Challenging the Dogma: Stage migration or negative lymph nodes, which of them is the main player on gastric cancer prognosis?

Expanding loco-regional nodes harvesting is expected to increase survival. This improvement may be associated to stage migration (SM). However, the great bulk of harvested lymph nodes observed in large dissections is negative. M&M: 830 patients who received R0 gastrectomy for adenocarcinoma were included. pN+ patients with <26 nodes (n = 209) were included for a simulation to "offer 26 nodes" - SM (proportional and exponential based) was simulated and analysed through machine learning algorithms. Overall Survival (OS), in native and simulated stages, were compared. OS of extended lymphadenectomies (pN+, D ≥ 26, n = 273) was compared with the simulated curves. OS of patients in the following dissection intervals of negative nodes were compared: <16 (n = 233), 16-25 (n = 258), ≥26 (n = 339). RESULTS: After simulation to 26 nodes (pN+, D < 26 patients, n = 209), staging was recomputed. OS of native vs simulated early-stages (I-II) and advanced stages (III) were not different (p > 0.05). OS of patients with lymphadenectomy (≥26) was better than simulated for early and advanced stages (p = 0.008; p = 0.005). OS of patients included in distinct intervals of negative lymph nodes were different (p < 0.001). These intervals were an independent prognostic factor (multivariate analysis). CONCLUSIONS: The influence of Stage Migration was null in this set of simulations and Will Rogers phenomenon was not observed. Extended dissection performed better in OS. But the influence of the number of negative nodes, even in large dissections, was highlighted. By emphasizing the role of negative nodes, we aim to facilitate more informed decision-making in management of gastric cancer patients, ultimately leading to improved treatment outcomes and patient care.

The impact of negative lymph nodes in the survival outcomes of pN+ patients following radical gastrectomy: the inverse lymph node ratio as a better score to study negative lymph nodes.

The impact of negative lymph nodes (LNs) on survival of pN+ patients has been recognized. The weight of negative LNs in an inverse lymph node ratio (nR) should be related to its prognostic impact. Five hundred and two consecutive gastric cancer patients, who underwent radical gastrectomy, were included. Patients were split into groups according to the number of harvested nodes and a cross-tabulation with pTNM stages was performed to test differences in the tumor burden. pN+ patients (n = 296) were split into groups of negative LNs harvested. We tested an alternative formula for computing a lymph node ratio: nR = total number of harvested nodes/total number of positive nodes. The median number of negative LNs was significantly different (p < 0.01) between dissection groups, but not the median of positive nodes (p > 0.05). No difference in pTNM percentage distribution was found between these groups (p > 0.05). When tested, the overall survival improved significantly for groups with larger numbers of negative LNs (p < 0.001). A cutoff of nR ≥ 6 was an independent prognostic factor for survival (p = 0.001), and the survival of pN+ patients with nR ≥ 6 was not different from pN0 patients. The impact of the number of negative LNs on the survival of the pN+ patients was demonstrated. The higher numbers in the numerator of the nR was due to the disproportion between harvested negative LNs and metastatic LNs. Larger ratios imply more negative lymph nodes in relation to positive lymph nodes, which was significantly associated with survival. We believe that the proposed nR is a friendlier to use format because of its intuitive interpretation.

Development of a preoperative risk score on admission in surgical intermediate care unit in gastrointestinal cancer surgery.

