Giovanni Sgroi

Prognostic Survival Associated With Left-Sided vs Right-Sided Colon Cancer: A Systematic Review and Meta-analysis.

Importance Primary tumor location is emerging as an important prognostic factor owing to distinct biological features. However, the side of origin of colon cancer (CC) still does not represent a prognostic parameter when deciding for adjuvant or palliative chemotherapy. Objective To determine the prognostic role of left vs right-sidedness of primary tumor location in patients with CC. Data Sources We searched PubMed, EMBASE, The Cochrane Library, Web of Science, LILACS, CINAHL, and SCOPUS for prospective or retrospective studies reporting data on overall survival for left-sided colon cancer (LCC) compared with right-sided colon cancer (RCC). Study Selection Studies were selected if: (1) side of CC was reported among variables entered into survival analysis, (2) survival information was available (overall survival [OS] was reported in the article as hazard ratio (HR) according to multivariate analysis, (3) articles were published in the English language. Data Extraction and Synthesis Data were pooled using HRs for OS of LCC vs RCC according to fixed or random-effects models. Subgroup analysis and multivariate random-effects model meta-regression was also implemented adjusting for stage distribution, sample size, race, year of publication, type and quality of studies, and adjuvant chemotherapy. Main Outcomes and Measures HRs for OS (the primary outcome measure) were pooled to provide an aggregate value. In this analysis, all HRs with 95% CIs were pooled to obtain prognostic information on the location of the primary tumor (left vs right location site of CC) independent of other common clinicopathological covariates. Results An analysis was made from the 66 studies conducted. It included 1 437 846 patients with a median follow-up of 65 months. Left sided primary tumor location was associated with a significantly reduced risk of death (HR, 0.82; 95% CI, 0.79-0.84; P < .001) and this was independent of stage, race, adjuvant chemotherapy, year of study, number of participants, and quality of included studies. Conclusions and Relevance Based on these results, CC side should be acknowledged as a criterion for establishing prognosis in all stages of disease. It should be considered when deciding treatment intensity in metastatic settings, and should represent a stratification factor for future adjuvant studies.

The Italian Research Group for Gastric Cancer (GIRCG) guidelines for gastric cancer staging and treatment: 2015

This article reports the guidelines for gastric cancer staging and treatment developed by the GIRCG, and contains comprehensive indications for clinical management, including radiological, endoscopic, surgical, pathological, and oncological paths.

Laparoscopic gastrectomies for cancer: The ACOI-IHTSC national guidelines

Abstract Guidelines for laparoscopy and cancer of stomach have been outlined by several scientific societies: The main recommendation being that laparoscopy should be used only by surgeons already highly skilled in gastric surgery. The laparoscopic approach to gastric cancer surgery has become more and more frequent in most Italian centers. On behalf of the Guideline Committee of the Italian Society of Hospital Surgeons and the Italian Hi-Tech Surgical Club, a panel of experts analyzed the highest evidence of all scientific papers focusing on laparoscopic gastrectomies for cancer and published from 2003 to 2011, and drew these national guidelines. Laparoscopic gastrectomy may be considered as a safe procedure with better short-term and comparable long-term results. compared to open gastrectomy (Grade A). There is a general agreement that a laparoscopic approach to the treatment of gastric cancer should be chosen only by surgeons already highly skilled in gastric surgery and other advanced laparoscopic interventions. Furthermore, the first procedures should be carried out during a tutoring program. Diagnostic laparoscopy is strongly recommended as the first step of laparoscopic as well as laparotomic gastrectomies (Grade B). Additional randomized controlled trials (RCT) that compare and investigate the long-term oncological outcomes of laparoscopic assisted gastrectomy are required.

The SIC-GIRCG 2013 Consensus Conference on Gastric Cancer

The topic chosen by the Board of the Italian Society of Surgery for the 2013 annual Consensus Conference was gastric cancer. With this purpose, under the direction of 2 chairmen, 36 experts nominated by the Regional Societies of Surgery and by the Italian Research Group for Gastric Cancer (GIRCG) participated in an experts consensus exercise, preceded by a questionnaire and mainly held by telematic vote, in accordance with the rules of the Delphi method. The results of this Consensus Conference, presented to the 115th National Congress of the Italian Society of Surgery, and approved in plenary session, are reported in the present paper.

