Occult Tumor Cells in Lymph Nodes of Patients with Gastric Cancer: A Systematic Review on Their Prevalence and Predictive Role.

BACKGROUND AND AIMS: The presence of lymph node (LN) metastasis is a key prognostic factor for gastric adenocarcinoma. However, even among patients without LN metastasis (N0), recurrence may occur. In some of these cases, occult tumor cells (OTC) are thought to play an important role. We aimed to determine the prevalence of OTC and its clinical relevance. METHODS: We conducted a systematic review of studies in English published until September 2013 that addressed OTC prevalence and/or its clinical relevance. The studies were retrieved from the MEDLINE database. RESULTS: We included 42 studies. The most frequently used methods for detecting OTC were immunohistochemical examination (IHC) and/or polymerase chain reaction (PCR) with a wide range of markers. Using IHC for OTC detection, in patients and in LN, the prevalence varied from 9 to 88% and 0.4 to 42%, respectively. With PCR, it ranged from 17 to 46% in patients, and from 3 to 33% in LN. In the studies assessing the predictive role of OTC in gastric cancer recurrence (n=24), 8 studies found no statistical association, while 18 concluded that OTC presence was associated with poorer prognosis. However, only 6 studies presented a significantly different 5-year survival rate between patients with and without LN micrometastasis. CONCLUSIONS: OTC seems to occur in gastric cancer patients with a variable prevalence, depending on the definition, methods and setting. The majority of the retrieved studies (75%) evaluating the predictive role of OTC conclude that its presence is associated with a worse prognosis.

Reevaluation of Self-Expanding Metal Stents as a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction: Six Years Experience.

INTRODUCTION: Self-expanding metal stents (SEMS) as a bridge to surgery have been used as an alternative for acute malignant left-sided colonic obstruction. However, the benefits are uncertain. The European Society of Gastrointestinal Endoscopy no longer recommends their use in patients with low surgical risk because of the risk of tumor recurrence. METHODS: Patients admitted for acute malignant left-sided colonic obstruction who underwent SEMS as a bridge to elective surgery or urgent surgery were retrospectively evaluated. Postoperative morbidity/mortality, stent complications and survival were recorded. Our aim was to compare the outcome between preoperative SEMS and direct emergent surgery in acute left-sided malignant colonic obstruction. RESULTS: 42 patients were included (SEMS group: 27 and surgery group: 15). There were no differences between groups in relation to age, ASA classification and tumor stage. The technical success of SEMS was 88.9% and the clinical success was 85.2%. There were three SEMS related perforations. In the surgery group, the stoma rate was higher (86.7% vs 25.9%, p < 0.001) and there was a trend for a lower length of hospital stay (18.9 days vs 26.3 days, p = 0.051). SEMS verses surgery group: There were no differences in the rate of temporary stoma (57.1% vs 61.5%, p = 0.84), definitive stoma (42.8% vs 38.5%, p = 0.84), success of primary anastomosis (86.7% vs 66.7%, p = 0.22) and Clavien-Dindo classification (≥III: 36% vs 58.2% p = 0.24). Overall survival at 1/5 years was identical in the two groups 100%/56% in the SEMS group vs 93%/43% in the surgery group, p = 0.14), as well as tumor recurrence at 3/5 years (24%/50% vs 20%/36% respectively, p = 0.68). CONCLUSIONS: SEMS are associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival and recurrence between the groups.

INTRODUÇÃO: As próteses metálicas auto-expansíveis (PMAE) como ponte para cirurgia são uma alternativa à cirurgia urgente nas neoplasias estenosantes do colon esquerdo. No entanto, os benefícios são controversos. A Sociedade Europeia de Endoscopia não as recomenda como ponte para cirurgia desde 2014, em doentes de baixo risco cirúrgico, pelo possível aumento de recidiva neoplásica. MÉTODOS: Avaliação retrospetiva dos doentes com neoplasia oclusiva do colon esquerdo candidatos a tratamento curativo, que colocaram PMAE como ponte para cirurgia ou que foram submetidos diretamente a tratamento cirúrgico urgente. Avaliada a morbilidade e mortalidade pós-operatória, complicações relacionadas com as PMAE e sobrevivência. O nosso objetivo foi comparar os resultados das PMAE como ponte para cirurgia com o tratamento cirúrgico urgente nas neoplasias oclusivas do colon esquerdo. RESULTADOS: Avaliados 42 doentes (grupo submetido a PMAE: 27; grupo submetido a cirurgia:15). Não existem diferenças entre os dois grupos no que diz respeito à idade classificação ASA e o estadio da neoplasia. O sucesso técnico das PMAE foi de 88,9% e o sucesso clínico da prótese foi de 85,2%. Ocorreram 3 perfurações após colocação das PMAE. No grupo submetido a cirurgia, a realização de estoma foi superior (86,7% vs 25,9%), p < 0,001), e verificou-se um menor número de dias de internamento hospitalar total, embora sem resultado estatisticamente significativo (18,9 vs 26,3 dias, p = 0,051). PMAE versus cirurgia: não existem diferenças no que diz respeito à constituição de estomas provisórios (57,1% vs 61,5%, p = 0,84), estomas definitivos (42,8% vs 38,5%, p = 0,84), sucesso de anastomose primária (86,7% vs 66,7%, p = 0,22) e classificação de Clavien­Dindo (≥III:36% vs 58,2% p = 0,24). A sobrevida aos 1 e 5 anos foi semelhante nos dois grupos (PMAE 1-5 anos vs cirurgia 1-5 anos: 100%-56% vs 93%-43%, p = 0,14), bem com a recidiva aos 3 e 5 anos (PMAE 3-5 anos vs cirurgia 3-5 anos 24%-50% vs 20%-36%, p = 0,68). CONCLUSÕES: A realização de estoma foi superior nos doentes submetidos a tratamento cirúrgico, no entanto, não há diferenças entre os dois grupos relativamente às complicações pós-cirurgicas, sucesso de anastomose primária, recidiva e mortalidade.