BACKGROUND: Gastrointestinal cancer surgery continues to be a significant cause of postoperative complications and mortality in high-risk patients. It is crucial to identify these patients. Our study aimed to evaluate the accuracy of specific perioperative risk assessment tools to predict postoperative complications, identifying the most informative variables and combining them to test their prediction ability as a new score. METHODS: A prospective cohort study of digestive cancer surgical patients admitted to the surgical intermediate care unit of the Portuguese Oncology Institute of Porto, Portugal was conducted during the period January 2016 to April 2018. Demographic and medical information including sex, age, date from hospital admission, diagnosis, emergency or elective admission, and type of surgery, were collected. We analyzed and compared a set of measurements of surgical risk using the risk assessment instruments P-POSSUM Scoring, ACS NSQIP Surgical Risk Calculator, and ARISCAT Risk Score according to the outcomes classified by the Clavien-Dindo score. According to each risk score system, we studied the expected and observed post-operative complications. We performed a multivariable regression model retaining only the significant variables of these tools (age, gender, physiological P-Possum, and ACS NSQIP serious complication rate) and created a new score (MyIPOrisk-score). The predictive ability of each continuous score and the final panel obtained was evaluated using ROC curves and estimating the area under the curve (AUC). RESULTS: We studied 341 patients. Our results showed that the predictive accuracy and agreement of P-POSSUM Scoring, ACS NSQIP Surgical Risk Calculator, and ARISCAT Risk Score were limited. The MyIPOrisk-score, shows to have greater discrimination ability than the one obtained with the other risk tools when evaluated individually (AUC = 0.808; 95% CI: 0.755-0.862). The expected and observed complication rates were similar to the new risk tool as opposed to the other risk calculators. CONCLUSIONS: The feasibility and usefulness of the MyIPOrisk-score have been demonstrated for the evaluation of patients undergoing digestive oncologic surgery. However, it requires further testing through a multicenter prospective study to validate the predictive accuracy of the proposed risk score.

Root causes and outcomes of postoperative pulmonary complications after abdominal surgery: a retrospective observational cohort study.

BACKGROUND: Postoperative pulmonary complications (PPCs) contribute significantly to overall postoperative morbidity and mortality. In abdominal surgery, PPCs remain frequent. The study aimed to analyze the profile and outcomes of PPCs in patients submitted to abdominal surgery and admitted in a Portuguese polyvalent intensive care unit. METHODS: From January to December 2017 in the polyvalent intensive care unit of Hospital Garcia de Orta, Almada, Portugal, we conducted a retrospective, observational study of inpatients submitted to urgent or elective abdominal surgery who had severe PPCs. We evaluated the perioperative risk factors and associated mortality. Logistic regression was performed to find which perioperative risk factors were most important in the occurrence of PPCs. RESULTS: Sixty patients (75% male) with a median age of 64.5 [47-81] years who were submitted to urgent or elective abdominal surgery were included in the analysis. Thirty-six patients (60%) developed PPCs within 48 h and twenty-four developed PPCs after 48 h. Pneumonia was the most frequent PPC in this sample. In this cohort, 48 patients developed acute respiratory failure and needed mechanical ventilation. In the emergency setting, peritonitis had the highest rate of PPCs. Electively operated patients who developed PPCs were mostly carriers of digestive malignancies. Thirty-day mortality was 21.7%. The risk of PPCs development in the first 48 h was related to the need for neuromuscular blocking drugs several times during surgery and preoperative abnormal arterial blood gases. Median abdominal surgical incision, long surgery duration, and high body mass index were associated with PPCs that occurred more than 48 h after surgery. The American Society of Anesthesiologists physical status score 4 and COPD/Asthma determined less mechanical ventilation needs since they were preoperatively optimized. Malnutrition (low albumin) before surgery was associated with 30-day mortality. CONCLUSION: PPCs after abdominal surgery are still a major problem since they have profound effects on outcomes. Our results suggest that programs before surgery, involve preoperative lifestyle changes, such as nutritional supplementation, exercise, stress reduction, and smoking cessation, were an effective strategy in mitigating postoperative complications by decreasing mortality.

[Esophageal cancer: surgical strategies]. / Cancro do Esófago: Estratégia de Abordagem Cirúrgica.

