à implantação de cateter peritoneal para quimioterapia intraperitoneal: adenocarcinoma gástrico estágio IV; idade 18-75 anos; carcinomatose peritoneal com índice de câncer peritoneal<12; ECOG 0/1; bom estado clínico e exames laboratoriais dentro da normalidade. O protocolo do estudo consiste em 4 ciclos de quimioterapia intraperitoneal com Paclitaxel associado à quimioterapia sistêmica. Após o tratamento, os pacientes com resposta peritoneal avaliada por laparoscopia serão submetidos à gastrectomia de conversão. RESULTADOS: O desfecho primário é a taxa de resposta peritoneal completa. A sobrevida livre de progressão e global são outros desfechos avaliados. O estudo foi iniciado em julho de 2022 e os pacientes serão selecionados para inclusão até que 30 sejam inscritos. CONCLUSIONS: Terapias para pacientes com câncer gástrico avançado foram avaliadas em ensaios clínicos, mas sem sucesso em pacientes com metástase peritoneal. O tratamento proposto neste estudo pode ser promissor, com fácil implantação do cateter e regime de quimioterapia intraperitoneal ambulatorial. Verificar a eficácia e segurança do Paclitaxel associado à quimioterapia sistêmica é um progresso importante que o presente estudo pretende investigar.

Short-Term Surgical Outcomes of Robotic Gastrectomy Compared to Open Gastrectomy for Patients with Gastric Cancer: a Randomized Trial.

BACKGROUND: Robotic gastrectomy (RG) has been shown to be a safe and feasible method in gastric cancer (GC) treatment. However, most studies are in Eastern cohorts and there is great interest in knowing whether the method can be used routinely, especially in the West. OBJECTIVES: The aim of this study was to compare the short-term surgical outcomes of D2-gastrectomy by RG versus open gastrectomy (OG). METHODS: Single-institution, open-label, non-inferiority, randomized clinical trial performed between 2015 and 2020. GC patients were randomized (1:1 allocation) to surgical treatment by RG or OG. Da Vinci Si platform was used. INCLUSION CRITERIA: gastric adenocarcinoma, stage cT2-4 cN0-1, potentially curative surgery, age 18-80 years, and ECOG performance status 0-1. EXCLUSION CRITERIA: emergency surgery and previous gastric or major abdominal surgery. Primary endpoint was short-term surgical outcomes. The study is registered at clinicaltrials.gov (NCT02292914). RESULTS: Of 65 randomized patients, 5 were excluded (3 palliatives, 1 obstruction and emergency surgery, and 1 for material shortage). Consequently, 31 and 29 patients were included for final analysis in the OG and RG groups, respectively. No differences were observed between groups regarding age, sex, BMI, comorbidities, ASA, and frequency of total gastrectomy. RG had similar mean number of harvested lymph nodes (p = 0.805), longer surgical time (p < 0.001), and less bleeding (p < 0.001) compared to OG. Postoperative complications, length of hospital stay, and readmissions in 30 days were equivalent between OG and RG. CONCLUSIONS: RG reduces operative bleeding by more than 50%. The short-term outcomes were non-inferior to OG, although surgical time was longer in RG.

Multivisceral resection compared to standard gastrectomy for gastric adenocarcinoma: A propensity score-matching analysis.

BACKGROUND: Multivisceral resection (MVR) in locally advanced gastric cancer (GC) is a morbid procedure. However, the precise impact of removing additional organs remains controversial. This study aimed to compare the outcomes of MVR versus standard gastrectomy (SG) in an unbiased cohort. METHODS: Patients who underwent curative-intent surgery for gastric adenocarcinoma were considered. Those submitted to SG were compared to the ones who received MVR using Propensity Score Matching (PSM) analysis. RESULTS: A total of 685 GC patients were included (621 SG and 64 MVR). Groups were distinct concerning the extent of the gastrectomy, tumor size, pTNM, R0, postoperative complications, and 90-day mortality. After PSM, 57 patients were matched in each group. All variables assigned in the score were well matched. Postoperative complication, 90-day mortality, and overall survival (OS) became similar among groups. Age >65 years old and resection of two or more organs, besides the stomach, were factors associated with 90-day mortality. R1 and not received multimodal therapy were independent prognostic factors for worse OS. CONCLUSIONS: After PSM, the difference in morbidity, mortality, and survival of MVR compared to SG was no longer statistically significant, suggesting that MVR is an acceptable therapeutic strategy to patients with advanced GC.

