Abstract Aims Outcomes for patients with oesophago-gastric cancer are variable across Europe. The reasons for this variability are not clear. The aim of this study was to describe and analyse ...clinical pathways to understand differences in service provision for oesophageal and gastric cancer in the countries participating in the EURECCA Upper GI group. Methods A questionnaire was devised to assess clinical presentation, diagnosis, staging, treatment, pathology, follow-up and service frameworks across Europe for patients with oesophageal and gastric cancer. The questionnaire was issued to experts from 14 countries. The responses were analysed quantitatively and qualitatively and compared. Results The response rate was (10/14) 71.4%. The approach to diagnosis was similar. Most countries established a diagnosis within 3 weeks of presentation. However, there were different approaches to staging with variable use of endoscopic ultrasound reflecting availability. There has been centralisation of treatments in most countries for oesophageal surgery. The most consistent area was the approach to pathology. There were variations in access to specialist nurse and dietitian support. Although most countries have multidisciplinary teams, their composition and frequency of meetings varied. The two main areas of significant difference were research and audit and overall service provision. Observations on service framework indicated that limited resources restricted many of the services. Conclusion The principle approaches to diagnosis, treatment and pathology were similar. Factors affecting the quality of patient experience were variable. This may reflect availability of resources. Standard pathways of care may enhance both the quality of treatment and patient experience.
Background
The impact of the weekday of surgery in major elective cases of the upper-GI has been discussed controversially. The objective of this study was to assess whether weekday of surgery ...influences outcome in patients undergoing D2-gastrectomy.
Materials and methods
Patients who underwent D2-gastrectomy for gastric adenocarcinoma between 1996 and 2016 were included. Weekday of surgery was recognized, and subgroups were analyzed regarding clinical and histopathological differences. Survival analysis was performed based on weekday of surgery, and early weekdays (Monday–Tuesday) were compared with late weekdays (Wednesday–Friday).
Results
In total, 460 patients, 71% male and 29% female, were included into analysis. The median age was 65 years. Distribution to each weekday was equal and ranged from 86 cases (Wednesday) to 96 cases (Tuesday). The pT, pN and M category and the rate of patients who underwent neoadjuvant treatment did not show significant differences (
p
= 0.641;
p
= 0.337;
p
= 0.752;
p
= 0.342, respectively). The subgroups did not differ regarding the number of dissected lymph nodes and rate of R-1/2 resections (
p
= 0.590;
p
= 0.241, respectively). Survival analysis showed a median survival of 43 months (95% CI 31–55 months), and there was no single weekday or a combination of weekdays (Mon/Tue vs Wed/Thu/Fri) with a significant favorable or worse outcome (
p
= 0.863;
p
= 0.30, respectively). The outcome did not differ regarding mortality within the first 90 days after surgery (
p
= 0.948).
Conclusions
The present study does not show any evidence for a significant impact of weekday of surgery on short- and long-term outcome of patients undergoing gastrectomy for gastric adenocarcinoma.
Abstract Background Preoperative lymph node staging of pancreatic cancer by CT relies on the premise that malignant lymph nodes are larger than benign nodes. In imaging procedures lymph nodes >1 cm ...in size are regarded as metastatic nodes. The extend of lymphadenectomy and potential application of neoadjuvant therapy regimens could be dependent on this evaluation. Patients and methods In a morphometric study regional lymph nodes from 52 patients with pancreatic cancer were analyzed. The lymph nodes were counted, the largest diameter of each node was measured, and each node was analyzed for metastatic involvement by histopathological examination. The frequency of metastatic involvement was calculated and correlated with lymph node size. Results A total of 636 lymph nodes were present in the 52 specimens examined for this study (12.2 lymph nodes per patient). Eleven patients had a pN0 status, whereas 41 patients had lymph nodes that were positive for cancer. Five-hundred-twenty (82%) lymph nodes were tumor-free, while 116 (18%) showed metastatic involvement on histopathologic examination. The mean (±SD) diameter of the nonmetastatic nodes was 4.3 mm, whereas infiltrated nodes had a diameter of 5.7 mm ( p = 0.001). Seventy-eight (67%) of the infiltrated lymph nodes and 433 (83%) of the nonmetastatic nodes were ≤5 mm in diameter. Of 11 pN0 patients, 5 (45%) patients had at least one lymph node ≥10 mm, in contrast only 12 (29%) out of 41 pN1 patients had one lymph node ≥10 mm. Conclusion Lymph node size is not a reliable parameter for the evaluation of metastatic involvement in patients with pancreatic cancer.
