Chun-Yi Tsai

Surgical management in metastatic gastrointestinal stromal tumor (GIST) patients after imatinib mesylate treatment

Imatinib mesylate (IM) demonstrates substantial efficacy in most patients with metastatic gastrointestinal stromal tumors (GISTs). However, progression of GIST eventually develops and emerges as a challenge. To assess the role of surgery in the multidisciplinary management of GISTs, we studied the surgical outcomes in GIST patients receiving IM.

Re: Aggressive Surgical Approach for Patients with T4 Gastric Carcinoma: Promise or Myth?

We read the article by Cheng et al. in January issue of Annals of Surgical Oncology with interest. They analyzed a cohort of 179 patients with advanced gastric cancer who underwent gastrectomy with curative intent, and they asserted that aggressive surgical management of T4 gastric cancer should be limited to patients without adverse prognostic factors, such as advanced nodal involvement and pancreatic invasion. However, we worried about some confusion made by the mixed-up usage of the pathologic terminology in terms of the classification of T stage, especially regarding the ‘‘pT4’’ group. According to the sixth edition of American Joint Committee on Cancer Staging System (AJCC), T4 designated as ‘‘the tumor has penetrated the peritoneal lining or serosa of the stomach and invaded the adjacent organ.’’ In this study, Cheng et al. described that among 91 patients with pT4 treated with multiple organ resection (MOR) only 18 patients (19%) had pathologically proven cancer cell infiltration in resected organs. Based on this result, the other 73 patients who were proven not to have adjacent organ infiltration with cancer cell should be classified as pT3 not pT4 based on sixth AJCC. Here, the authors might use the pT4 as in the seventh AJCC classification. We agreed that in cases of clinically T4 (cT4) gastric cancer based on preoperative evaluation, it is not always easy to discern whether it invades adjacent organ. Secondly, Cheng et al. proposed that radical gastrectomy with combined MOR should be applied to patients without advanced nodal involvement and pancreatic invasion. In our opinion, the advanced nodal involvement could be inevitably associated with advanced disease status of the main mass lesion of the stomach. So, it is not appropriate to say that advanced nodal involvement itself should be regarded as exclusion criteria for aggressive surgical approach. Also, pancreatic invasion may impose the morbidity or mortality, such as pancreatic fistula, bleeding, or leakage. But it is rather associated with the preoperative performances of the patient not with the advanced disease status. We proposed that Cheng et al. must clarify their definition of pT4 because of the mixed-up application of the sixth or seventh AJCC classification. In this report, we could probably draw a conclusion as such; in some cT4 patients, they could get survival benefit by the aggressive surgical approach if they are proven to have pT3 disease.

Pain relief from combined wound and intraperitoneal local anesthesia for patients who undergo laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy (LC) has become the treatment of choice for gallbladder lesions, but it is not a pain-free procedure. This study explored the pain relief provided by combined wound and intraperitoneal local anesthetic use for patients who are undergoing LC.MethodsTwo-hundred and twenty consecutive patients undergoing LC were categorized into 1 of the following 4 groups: local wound anesthetic after LC either with an intraperitoneal local anesthetic (W + P) (group 1) or without an intraperitoneal local anesthetic (W + NP) (group 2), or no local wound anesthetic after LC either with intraperitoneal local anesthetic (NW + P) (group 3) or without an intraperitoneal local anesthetic (NW + NP) (group 4). A visual analog scale (VAS) was used to assess postoperative pain. The amount of analgesic used and the duration of hospital stay were also recorded.ResultsThe VAS was significantly lower immediately after LC for the W + P group than for the NW + NP group (5 vs. 6; p = 0.012). Patients in the W + P group received a lower total amount of meperidine during their hospital stay. They also had the shortest hospital stay after LC, compared to the patients in the other groups.ConclusionCombined wound and intraperitoneal local anesthetic use after LC significantly decreased the immediate postoperative pain and may explain the reduced use of meperidine and earlier discharge of patients so treated.

Does a Higher Cutoff Value of Lymph Node Retrieval Substantially Improve Survival in Patients With Advanced Gastric Cancer?—Time to Embrace a New Digit