Esophagojejunostomy after total gastrectomy: A systematic review and meta-analysis comparing hand-sewn and stapled anastomosis.

This review aims to evaluate the surgical outcomes of hand-sewn esophageal anastomosis compared to mechanical anastomosis to reconstruct total gastrectomy. A systematic review and meta-analysis of comparative studies evaluating hand-sewn and stapled anastomosis were performed. A total of 12 studies were selected, comprising 1761 individuals. The results indicate that the hand-sewn and stapled esophageal anastomosis have similar surgical outcomes. Stapled anastomosis has a shorter operation time.

SURGICAL TREATMENT IN CLINICAL STAGE IV GASTRIC CANCER: A COMPARISON OF DIFFERENT PROCEDURES AND SURVIVAL OUTCOMES.

AIM: Even in clinical stage IV gastric cancer (GC), surgical procedures may be required to palliate symptoms or in an attempt to improve survival. However, the limited survival of these patients raises doubts about who really had benefits from it. This study aimed to analyze the surgical outcomes in stage IV GC treated with surgical procedures without curative intent. METHODS: Retrospective analyses of patients with stage IV GC submitted to surgical procedures including tumor resection, bypass, jejunostomy, and diagnostic laparoscopy were performed. Patients with GC undergoing curative gastrectomy served as the comparison group. RESULTS: Surgical procedures in clinical stage IV were performed in 363 patients. Compared to curative surgery (680 patients), stage IV patients had a higher rate of comorbidities and ASA III/IV classification. The surgical procedures that were performed included 107 (29.4%) bypass procedures (partitioning/gastrojejunal anastomosis), 85 (23.4%) jejunostomies, 76 (20.9%) resections, and 76 (20.9%) diagnostic laparoscopies. Regarding patients' characteristics, resected patients had more distant metastasis (p=0.011), bypass patients were associated with disease in more than one site (p<0.001), and laparoscopy patients had more peritoneal metastasis (p<0.001). According to the type of surgery, the median overall survival was as follows: resection (13.6 months), bypass (7.8 months), jejunostomy (2.7 months), and diagnostic (7.8 months, p<0.001). On multivariate analysis, low albumin levels, in case of more than one site of disease, jejunostomy, and laparoscopy, were associated with worse survival. CONCLUSION: Stage IV resected cases have better survival, while patients submitted to jejunostomy and diagnostic laparoscopy had the worst results. The proper identification of patients who would benefit from surgical resection may improve survival and avoid futile procedures.

CARNOY'S SOLUTION INCREASES LYMPH NODES COUNT IN COLON CANCER SPECIMENS WHEN COMPARED TO FORMALIN FIXATION: A RANDOMIZED TRIAL.

AIM: At least 12 lymph nodes (LNs) should be examined following surgical resection of colon cancer. As it is difficult to find small LNs, fat clearing fixatives have been proposed, but there is no consensus about the best option. The objective of this study was to verify if Carnoy's solution (CS) increases the LN count in left colon cancer specimens. METHODS: A prospective randomized trial (clinicaltrials.gov registration: NCT02629315) with 60 patients with left colon adenocarcinoma who underwent rectosigmoidectomy. Specimens were randomized for fixation with CS or 10% neutral buffered formalin (NBF). After dissection, the pericolic fat from the NBF group was immersed in CS and re-dissected (Revision). The primary endpoint was the total number of LNs retrieved. RESULTS: Mean LN count was 36.6 and 26.8 for CS and NBF groups, respectively (p=0.004). The number of cases with <12 LNs was 0 (CS) and 3 (NBF, p=0.237). The duration of dissection was similar. LNs were retrieved in all cases during the revision (mean: 19, range: 4-37), accounting for nearly 40% of the LNs of this arm of the study. After the revision, no case was found in the NBF arm with <12 LNs. Two patients had metastatic LNs during the revision (no upstaging occurred). CONCLUSION: Compared to NBF, CS increases LN count in colon cancer specimens. After conventional pathologic analysis, fixing the pericolic fat with CS and performing a second dissection substantially increased the number of LNs.

THE PROGNOSIS OF THE DIFFERENT ESOPHAGEAL NEUROENDOCRINE CARCINOMA SUBTYPES: A POPULATION-BASED STUDY.

