Hepatic metastases from gastric cancer: A surgical perspective

Management of patients with hepatic metastases as the sole metastatic site at diagnosis of gastric cancer (synchronous setting) or detected during follow-up (metachronous) is controversial. The prevailing attitude in these cases is passive, leading to surgical palliation and, possibly, to chemotherapy. Authors focused this editorial in order to promote a more pragmatic attitude. They stress the importance of recognizing the good candidates to curative surgery of both gastric cancer and hepatic metastases (synchronous setting) or hepatic disease alone (metachronous disease) from those who will not benefit from surgical therapy. In fact, in adequately selected subgroup of patients surgery, especially if integrated in multimodal therapeutic strategies, may achieve unexpected 5-year survival rates, ranging from 10% to 40%. The critical revision of the literature suggests that some simple clinical criteria exist that may be effectively employed in patients selection. These are mainly related to the gastric cancer (factors T, N, G) and to the extent of hepatic involvement (factor H). Upon these criteria it is possible to adequately select about 50% of cases. In the remaining 50% of cases a critical discussion on a case-by-case basis is recommended, considering that among these patients some potential long-survivors exist, that survival is strictly influenced by the ablation of the tumor bulk and by multimodality treatments including chemotherapy and that in expert institutions this kind of surgery is performed with very low mortality and morbidity rates

Para-aortic lymphadenectomy in surgery for gastric cancer: current indications and future perspectives

Involvement of para-aortic nodes (PAN) has been detected at pathological examination in 10-25% of locally advanced gastric cancer. Based on these data of nodal diffusion, the lymphadenectomy of para-aortic stations would be desirable in locally advanced gastric cancer. However, the debate on the oncological benefit of para-aortic nodes dissection is still not solved. A review of the literature was performed and papers reporting either the rate of para-aortic nodal metastases or the long-term survival outcomes after D2+ para-aortic nodes dissection (PAND) or D3 lymphadenectomy were descriptively reported. The literature survey yielded 14 studies. Most of the papers show the outcome of series of advanced gastric cancer treated with surgery alone, while starting from 2012, 3 articles report the outcomes of D2 + PAND or D3 lymphadenectomy after preoperative chemotherapy. The rate of PAN metastases ranges between 8.5 and 28% in surgical series. Survival outcomes largely improved in series of patients treated with multimodal approach compared to those of surgery alone. In patients with clinically detected para-aortic nodal metastases, preoperative chemotherapy followed by PAND is indicated. More data are needed to clarify the indication to prophylactic PAND in the era of multimodal treatment, anyway super-extended lymphadenectomies have to be performed by experienced surgeons in dedicated centres

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4-6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain's role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous

Extension of lymphadenectomy for gastric cancer:Audit at European specialist centres.

Gastric cancer is still one of the leading causes of cancer-related deaths worldwide, and its treatment management differs between Eastern Asia and Western countries. Screening program, early diagnosis, and surgical treatment was primarily established in Japan and was rapidly disseminated to other countries. In other parts of the world, such as the USA and Western Europe, the incidence of gastric cancer has declined, and efforts for screening and early detection have not been an issue of higher priority over the management of other diseases. Thus, gastric cancer in the West is often more advanced and is either inoperable or needs more radical surgery for resection. The only treatment method that can potentially cure gastric cancer is the surgical approach. Depending on the extension of the tumor, surgeons may execute an operation that involves removing all or part of the stomach with some nearby lymph nodes (lymphadenectomy). Lymphadenectomy is a crucial step during surgical operation that involves the removal of one or more lymph nodes located in the drainage area of a tumor, in which there is a high possibility of lymph node metastasis. The Japanese guidelines define the criteria of lymphadenectomy procedure into D1 D1+ or D2 according to the type of gastrectomy executed. The extent of lymphadenectomy has long been a subject of debate. Indeed, Japanese surgeons introduced extended lymphadenectomy (D2), which has also been progressively adopted in Europe and included in almost all international guidelines. However, the procedure requires a long learning curve, which involves a high volume of interventions; therefore, US guidelines do not recommend the D2, and many Italian and European centres do not yet perform this procedure. Indeed, the current European Consensus guidelines recommend D2 dissection in regional specialist centres for patients with moderate comorbidity. However, compliance with guidelines is unclear, and in some recent RCTs, the standard approach of surgical treatment is at the "surgeon's discretion." This study aims to evaluate the current practice of D2 lymphadenectomy in Europe to determine any variation in practice and compare it with the Japanese guidelines. The study consists of two parts: first, a questionnaire based on hypothetical clinical scenarios was administered to expert surgeons belonging to European Chapter of the International Gastric Cancer Association from high-volume European centers. They were asked to select the appropriate lymphadenectomy extension for each hypothetical case and the associated lymph node stations to remove. In the second part of the study, the same surgeons were asked to collect their data about gastric cancer gastrectomies performed in 2015 for comparative analysis. The study results show that the expert surgeons of high-volume centres are quite in agreement with the choice of D2 lymphadenectomy in the different clinical scenarios. The surgical choice seems to have been influenced by the tumor stage, site, and histology of the tumor. More specifically, the D2 procedure is recommended for cases with diffuse histology compared to tumors with intestinal histology. However, the selection of the D2 dissection procedure rarely conformed to Japanese guidelines: the choice of lymph node stations revealed the presence of a wide variation in execution. In the review of the gastrectomy experience, it was observed that a high surgical standard was achieved: in fact, in 97% of gastric cancer gastrectomies after D2, an adequate number of lymph nodes (≥15 nodes) were removed. In conclusion, even if an adequate lymphadenectomy was obtained in almost all cases in dedicated centers, there is still significant variability in the number of recovered lymph nodes. The histology of the tumor largely influences the surgeon's choice regarding the extent of the lymphadenectomy; however, the role of histology in the planning of surgical procedures is not considered in the current guidelines and must be verified in prospective studies