BACKGROUND The present study assessed the impact of the retrieval of >25 lymph nodes (LNs) on the survival outcome of patients with advanced gastric cancer after curative-intent gastrectomy. PATIENTS AND METHODS A total of 5,386 patients who had undergone curative gastrectomy for gastric cancer from 1994 to 2011 were enrolled. The clinicopathological parameters and overall survival (OS) were analyzed according to the number of LNs examined (≤15, n = 916; 16-25, n = 1,458; and >25, n = 3,012). RESULTS The percentage of patients with >25 LNs retrieved increased from 1994 to 2011. Patients in the LN >25 group were more likely to have undergone total gastrectomy and to have a larger tumor size, poorer tumor differentiation, and advanced T and N stages. Hospital mortality among the LN ≤15, LN 16-25, and LN >25 groups was 6.1%, 2.7%, and 1.7%, respectively (p < .0001). The LN >25 group consistently exhibited the most favorable OS, in particular, with stage II disease (p = .011) when OS was stratified according to tumor stage. Similarly, the LN >25 group had significantly better OS in all nodal stages (from N1 to N3b). The discrimination power of the lymph node ratio (LNR) for the LN ≤15, LN 16-25, and LN >25 groups was 483, 766, and 1,560, respectively. Multivariate analysis demonstrated that the LNR was the most important prognostic factor in the LN >25 group. CONCLUSION Retrieving more than 25 lymph nodes during curative-intent gastrectomy substantially improved survival and survival stratification of advanced gastric cancer without compromising patient safety. The Oncologist 2017;22:97-106Implications for Practice: D2 lymph node (LN) dissection is currently the standard of surgical management of gastric cancer, which is rarely audited by a third party. The present study, one of the largest surgical series worldwide, has shown that the traditionally recognized retrieval of ≥16 LNs during curative-intent gastrectomy might not be adequate in regions in which locally advanced gastric cancers predominate. The presented data show that retrieval of >25 LNs, which more greatly mimics D2 dissection, improves long-term outcomes and survival stratification without compromising patient safety.

Comprehensive profiling of virus microRNAs of Epstein–Barr virus‐associated gastric carcinoma: highlighting the interactions of ebv‐Bart9 and host tumor cells

Epstein–Barr virus (EBV) is suggested to actively utilize its ebv‐microRNAs (miRNAs) to manipulate viral and cellular functions during neoplasia transformation. A systemic profiling of ebv‐miRNAs expressed in EBV‐associated gastric carcinoma (EBVa GC) helps understand its epigenetic regulation of carcinogenesis.

N3 Subclassification Incorporated into the Final Pathologic Staging of Gastric Cancer: A Modified System Based on Current AJCC Staging

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Prognostic Value of the Metastatic Lymph Node Ratio in Patients With Resectable Carcinoma of Ampulla of Vater

Abstract Patients with carcinoma of the ampulla of Vater (CAV) have better outcomes among periampullary malignancies. However, little is known about the metastatic lymph node ratio (LNR) as a prognostic factor for resectable CAV. We retrospectively reviewed our CAV patients undergoing curative surgery and analyzed their prognostic factors. A total of 212 CAV patients who received radical surgery at Chang Gung Memorial Hospital, Linkou, between 2000 and 2010 were admitted in this study. The lymph node ratio was defined as the number of metastatic lymph nodes (LNs) divided by the total number of LNs removed. The patients’ demographic data, comorbidities, operation type, and tumor features were analyzed retrospectively for survival prediction of patients. The median age of the patients was 62 years, and 57% of the patients were men. The surgical procedure was standard pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy in 53% and 47% of the patients, respectively. The median follow-up duration was 32.6 months, and 50% of the patients had died by the end of the study. The median overall survival time (OS) and disease-free survival time (DFS) were 65.8 and 33.7 months, respectively. In multivariate analysis, patients with a metastatic LNR >0.056 had a significantly poor prognosis in both OS and DFS. A metastatic LNR >0.056 predicted a poor DFS and OS in CAV patients after radical surgery. Greater awareness on the impact of metastatic LNR may help clinicians provide appropriate adjuvant treatment for high-risk CAV patients.

Selective reoperation after primary resection as a feasible and safe treatment strategy for recurrent pancreatic cancer.

AbstractLocal recurrence frequently occurs in patients with pancreatic cancer after intended curative resections. However, no treatment strategies have been established for isolated local recurrence. Several series have demonstrated a survival benefit for reoperation in selected pancreatic recurrence cases. This study compares the difference in overall survival (OS) between surgery and nonsurgery groups in recurrent pancreatic cancer.All patients from 1990 to 2014 with recurrent pancreatic cancer who underwent curative resections were investigated and retrospectively reviewed. Clinicopathological features and OS were compared.A total of 332 patients were recruited in this series. The majority had histologically pancreatic adenocarcinoma (289 patients, 87.0%). Fourteen of 332 patients (4.2%) with recurrent pancreatic cancer received subsequent resection. Most of these patients underwent curative surgery (R0 resection, 13 patients, 92.9%), and only 1 patient (7.1%) had microscopic residual tumor (R1 resection). Disease-free survival (DFS), OS, and postrecurrence survival (PRS) were all significantly longer in the surgery group (DFS 10.6 vs 6.1 months, P = 0.044; OS 57.8 vs 14.0 months, P < 0.001; PRS 14.1 vs 6.0 months, P < 0.001). The median survival times were comparable in patients with recurrent pancreatic adenocarcinoma who received surgery and those who did not (DFS 10.6 vs 6.1 months, P = 0.226; OS 23.7 vs 14.0 months, P = 0.074; PRS 8.9 vs 5.8 months, P = 0.183). However, the OS and PRS were superior in the patients who did not display adenocarcinoma histologically but underwent operation for recurrence (OS 97.2 vs 16.9 months, P = 0.016; PRS 65.7 vs 6.9 months, P = 0.010). Notably, DFS levels were similar (16.0 vs 7.0 months, P = 0.265).Surgery can feasibly and safely provide survival benefits in selective recurrent pancreatic cancer. In patients who are histologically negative for adenocarcinoma, survival is prolonged when the operation is performed with R0 resection. Patients with isolated recurrent pancreatic adenocarcinoma need multidisciplinary therapy. In addition to operation, chemoradiotherapy and intraoperative radiotherapy may also be considered; their roles should be further investigated.