BACKGROUND: Neuroendocrine neoplasms are extremely rare and account for 0.4% to 2% of all malignant esophageal neoplasms. The burden of the neuroendocrine histological type on the patients' prognosis and survival is poorly debated. This study aimed to compare the survival rates of primary neuroendocrine neoplasms compared with adenocarcinoma and squamous cell carcinoma of the esophagus. METHODS: This is a retrospective cohort from the Surveillance, Epidemiology, and End Results Program database. Overall survival and cancer-specific survival were evaluated with Kaplan-Meier curves and logrank tests. Proportional Cox regression models were used to evaluate variables related to overall survival. RESULTS: After eligibility criteria, 66,528 patients were selected. The mean follow-up was 22.6 months (SD 35.6). Adenocarcinoma was predominant (62%), followed by squamous cell carcinoma (36%). Large cell carcinoma, small cell carcinoma, and mixed adenoneuroendocrine carcinoma each account for less than 1% each. On the long-term overall survival analysis, esophageal adenocarcinoma showed a better prognosis than all the other histologic types (P-value for logrank test <0.001). With adenocarcinoma as a reference, HR was 1.32 for large cell carcinoma (95%CI 1.2 to 1.45) and 1.37 for small cell carcinoma (95%CI 1.23 to 1.53). The HR was 1.22 for squamous cell carcinoma (95%CI: 1.2 to 1.24); and 1.3 for adenoneuroendocrine carcinoma (95%CI 1.01 to 1.66). For multivariate Cox regression analysis, besides age and stage, the neuroendocrine subtypes large cell carcinoma and small cell carcinoma were considered independent prognostic variables. CONCLUSION: In the esophagus, large cell carcinoma and small cell carcinoma show poorer long-term survival rates than squamous cell carcinoma and adenocarcinoma.

O prognóstico dos diferentes subtipos de carcinomas de esôfago neuroendócrinos: um estudo de base populacional / The prognosis of the different esophageal neuroendocrine carcinoma subtypes: a population-based study

ABSTRACT Background Neuroendocrine neoplasms are extremely rare and account for 0.4% to 2% of all malignant esophageal neoplasms. The burden of the neuroendocrine histological type on the patients' prognosis and survival is poorly debated. This study aimed to compare the survival rates of primary neuroendocrine neoplasms compared with adenocarcinoma and squamous cell carcinoma of the esophagus. Methods This is a retrospective cohort from the Surveillance, Epidemiology, and End Results Program database. Overall survival and cancer-specific survival were evaluated with Kaplan-Meier curves and logrank tests. Proportional Cox regression models were used to evaluate variables related to overall survival. Results After eligibility criteria, 66,528 patients were selected. The mean follow-up was 22.6 months (SD 35.6). Adenocarcinoma was predominant (62%), followed by squamous cell carcinoma (36%). Large cell carcinoma, small cell carcinoma, and mixed adenoneuroendocrine carcinoma each account for less than 1% each. On the long-term overall survival analysis, esophageal adenocarcinoma showed a better prognosis than all the other histologic types (P-value for logrank test <0.001). With adenocarcinoma as a reference, HR was 1.32 for large cell carcinoma (95%CI 1.2 to 1.45) and 1.37 for small cell carcinoma (95%CI 1.23 to 1.53). The HR was 1.22 for squamous cell carcinoma (95%CI: 1.2 to 1.24); and 1.3 for adenoneuroendocrine carcinoma (95%CI 1.01 to 1.66). For multivariate Cox regression analysis, besides age and stage, the neuroendocrine subtypes large cell carcinoma and small cell carcinoma were considered independent prognostic variables. Conclusion In the esophagus, large cell carcinoma and small cell carcinoma show poorer long-term survival rates than squamous cell carcinoma and adenocarcinoma.