Multicenter Study of Presentation, Management, and Postoperative and Long-Term Outcomes of Septegenerians and Octogenerians Undergoing Gastrectomy for Gastric Cancer

Background: The optimal treatment strategy for elderly patients with gastric cancer is still controversial. This study aimed to assess the impact of age on short- and long-term outcomes after treatment for primary gastric cancer. Methods: From January 2004 to December 2014, a total of 507 patients underwent gastrectomy for gastric adenocarcinoma at two high-volume upper gastrointestinal (GI) centers. The patients were classified into three groups as follows: group A (patients ≤ 69 years old, n = 266), group B (patients 70–79 years old, n = 166), and group C (patients ≥ 80 years old, n = 75). Clinicopathologic characteristics as well as, short- and long-term outcomes were compared between the groups. Results: The patients in groups B and C had more comorbidities, whereas the younger subjects (group A) had more advanced tumor stages. Less extensive surgery was performed in the groups B and C. Older patients (age ≥ 70 years) had more postoperative medical complications. Moreover, group C had a higher postoperative mortality rate (8.1%) than group A (1.8%) or group B (1.9%). In the multivariable analysis, age older than 80 years (group C) was a negative independent factor for overall survival (OS) (hazard ratio [HR], 2.36) compared with group A, whereas group B seemed to have a comparable risk (HR, 1.37). Notably, the three groups did not show significant differences in disease-related survival (DRS). Conclusion: The data suggest that patients 70–79 years of age show a risk of postoperative death comparable with that of younger subjects. However, patients older than 80 years should be carefully selected for surgical treatment due to the increased risk of postoperative mortality

CONCORDANZA INTER-OSSERVATORE ED ACCURATEZZA DIAGNOSTICA DELLA TC NELLA VALUTAZIONE DEL DANNO ESOFAGO-GASTRICO DOPO INGESTIONE DI CAUSTICI

Scopo: Recenti studi hanno proposto l’utilizzo della TC con mezzo di contrasto in luogo dell’endoscopia nella valutazione in emergenza del danno esofago-gastrico secondario ad ingestione di caustici. Lo scopo di questo studio è valutare la concordanza inter-osservatore e l’accuratezza diagnostica della TC nella valutazione del danno esofagogastrico dopo ingestione di caustici. Materiali e metodi: Gli esami TC eseguiti da 15 pazienti dopo ingestione di caustici sono stati retrospettivamente ed indipendentemente analizzati da due Radiologi esperti in radiologia addominale e due specializzandi in Radiologia. La concordanza inter-osservatore nella valutazione del danno esofago-gastrico è stata calcolata secondo il metodo kappa di Cohen. L’accuratezza diagnostica della TC è stata valutata utilizzando l’endoscopia o i risultati patologici come riferimento. Risultati: La concordanza inter-osservatore per i lettori esperti/ giovani è risultata pari a .277/.156 per la valutazione dell’esofago e .625/.095 per la valutazione dello stomaco. I valori medi di sensibilità, specificità e accuratezza della TC nell’identificazione della necrosi transmurale esofagea/gastrica sono risultati pari a 37.5%/14.3%, 79.5%/97%, e 71.8%/58.3%. Conclusioni: La TC ha una concordanza inter-osservatore variabile nella gradazione del danno e una bassa sensibilità nell’identificazione della necrosi transmurale, pertanto non sembra in grado di poter sostituire l’endoscopia nella valutazione in emergenza del danno esofagogastrico dopo ingestione di caustici