Feasibility and Timing of Cytoreduction Surgery in Advanced (Metastatic or Recurrent) Gastrointestinal Stromal Tumors During the Era of Imatinib

AbstractThe prognosis of advanced gastrointestinal stromal tumors (GISTs) was dramatically improved in the era of imatinib. Cytoreduction surgery was advocated as an additional treatment for advanced GISTs, especially when patients having poor response to imatinib or developing resistance to it. However, the efficacy and benefit of cytoreduction were still controversial. Likewise, the sequence between cytoreduction surgery and imatinib still need evaluation. In this study, we tried to assess the feasibility and efficiency of cytoreduction in advanced GISTs. Furthermore, we analyzed the impact of timing of the cytoreduction surgery on the prognosis of advanced GISTs.We conducted a prospective collecting retrospective review of patients with advanced GISTs (metastatic, unresectable, and recurrent GISTs) treated in Chang Gung memorial hospital (CGMH) since 2001 to 2013. We analyzed the impact of cytoreduction surgery to response to imatinib, progression-free survival (PFS), and overall survival (OS) in patients with advanced GISTs. Moreover, by the timing of cytoreduction to imatinib, we divided the surgical patients who had surgery before imatinib use into early group and those who had surgery after imatinib into late. We compared the clinical response to imatinib, PFS and OS between early and late cytoreduction surgical groups.Totally, 182 patients were enrolled into this study. Seventy-six patients underwent cytoreduction surgery. The demographic characteristics and tumor presentation were similar between surgical and non-surgical groups. The surgical group showed better complete response rate (P < 0.001) and partial response rate (P = 0.008) than non-surgical group. The 1-year, 3-year, and 5-year PFS were significantly superior in surgical group (P = 0.003). The 1-year, 3-year, and 5-year OS were superior in surgical group, but without statistical significance (P = 0.088). Dividing by cytoreduction surgical timing, the demographic characteristics and tumor presentation were comparable in early and late groups. The late cytoreduction group presented higher R0 resection rate (59.1% vs 31.5%, P = 0.025). However, the PFS and OS were comparable in both groups.Combining imatinib with cytoreduction increased the response rate to imatinib and prolonged PFS in patients with advanced GISTs. Moreover, early and late cytoreduction surgery was comparable in prognosis, although late cytoreduction revealed higher complete resection rate.

Learning curve of laparoscopic Roux-en-Y gastric bypass in an Asian low-volume bariatric unit

BACKGROUND Obesity has become a healthcare burden in Taiwan and the rest of Asia. Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides good weight loss outcome, and improves comorbidity as well as quality of life. We present our experience of the learning curve for LRYGB in a low-volume bariatric unit. METHODS From March 2009 to August 2011, 60 consecutive patients who underwent LRYGB were included. They were separated into two groups, with the first 30 cases in Group 1 and the remaining 30 cases in Group 2. Indicators for evaluating the learning curve for LRYGB included surgical time, rate of conversion to open surgery, surgical and total complication rates, length of hospital stay, mortality, and postoperative weight loss. RESULTS There were no significant differences in demographic measurements between the two groups. In Group 1, the median surgical time was 120 minutes and in Group 2 it was 80 minutes (p<0.01). Two cases were converted to laparotomy in Group 1, but none in Group 2. There was no surgical mortality and the total complication rate of all patients was 16.7%. The complication rate significantly decreased from Group 1 (26.7%) to Group 2 (6.7%). Three patients needed further surgical procedures in Group 1, with no patients needing them in Group 2. There was no significant difference in hospital stay and percentage excess weight loss between the two groups. CONCLUSION The learning curve for LRYGB has no mortality and an acceptable complication rate. The operating time and morbidity rate are the indicators for overcoming the learning curve.