Simone Maria Tierno

Log Odds of Positive Lymph Nodes (LODDS): What Are Their Role in the Prognostic Assessment of Gastric Adenocarcinoma?

BackgroundNodal status is an important prognostic factor for patients with gastric cancer. Log odds of positive nodes (LODDS) (log of the ratio between the number of positive nodes and the number of negative nodes) are a new effective indicator of prognosis. The aim of the study is to evaluate if LODDS are superior to N stage and lymph nodal ratio (LNR).MethodsPrognostic efficacy of pN, nodal ratio, and LODDS was analyzed and compared in a group of 177 patients with gastric adenocarcinoma who underwent curative gastrectomy.ResultspT, pN, LNR, and LODDS were all significantly correlated with 5-year survival. Multivariate analyses showed significant values as prognostic factor for pN, LNR, and LODDS. A Pearson test demonstrated no significant correlation between LODDS and retrieved nodes. In patients with less than 15 examined nodes, LODDS classification and pN were significantly correlated with survival, whereas LNR classification was not significantly related.ConclusionsLODDS are not correlated with the extension of the lymphadenectomy and are able to predict survival even if less than 15 nodes are examined. They permit an effective prognostic stratification of patients with a nodal ratio approaching 0 and 1. Further studies are needed to clarify their role and if they are capable of guaranteeing some advantages over pN and LNR.

Margin Distance Does Not Influence Recurrence and Survival After Wedge Resection for Lung Cancer.

BACKGROUND The relationship between the free margin distance and the recurrence rate and overall survival after R0 wedge resection for non-small cell lung cancer (NSCLC) is still not clear. We retrospectively evaluated the long-term oncologic outcome of patients who had undergone wedge resection for NSCLC to assess the prognostic effect of margin distance in this setting. METHODS Between 2003 and 2013, 243 consecutive patients with a functional contraindication to major lung resection underwent wedge resection with systematic lymph node dissection for clinical stage I NSCLC. The study enrolled 182 patients with pathologic stage I and R0 resection and divided them into three subgroups according to margin distance of less than 1 cm (n = 30), 1 to 2 cm (n = 80), and more than 2 cm (n = 72). RESULTS The histologic assessment was adenocarcinoma in 112 patients, squamous cell in 30, and other in 40. Postoperative morbidity was 18.7%, and postoperative mortality was 1.1%. The median follow-up was 31 months (range, 2 to 133 months). The locoregional (lung parenchyma, hilum, mediastinum) recurrence rate was 26.4% (n = 48). The distant recurrence rate was 11% (n = 20). Overall 5-year survival was 70.4%. Disease-free 5-year survival was 51.7%. There was no statistical difference in locoregional (p = 0.9) and distant (p = 0.3) recurrence rate and no difference in overall survival (p = 0.07) when the three groups were compared. CONCLUSIONS Wedge resection is a viable option for the surgical treatment of stage I NSCLC when lobectomy is contraindicated. The distance between the tumor and the parenchymal suture margin does not influence recurrence or the survival rate when an R0 resection is achieved.

Tumor-Stroma Ratio is an independent predictor for overall survival and disease free survival in gastric cancer patients

BACKGROUND Despite different prognostic factors have been already studied, patients undergoing potentially curative resection for gastric cancer, still have a poor outcome. There is therefore the need to identify novel prognostic factors. Recently, Tumor-Stroma Ratio (TSR) was proven to be associated with prognosis in different types of cancers. Aim of this study was to evaluate the prognostic value of TSR in gastric cancer patients. METHODS 106 patients underwent gastrectomy between January 2004 and December 2015. Demographics and histopathological characteristics were collected. We considered a 50% TSR cutoff value to divide patients in Stroma-Rich (≥50%) and Stroma-Poor (<50%) groups. RESULTS Forty-one (38.7%) patients were classified as Stroma-Poor while 65 (61.3%) as Stroma-Rich (61.3%). The Stroma-Rich patients had a higher number of positive lymph-nodes, lymph node ratio (LNR), a higher percentage of T3/T4 local invasion and N2/N3, and a more advanced TNM. Moreover, these patients showed a higher percentage of lymphovascular and perineural invasion. With a median FU of 38 months Stroma-Rich patients had a significantly worse 5-years actuarial overall survival (OS) and disease free survival (DFS) compared to Stroma-Poor patients. Moreover, the multivariate analysis showed that Stroma-Rich was the only independent factor associated with OS and DFS together with TNM-Stage. CONCLUSIONS TSR is an independent marker of poor prognosis in patients with gastric cancer that should be readily incorporated into routine clinical pathology reporting. Identification of sensitive markers for patients who had undergone curative gastrectomy and who are at high risk of recurrence could provide useful information for planning follow-up after surgery or intensive and or/targeting adjuvant chemotherapy.

Influence of perineural invasion in predicting overall survival and disease-free survival in patients with locally advanced gastric cancer.