Prognostic value of diffuse versus intestinal histotype in patients with gastric cancer: a systematic review and meta-analysis

BACKGROUND There are two distinct types of gastric carcinoma (GC), intestinal, more frequently sporadic and linked to environmental factors, and diffuse (undifferentiated) that is highly metastatic and characterized by rapid disease progression and a poor prognosis. However, there are many conflicting data in the literature concerning the association between histology and prognosis in GC. This meta-analysis was performed to provide demonstration if histology according to Lauren classification is associated with different prognosis in patients with GC. METHODS We searched PubMed, the Cochrane Library, SCOPUS, Web of Science, CINAHL, and EMBASE for all eligible studies. The combined hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) in terms of overall survival (OS) were evaluated. RESULTS A total of 73 published studies including 61,468 patients with GC were included in this meta-analysis. Our analysis indicates that GC patients with diffuse-type histology have a worst prognosis than those with intestinal subgroup in all studies (HR 1.23; 95% CI, 1.17-1.29; P<0.0001), in both loco-regional confined (HR 1.21; 95% CI, 1.12-1.30; P<0.0001) and advanced disease (HR 1.25; 95% CI, 1.046-1.50; P=0.014), in Asiatic (HR 1.2; 95% CI, 1.14-1.27; P<0.0001) and Western patients (HR 1.3; 95% CI, 1.19-1.41; P<0.0001), and in those not exposed (HR 1.15; 95% CI, 1.07-1.24; P<0.0001) or exposed (HR 1.27; 95% CI, 1.17-1.37; P<0.0001) to (neo)adjuvant therapy. CONCLUSIONS Our results indicated that histology might be a useful prognostic marker for both early and advanced GC patients, with intestinal-type associated with a better outcome. This information could be used for stratification purpose in future clinical trials.

Rituximab Treatment Prevents Lymphoma Onset in Gastric Cancer Patient-Derived Xenografts

Patient-Derived Xenografts (PDXs), entailing implantation of cancer specimens in immunocompromised mice, are emerging as a valuable translational model that could help validate biologically relevant targets and assist the clinical development of novel therapeutic strategies for gastric cancer. More than 30% of PDXs generated from gastric carcinoma samples developed human B-cell lymphomas instead of gastric cancer. These lymphomas were monoclonal, Epstein Barr Virus (EBV) positive, originated tumorigenic cell cultures and displayed a mutational burden and an expression profile distinct from gastric adenocarcinomas. The ability of grafted samples to develop lymphomas did not correlate with patient outcome, nor with the histotype, the lymphocyte infiltration level, or the EBV status of the original gastric tumor, impeding from foreseeing lymphoma onset. Interestingly, lymphoma development was significantly more frequent when primary rather than metastatic samples were grafted. Notably, the development of such lympho-proliferative disease could be prevented by a short rituximab treatment upon mice implant, without negatively affecting gastric carcinoma engraftment. Due to the high frequency of human lymphoma onset, our data show that a careful histologic analysis is mandatory when generating gastric cancer PDXs. Such care would avoid misleading results that could occur if testing of putative gastric cancer therapies is performed in lymphoma PDXs. We propose rituximab treatment of mice to prevent lymphoma development in PDX models, averting the loss of human-derived samples.

Large retrorectal leiomyosarcoma: case report and considerations about a rare and challenging disease