RESUMO Contexto As neoplasias neuroendócrinas são extremamente raras e representam 0,4% a 2% de todas as neoplasias malignas do esôfago. A determinação prognóstica e avaliação de sobrevida para o tipo histológico neuroendócrino é pouco debatida. Este estudo teve como objetivo comparar as taxas de sobrevida de neoplasias neuroendócrinas primárias comparadas com adenocarcinoma e carcinoma espinocelular de esôfago. Métodos Este é um estudo coorte retrospectivo do banco de dados do Surveillance, Epidemiology, and End Results Program. A sobrevida global e a sobrevida específica do câncer foram avaliadas com curvas de Kaplan-Meier e testes de logrank. Modelos de regressão de Cox proporcional foram utilizados para avaliar as variáveis relacionadas à sobrevida global. Resultados Após critérios de elegibilidade, foram selecionados 66,528 pacientes. O seguimento médio foi de 22,6 meses (DP 35,6). O adenocarcinoma foi predominante (62%), seguido pelo carcinoma espinocelular (36%). Carcinoma de grandes células, carcinoma de pequenas células e carcinoma adenoneuroendócrino misto representam menos de 1% cada. Na análise de sobrevida global, o adenocarcinoma de esôfago apresentou um prognóstico melhor do que todos os outros tipos histológicos (P valor para teste de logrank < 0,001). Com adenocarcinoma como referência, HR foi de 1,32 para carcinoma de grandes células (IC95% 1,2 a 1,45) e 1,37 para carcinoma de pequenas células (IC95% 1,23 a 1,53). O HR foi de 1,22 para carcinoma espinocelular (IC95%: 1,2 a 1,24); e 1,3 para carcinoma adenoneuroendócrino (IC95% 1,01 a 1,66). Para a análise multivariada da regressão de Cox, além da idade e do estadiamento, os subtipos neuroendócrinos carcinoma de grandes células e carcinoma de pequenas células foram considerados variáveis prognósticas independentes. Conclusão No esôfago, o carcinoma de grandes células e o carcinoma de pequenas células apresentam menores taxas de sobrevida a longo prazo do que o carcinoma espinocelular e o adenocarcinoma.

SALVAGE SURGERY IN GASTRIC CANCER. / CIRURGIA DE RESGATE NO CÂNCER GÁSTRICO.

AIM: Salvage surgery (SS) is defined as surgical resection after the failure of the first treatment with curative intent. The aim of this study was to report the experience of a reference center with SS for stomach adenocarcinoma. METHODS: This is a retrospective study of patients with gastric cancer (GC) operated on between 2009 and 2020. RESULTS: Notably, 40 patients were recommended for salvage gastrectomy with curative-intent treatment. For analysis purpose, patients were divided into two groups: 23 patients after endoscopic resection and 17 patients after gastrectomy. In the first group, all patients underwent R0 resection, their average hospital length of stay (LOS) was 15.7 days, and 2 (8.6%) patients had major complications. During the average follow-up of 37.2 months, there was only one recurrence. The median overall survival (OS) was 46 months. In the postgastrectomy group, 9 (52.9%) patients were rescued with curative intent, the average hospital LOS was 12.2 days, and 3 (17.6%) had major complications. In a mean follow-up of 22 months, five patients relapsed. Median OS and disease-free survival were 24 and 16.5 months, respectively. CONCLUSION: SS in GC offers the possibility of long-term disease control and increased survival rate with an acceptable complication rate.

OBJETIVO: A cirurgia de resgate é definida como a ressecção cirúrgica após falha de primeiro tratamento com intuito curativo. Relatar a experiência de um centro de referência no tratamento do câncer gástrico com a cirurgia de resgate para o adenocarcinoma de estômago. MÉTODOS: Análise retrospectiva dos pacientes com câncer gástrico operados entre 2009 e 2020. RESULTADOS: 40 pacientes foram submetidos à tentativa de gastrectomia de resgate com intuito curativo. Para análise, foram divididos em dois grupos: 23 pacientes após ressecção endoscópica e 17 após gastrectomia. No primeiro grupo, todos tiveram ressecção com margens livres, a média de internação foi 15,7 dias e 2 (8,6%) tiveram complicações maiores. No seguimento médio de 37,2 meses, houve apenas 1 recidiva. A sobrevida global média foi 46 meses. No grupo pós-gastrectomia 9 (52,9%) foram resgatados com intenção curativa, a média de internação foi 12,2 dias e 3 (17,6%) apresentaram complicações maiores. No seguimento médio de 22 meses, 5 recidivaram. A sobrevida global média e a sobrevida livre de doença foram respectivamente: 24 e 16,5 meses. CONCLUSÃO: A cirurgia de resgate no câncer gástrico oferece nova possibilidade de controle da doença a longo prazo e/ou aumento de sobrevida, tendo taxa de complicações aceitáveis.

Prognostic implications of tumor-infiltrating lymphocytes in association with programmed cell death ligand 1 expression in remnant gastric cancer.