BACKGROUND The aim of the present study was to evaluate the prognostic significance of perineural invasion (PNI) in locally advanced gastric cancer patients who underwent D2 gastrectomy and adjuvant chemotherapy. METHODS The records of a series of 103 patients undergoing D2 gastrectomy with curative intent combined with adjuvant chemotherapy from January 2004 to December 2014 were retrospectively reviewed. RESULTS PNI was positive in 47 (45.6%) specimens. The 1-, 3-, and 5-year overall survival rates were 81%, 55%, and 42%, respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 76%, 57%, and 49%, respectively. A multivariate analysis showed that age number of positive lymph nodes, T stage, and PNI were independently associated with overall survival. Regarding DFS, the multivariate analysis showed that only PNI was independently associated with DFS. CONCLUSIONS PNI and T stage and positive lymph nodes are independent markers of poor prognosis in patients with gastric cancer. PNI should be incorporated in the postoperative staging system for planning follow-up after surgery and in our opinion to propose more aggressive postoperative therapies in PNI-positive patients.

Emergency abdominal surgery in the elderly: a ten-year experience.

The mean age of the population is increasing in the western countries. In particular, in Italy 14% of the population are over 70 years old. The rising of the older population is associated to the increase of the number of emergency abdominal surgical procedures. Postoperative morbidity and mortality are strictly dependent on comorbidities. The aim of this study was to analyze morbidity and mortality in older patients who underwent emergency abdominal surgery.

Superior Vena Cava Replacement for Thymic Malignancies

BACKGROUND Advanced-stage thymic tumors infiltrating the superior vena cava (SVC), when radically resectable, can be surgically treated by SVC prosthetic replacement within a multimodality therapeutic approach. We hereby present our series of patients undergoing SVC resection and prosthetic reconstruction for stage III or IV thymic malignancies. METHODS Between 1989 and 2015, 27 patients with thymic tumors (21 thymoma, 6 thymic carcinoma) infiltrating the SVC underwent radical resection with a SVC prosthetic replacement by a bovine pericardial conduit in 12 cases, a polytetrafluoroethylene conduit in 13, a porcine pericardial conduit in 1, and a saphenous vein conduit in 1. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. RESULTS Six patients were myasthenic. All resections were complete (R0). Twelve patients received induction treatment. Pulmonary resection was associated in 16 patients (11 wedge, 5 pneumonectomy). Twenty-two patients were Masaoka stage III and 5 were stage IVa. Mortality rate was 7.4%; no mortality was related to the vascular reconstruction. Major complication rate was 11.1%. At a median follow-up of 58 (range, 4 to 134) months, recurrence occurred in 9 (36%) patients. Three- and 5-year overall survival rates were 80% and 58.1%, respectively. Three-and 5-year cancer-specific survival were 90.5% and 75.4%. Cancer-specific survival rates of thymoma patients at 5 years were 93.8%. Five-year cancer-specific survival of all stage III patients was 77.1%. Thymic carcinoma histology was a negative prognostic factor. Long-term patency of the pericardial conduits was 100%. CONCLUSIONS En bloc resection and conduit reconstruction of the SVC is a good option to allow radical resection of locally advanced thymic tumors. A heterologous pericardial conduit represents the favorite option in our experience.

Reimplantation of the upper lobe bronchus after lower sleeve lobectomy or bilobectomy: long-term results

OBJECTIVES The advantages of a bronchial sleeve resection are well established. A clear majority of reported cases are of upper lobe sleeve resection. Reimplantation of the upper lobe bronchus after a lower sleeve lobectomy or bilobectomy (the so-called Y-sleeve resection) is infrequent. Related technical peculiarities are the main issues. We present our experience and results in this setting. METHODS Between 1989 and 2015, we performed 28 Y-sleeve resections of the left lower lobe (n = 18) or right middle and lower lobes (n = 10). The lung-sparing reconstructive operation was performed for non-small-cell lung cancer in 23 cases, for bronchial carcinoid tumour in 4 cases and for a cystic adenoid carcinoma in 1 case. Anastomotic reconstruction was performed by interrupted 4-0 absorbable sutures (monofilament material). RESULTS All the resections were complete (R0). Postoperative mortality was 3.6%. The rate of major complications was 10.7% (1 myocardial infarction, 1 anastomotic stenosis requiring dilatation and 1 anastomotic fistula). Among the 23 patients with non-small-cell lung cancer (18 men and 5 women; mean age 58 ± 12 years), 8 were Stage I, 9 were Stage II and 6 were Stage IIIa. At a mean follow-up of 46 months, the recurrence rate was 32%. There were 2 loco-regional recurrences. No endobronchial or perianastomotic recurrence occurred. The 3- and 5-year overall and disease-free survival rates of patients with non-small-cell lung cancer were 76.3% and 55.1% and 68.7% and 62.9%, respectively. CONCLUSIONS A Y-sleeve resection with reimplantation of the upper load bronchus is a technically feasible and oncologically adequate operation.