Retrorectal sarcomas are not common, and few data are available in the literature on the best way to treat them. We report a case of a 75-year-old man, with only hypertension in anamnesis, presenting with proctorrhagia and pelvic and lower abdominal pain. Colonoscopy showed a stenotizing lesion from the dentate line extended for 10 cm, partially ulcerated but mostly with the features of ab extrinseco compression with normal mucosa. Histological examination of the biopsies revealed a malignancy of the mesenchymal line. Pelvis MRI showed a 11.5 9 17.5 pelvic mass with an anterior growth infiltrating the rectum ab extrinseco and in contact with prostate, bladder, and seminal vesicles. An endoscopic ultrasound confirmed a bulky pelvic hypoechoic mass-infiltrating prostate and seminal vesicles and penetrating the lumen of the proximal rectum. No lung or liver metastases at CT scan were present. Surgery was a join venture by general surgeons and urologists, and a total pelvic exenteration was performed. The patient was discharged on the 35th day, with a postoperative complicated by a chylous leakage, conservatively treated with an alipidic diet. The histological examination revealed a retrorectal spindle cell leiomyosarcoma G2, pT2bN0M0, Ki-67 50 %, 10 mitoses per 10 hpf, high polymorphism, neither lymphovascular nor perineural invasion, with a suspected focal involvement of the circumferential radial margin. Differential diagnoses were obtained also with an immunohistochemical analysis that resulted positive for desmin, caldesmon and MSA, and negative for C kit and DOG1. During a multidisciplinary evaluation, the possibility of an adjuvant radiotherapy was discussed, but finally, only follow-up was decided for the patient, also according to his will. A CT scan performed after 6 months showed a hepatic progression of the tumor with multiple bilateral lesions, and only the best supportive care was decided for the patient. Retrorectal sarcomas are a heterogeneous group of rare malignant neoplasms [1] that may often present as large, high grade, and locally advanced lesions. Due to their rarity, in the literature, there are no strong evidences on the best way to treat them, but only small series or single-case reports and limited and variable data exist on the long-term oncologic outcomes [1, 3]. Historically, preoperative biopsies of the lesion, which are not in communication with a lumen (as it was in our case report), were considered at a high risk of seeding and complications; today, it could be considered safe and useful to guide management decisions [2]. Surely, nowadays, a multidisciplinary discussion of each case should be recommended to evaluate if a multimodal treatment can be proposed. The goal of surgery should be curative, and sometimes, this could lead to enbloc extended resections; bony resections, such as sacrectomy and hemipelvectomy, can be proposed in selected patients, with a high risk of postoperative complications and disability. The Mayo Clinic group presented 37 cases between 1985 and 2005 [4] and affirmed that the improving in survival rate was mostly related either to a high number of R0 resections, as a consequence of a better surgical & Luca Turati dott.luca.turati@gmail.com

Signet-ring cell carcinoma of the rectum and synchronous renal cell carcinoma in a young man.

imately 1 %, and is associated with younger patient population, higher stage on presentation, and worse outcome compared to non-signet-ring cell carcinomas [1]. We report a case of a 29-year-old man with no comorbidities who underwent colonoscopy for hematochezia, tenesmus, and modification in bowel movements, alternating constipation and diarrhea. The rectal examination revealed a solid circumferential lesion of the ultra low rectum and anal canal. The endoscopic evaluation showed a disproliferative, substenotic lesion extended from the dentate line for 8 cm proximally. The histologic examination of the lesion was diagnostic for a signet-ring cell carcinoma.The patientunderwentclinicalstaging with contrastenhanced thoracoabdominal CT scan, endoscopic ultrasound, and pelvic contrast-enhanced MRI. The CT scan excluded secondary lesion of the liver or lungs and showed, as an incidental finding, a 25-mm solid lesion of the inferior pole of the right kidney, with contrast enhancement, suspected to be a primary malignancy. We decided to perform a PET scan, as a second level imaging technique, to study the kidney lesion: it resulted PET negative, as sometimes a renal cell carcinoma is, whereas the rectal cancer was highly positive, suggesting that probably the kidney lesion was not related to the primitive tumor. The EUS revealed an involvement of the internal anal sphincter of the prostate and two mesorectal nodes with pathological features. The MRI confirmed the presence of a stenotic mass with a concentric wall thickening of the medium and low rectum, 83×60 mm with cranio-caudal extension of 75 mm, characterized by a mostly anterior growth associated with a wide invasion of the mesorectal fascia, prostate, both seminal vesicles, and an uncertain infiltration of the bladder. Also the internal anal sphincter was confirmed to be involved until 1.5 cm from the anal verge. Finally, multiple lymph nodesofthemesorectumweredescribedaspathological.With a clinical stage cT4bN+, after a first multidisciplinary evaluation, considering the stenotizing feature of the neoplasm, the patient was candidate for a diverting ostomy before starting