A Case of Hypotonia-Cystinuria Syndrome With Genito-Urinary Malformations and Extrarenal Involvement

Hypotonia-Cystinuria syndrome (HCS) is a rare disease, caused by a mutation in two contiguous genes (SLC3A1 and PREPL) localized on chromosome 2p21, and it is characterized by both renal involvement with cystine stones and nervous involvement with hypotonia. We here describe a 2 years old child with HCS associated with other clinical features as congenital anomalies of kidney and urinary tract (primary obstructed megaureter, POM), cryptorchidism and cardiac involvement (patent foramen ovale with atrial septum aneurysm). To the best of our knowledge, cryporchidism and POM have never been reported before in patients with HCS. Moreover, a cardiac involvement has been described only in another case of HCS that, interestingly, presents the same genetic abnormalities as our patient. The diagnosis of HCS can be difficult because neurological signs are aspecific and kidney stones are commonly absent during the first months of life. A better understanding of the complete clinical scenario associated with HCS can help clinicians suspect, diagnose and treat HCS earlier with a positive influence on both neurological and renal outcome

Are the forearm muscles excited equally in different, professional piano players?

Background and objectives Professional pianists tend to develop playing-related musculoskeletal disorders mostly in the forearm. These injuries are often due to overuse, suggesting the existence of a common forearm region where muscles are often excited during piano playing across subjects. Here we use a grid of electrodes to test this hypothesis, assessing where EMGs with greatest amplitude are more likely to be detected when expert pianists perform different excerpts. Methods Tasks were separated into two groups: classical excerpts and octaves, performed by eight, healthy, professional pianists. Monopolar electromyograms (EMGs) were sampled with a grid of 96 electrodes, covering the forearm region where hand and wrist muscles reside. Regions providing consistently high EMG amplitude across subjects were assessed with a non-parametric permutation test, designed for the statistical analysis of neuroimaging experiments. Spatial consistency across trials was assessed with the Binomial test. Results Spatial consistency of muscle excitation was found across subjects but not across tasks, confining at most 20% of the electrodes in the grid. These local groups of electrodes providing high EMG amplitude were found at the ventral forearm region during classical excerpts and at the dorsal region during octaves, when performed both at preferred and at high, playing speeds. Discussion Our results revealed that professional pianists consistently load a specific forearm region, depending on whether performing octaves or classical excerpts. This spatial consistency may help furthering our understanding on the incidence of playing-related muscular disorders and provide an anatomical reference for the study of active muscle loading in piano players using surface EMG

Neoadjuvant Concurrent Chemoradiotherapy for Locally Advanced Esophageal Cancer in a Single High-Volume Center.

Background. Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care bymany centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival.Methods. From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse.Results. One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic.Conclusions. This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma

Conversion gastrectomy for stage IV unresectable gastric cancer: a GIRCG retrospective cohort study

Background: The aim of this study is to report the experience with conversion surgery from six Gruppo Italiano Ricerca Cancro Gastrico (GIRCG) centers, focusing our analysis on factors affecting survival and the risk of recurrence. Methods: A retrospective, multicenter cohort study was performed in patients who had undergone conversion gastrectomy between 2005 and 2017. Data were extracted from a GIRCG database including all metastatic gastric cancer patients submitted to surgery. Only stage IV unresectable tumors/metastases which became resectable after chemotherapy were included in this analysis. Results: Forty-five resected M1 patients were included in the analysis. Reasons for being deemed unresectable at diagnosis were peritoneal involvement (PCI > 6) (n = 38, 84.4%), distant metastatic nodes (n = 3, 6.6%) and extensive liver involvement (n = 4, 8.8%). Median follow-up was 25 months (IQR 9-50). Median overall survival from surgery was 15 months and 1-, 3- and 5-year survivals were 57.2, 36.1 and 24%, respectively. Median progression-free survival was 12 months with 1- and 3-year survival of 46.4 and 33.9%, respectively. At cox regression analysis the only independent prognostic factor for OS was the presence of more than one type of metastasis (HR 4.41, 95% CI 1.72\u201311.3, p = 0.002). A positive microscopic resection margin was the only risk factor for recurrence (HR 5.72, 95% CI 1.04\u201331.4, p = 0.045). Conclusions: Unresectable stage IV GC patients could benefit from radical surgery after chemotherapy and achieve long survivals. The main prognostic factor for these patients was the presence of more than one type of extra-gastric metastatic involvement