Objective: Remnant gastric cancer (RGC) is usually associated with a worse prognosis. As they are less common and very heterogeneous tumors, new prognostic and reliable determinants are required to predict patients' clinical course for RGC. This study aimed to investigate the tumor-infiltrating lymphocytes (TILs) and programmed cell death ligand 1 (PD-L1) status as prognostic biomarkers in a cohort of patients with RGC to develop an immune-related score. Methods: Patients with gastric cancer (GC) who underwent curative intent gastrectomy were retrospectively investigated. RGC resections with histological diagnosis of gastric adenocarcinoma were enrolled in the study. The risk score based on immune parameters was developed using binary logistic regression analysis. RGCs were divided into high-risk (HR), intermediate-risk (IR), and low-risk (LR) groups based on their immune score. The markers (CD3+, CD4+/CD8+ T cells and PD-L1) were selected for their potential prognostic, therapeutic value, and evaluated by immunohistochemistry (IHC). Results: A total of 42 patients with RGC were enrolled in the study. The score based on immune parameters exhibited an accuracy of 79% [the area under the receiver operating characteristic curve (AUC)=0.79, 95% confidence interval (95% CI), 0.63-0.94, P=0.002], and the population was divided into 3 prognostic groups: 10 (23.8%) patients were classified as LR, 15 (35.7%) as IR, and 17 (40.5%) as HR groups. There were no differences in clinicopathological and surgical characteristics between the three groups. In survival analysis, HR and IR groups had worse disease-free survival and overall survival rates compared to the LR group. In the multivariate analysis, lymph node metastasis and the immune score risk groups were independent factors related to worse survival. Conclusions: A scoring system with immune-related markers was able to distinguish prognostic groups of RGC associated with survival. Accordingly, tumor-infiltrating immune lymphocytes and PD-L1 status may serve as a potential prognostic biomarker for patients with RGC.

Surgical treatment in clinical stage iv gastric cancer: a comparison of different procedures and survival outcomes / Tratamento cirúrgico no câncer gástrico estágio clínico iv: uma comparação de diferentes procedimentos e resultados de sobrevida

ABSTRACT - BACKGROUND: Even in clinical stage IV gastric cancer (GC), surgical procedures may be required to palliate symptoms or in an attempt to improve survival. However, the limited survival of these patients raises doubts about who really had benefits from it. AIM: This study aimed to analyze the surgical outcomes in stage IV GC treated with surgical procedures without curative intent. METHODS: Retrospective analyses of patients with stage IV GC submitted to surgical procedures including tumor resection, bypass, jejunostomy, and diagnostic laparoscopy were performed. Patients with GC undergoing curative gastrectomy served as the comparison group. RESULTS: Surgical procedures in clinical stage IV were performed in 363 patients. Compared to curative surgery (680 patients), stage IV patients had a higher rate of comorbidities and ASA III/IV classification. The surgical procedures that were performed included 107 (29.4%) bypass procedures (partitioning/gastrojejunal anastomosis), 85 (23.4%) jejunostomies, 76 (20.9%) resections, and 76 (20.9%) diagnostic laparoscopies. Regarding patients' characteristics, resected patients had more distant metastasis (p=0.011), bypass patients were associated with disease in more than one site (p<0.001), and laparoscopy patients had more peritoneal metastasis (p<0.001). According to the type of surgery, the median overall survival was as follows: resection (13.6 months), bypass (7.8 months), jejunostomy (2.7 months), and diagnostic (7.8 months, p<0.001). On multivariate analysis, low albumin levels, in case of more than one site of disease, jejunostomy, and laparoscopy, were associated with worse survival. CONCLUSION: Stage IV resected cases have better survival, while patients submitted to jejunostomy and diagnostic laparoscopy had the worst results. The proper identification of patients who would benefit from surgical resection may improve survival and avoid futile procedures.

RESUMO - RACIONAL: Mesmo no câncer gástrico (CG) em estágio clínico IV (ECIV), procedimentos cirúrgicos podem ser necessários para aliviar sintomas ou na tentativa de melhorar a sobrevida. No entanto, a sobrevida limitada desses pacientes levanta dúvidas sobre quem realmente se beneficiaria. OBJETIVO: Analisar os resultados cirúrgicos do CG ECIV tratado com procedimentos cirúrgicos sem intenção curativa. MÉTODOS: Análise retrospectiva dos pacientes com CG ECIV submetido a procedimentos cirúrgicos, incluindo: ressecção tumoral, bypass, jejunostomia e laparoscopia diagnóstica. Pacientes submetidos à gastrectomia curativa serviram como grupo de comparação. RESULTADOS: Os procedimentos cirúrgicos em ECIV foram realizados em 363 pacientes. Comparado à cirurgia curativa (680 pacientes), os pacientes em ECIV apresentaram maior taxa de comorbidades e classificação ASA III/IV. Os procedimentos cirúrgicos realizados foram: 107 (29,4%) bypass (partição/anastomose gastrojejunal), 85 (23,4%) jejunostomias, 76 (20,9%) ressecções e 76 (20,9%) laparoscopias diagnósticas. Em relação às características dos pacientes, os ressecados apresentaram predomínio de metástases distantes (p=0,011); os de bypass associaram-se a doença em mais de um sítio (p<0,001); e os laparoscópicos, metástases peritoneais (p<0,001). A sobrevida global mediana de acordo com o tipo de cirurgia foi: ressecção (13,6 meses), bypass (7,8 meses), jejunostomia (2,7 meses) e diagnóstica (7,8 meses) (p<0,001). Na análise multivariada, níveis baixos de albumina, mais de um sítio de doença, jejunostomia e laparoscopia associaram-se a pior sobrevida. CONCLUSÃO: Pacientes em ECIV ressecados apresentam melhor sobrevida, enquanto aqueles submetidos à jejunostomia e laparoscopia diagnóstica tiveram piores resultados. A identificação adequada dos pacientes que se beneficiariam com a ressecção cirúrgica pode melhorar a sobrevida e evitar procedimentos pouco eficazes.