INTRODUCTION: Oesophagectomy for cancer is associated to a significant morbidity and mortality. The superiority of transthoracic vs transhiatal is still a matter of controversy. The aim of this paper is to discuss the results of a series of patients submitted to either a transthoracic or a transhiatal according to the anatomic location regarding the carina. MATERIAL AND METHODS: Retrospective analysis of 52 consecutive patients, with oesophageal carcinoma, 7 female and 45 males, median age 64 [46-85] years. Location: cervical - 1; above carina - 22; below or at carina level - 19; cardia type I -10. 19 adenocarcinoma, 32 squamous cells, 1 lymphoma. Twenty patients (40%) - neo-adjuvant therapy. Thoracoabdominal approach - 3, cervico-thoracoabdominal - 20, transhiatal - 27, exploratory thoracotomy - 2. Gastric pull-up 49 (cervical anastomosis - 46; thoracic - 3); cervical oesofagocoloplasty -1. RESULTS: Pathologic staging: complete remission - 8; Ib - 3; IIa - 9; IIb - 4; IIa - 11; IIIb -2; IIIc - 10; IV - 1; non-stageable - 3. Major complications: 37%. Resectability: 96% (50/52). Mortality: 4th week - 6%; in-hospital - 14%. Median survival 18 months [3-80]. Survival Curves (Kaplan-Meier): 2 years - 47%; 5 years - 19% (transthoracic vs transhiatal p > 0.05). DISCUSSION: Selection of surgical approach based on the anatomic location of the tumour regarding the carina was safe, the resectability was high and similar when a transthoracic or a transhiatal was planed and carry-on. CONCLUSIONS: In this series of oesophageal cancer patients, in advanced pathologic condition (52% p Stages III/IV) the overall survival was similar for transthoracic and transhiatal. Neo-adjuvant treatments definitively contributed to enhance resectability.

Introdução: A ressecção transmediastínica e a ressecção transtorácica têm mortalidade hospitalar (1,4% -14%) e sobrevivência (± 25% aos cinco anos) semelhantes. A terapêutica neo-adjuvante é opção em estádios avançados. A intenção deste trabalho é apresentar uma série consecutiva de 52 doentes - opção operatória baseada na localização anatómica: tumores infra-carinais e cervicais submetidos a ressecção transmediastínica e restantes ressecções transtorácicas.Material e Métodos: O estudo incluiu 52 doentes consecutivos, sete mulheres e 45 homens, mediana de idade: 64 anos [46- 85]. Localização: cervical – um; montante da carina - 22; jusante da carina -19; cárdia tipo I –10. Histologia: 19 adenocarcinomas, 32 carcinomas pavimento-celulares, um linfoma. Vinte doentes (40%) - terapêutica neoadjuvante. Abordagem tóraco-abdominal – três, tóraco-abdómino-cervical – 20, transhiatal – 27, toracotomia exploradora – dois. Transposição gástrica 49 (anastomose cervical – 46; torácica - três); esofagocoloplastia cervical - um.Resultados: Estadiamento patológico: regressão completa - 8; Ib – 3; IIa – 9; IIb - 4; IIa – 11; IIIb -2; IIIc – 10; IV – 1; linfoma - um; não classificáveis – três. Complicações major: 37%. Ressecabilidade: 96% (50/52). Mortalidade: quatro semanas - 6%; hospitalar - 14%. Sobrevida mediana 18 meses [3-80]. Curvas de sobrevida (Kaplan-Meier): dois anos - 47%; cinco anos - 19%.Discussão: Não tendo sido demonstrada vantagem oncológica para a ressecção transtorácica ou a ressecção transmediastínica,basear a opção operatória na localização do tumor permitiu-nos com segurança e eficácia, planear e executar as ressecções esofágicas desta série.Conclusão: As curvas de sobrevida foram sobreponíveis para ressecção transtorácica e ressecção transmediastínica e bastantefavoráveis numa população com 52 % de estádios pIII/IV. A quimio-radioterapia contribuiu para aumentar a ressecabilidade.

Entre o desejo e o ser feminino / Between desire and the feminine

"O que deseja uma mulher?" A pergunta clássica e o fio condutor desse artigo. A feminilidade e suas relações com o desejo são investigadas a partir de concepções freudianas e lancanianas. O conceito de histeria é explorado no sentido de diferenciá-lo do que se constitui como uma posição feminina. com base nos fundamentos de Lacan, chega-se à conclusão de que ser mulher significa uma não total submissão à lei fálica, o que leva a uma constatação de uma falta de inconsciente na mulher, já que não está completamente imersa na linguagem. A resposta encontrada para o questionamento inicial é: uma mulher quer ser sujeito onde ela não é, o que justifica, portanto, todos os artifícios que ela utiliza para provar-se sujeito para o outro(AU)