Carnoy's solution increases lymph nodes count in colon cancer specimens when compared to formalin fixation: a randomized trial / A solução de carnoy aumenta a contagem de linfonodos em espécimes de câncer de cólon quando comparada à fixação com formalina. um estudo randomizado

ABSTRACT - BACKGROUND: At least 12 lymph nodes (LNs) should be examined following surgical resection of colon cancer. As it is difficult to find small LNs, fat clearing fixatives have been proposed, but there is no consensus about the best option. AIM: The objective of this study was to verify if Carnoy's solution (CS) increases the LN count in left colon cancer specimens. METHODS: A prospective randomized trial (clinicaltrials.gov registration: NCT02629315) with 60 patients with left colon adenocarcinoma who underwent rectosigmoidectomy. Specimens were randomized for fixation with CS or 10% neutral buffered formalin (NBF). After dissection, the pericolic fat from the NBF group was immersed in CS and re-dissected (Revision). The primary endpoint was the total number of LNs retrieved. RESULTS: Mean LN count was 36.6 and 26.8 for CS and NBF groups, respectively (p=0.004). The number of cases with <12 LNs was 0 (CS) and 3 (NBF, p=0.237). The duration of dissection was similar. LNs were retrieved in all cases during the revision (mean: 19, range: 4-37), accounting for nearly 40% of the LNs of this arm of the study. After the revision, no case was found in the NBF arm with <12 LNs. Two patients had metastatic LNs during the revision (no upstaging occurred). CONCLUSION: Compared to NBF, CS increases LN count in colon cancer specimens. After conventional pathologic analysis, fixing the pericolic fat with CS and performing a second dissection substantially increased the number of LNs.

RESUMO - RACIONAL: Pelo menos 12 linfonodos (LNs) devem ser examinados após a ressecção cirúrgica do câncer de cólon. Como é difícil encontrar LNs pequenos, fixadores de clareadores de gordura foram propostos, mas não há consenso sobre a melhor opção. OBJETIVO: Verificar se a solução de Carnoy (SC) aumenta o número de LNs obtidos em espécimes de câncer de cólon esquerdo. MÉTODOS: Ensaio prospectivo randomizado (clinictrials.gov: NCT02629315) com 60 pacientes com adenocarcinoma de cólon esquerdo submetidos à retossigmoidectomia. As amostras foram randomizadas para fixação com SC ou formalina tamponada neutra a 10% (NBF). Após a dissecção, a gordura pericólica do grupo NBF foi imersa em SC e redissecada (Revisão). O endpoint primário foi o número total de LNs recuperados. RESULTADOS: O número médio de LNs foi de 36,6 e 26,8 para os grupos CS e NBF, respectivamente (p=0,004). O número de casos com <12 LNs foi 0 (CS) e 3 (NBF, p=0,237). A duração da dissecção foi semelhante. LNs foram recuperados em todos os casos durante a revisão (média de 19, intervalo: 4-37), representando quase 40% dos LNs deste braço do estudo. Após a revisão, nenhum caso no braço NBF permaneceu com <12 LNs. Dois pacientes tiveram LNs metastáticos encontrados durante a revisão (não ocorreu upstaging). CONCLUSÃO: Em comparação com NBF, a SC aumenta a contagem de LNs em espécimes de câncer de cólon. Após a análise patológica convencional, a fixação da gordura pericólica com SC e a realização de uma segunda dissecção aumentaram o número de LNs.