Summary
There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using ...Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine ‘fit-for-discharge’ status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.
Overexpression of MUC1 and cytosolic interaction of the mucin with beta-catenin are claimed to be involved in colorectal carcinogenesis. In vitro data published recently suggest that MUC1 ...overexpression results in an increase of steady state levels of nuclear beta-catenin. We tried to elucidate the coexpression of both molecules in colorectal cancer to demonstrate possible correlations with clinical, pathological, and prognostic data.
An immunohistochemical double staining study was performed to characterize the expression and subcellular distribution of MUC1 and beta-catenin in a series of 205 patients with colorectal carcinoma. The results were correlated with clinicopathological variables as well as overall survival.
MUC1 was strongly expressed in the tumor center and at the invasion front in approximately 50% of the cases. Similar results were obtained with regard to nuclear accumulation of beta-catenin at the invasive tumor parts. MUC1 protein expression in the tumor center correlated significantly with a low grade of differentiation, and nuclear beta-catenin in the tumor periphery was more frequent in carcinomas of the left colon and rectum. Overexpression of MUC1 and beta-catenin, as well as their nuclear coexpression at the invasion front correlated with a worse overall survival in an univariate analysis. However, only pathological tumor-node-metastasis staging and MUC1 at the invasion front revealed as independent prognostic factors.
These results suggest that MUC1 and beta-catenin are coexpressed at the invasion front of colorectal carcinomas and that this feature is associated with an accelerated course of disease and worse prognosis.
The assessment of lymphatic metastases is an important factor in the staging of gastric cancer. Lymph node size has been used as one criterion for possible nodal metastasis. Although enlarged ...regional lymph nodes are generally interpreted as metastases, few data are available that correlate lymph node size with metastatic infiltration.
In a prospective morphometric study, the regional lymph nodes from 31 gastrectomy specimens of consecutive patients with primary gastric adenocarcinoma were analyzed. The lymph nodes were counted, the largest diameter of each node was measured, and each node was analyzed for metastatic involvement by histologic examination. The frequency of metastatic involvement was calculated and correlated to lymph node size.
A total of 1253 lymph nodes were present in the 31 specimens examined for this study. A mean number of 40 lymph nodes (range, 20-53) were found in each specimen. Of these 1253 nodes, 922 (74%) were tumor-free and 331 (26%) contained metastases. The mean diameter of the lymph nodes free of metastases was 4.1 mm, whereas that of nodes infiltrated by metastases was 6.0 mm (p < .0001). Of the tumor-free lymph nodes, 735 (80%) were less than 5 mm in diameter, whereas 182 (55%) nodes containing metastases were less than 5 mm in diameter. Of the 10 patients without lymph node metastases, seven had at least one node that was 10 mm or greater in diameter; similarly, 15 (71%) of the 21 patients with node metastases had at least one node that was 10 mm or greater in diameter.
Lymph node size is not a reliable indicator for lymph node metastasis in patients with gastric cancer.
Abstract
Background and aim
Minimally invasive gastrectomy for gastric cancer shows slower adoption in Western countries, probably due to more advanced stages and a more frequently proximal ...localization, which requires a total gastrectomy. We aimed to assess the perioperative outcomes in early and locoregional advanced gastric cancer.
Methods
We retrospectively reviewed a prospectively collected database. A total of 51 patients who underwent oncologic total gastrectomy or subtotal gastrectomy by robotic or open approach of stage pT1-T4a, pN0–3 were identified from June 2016 until June 2020. Nine patients were operated on robotically, and 42 patients by laparotomy.
Results
The age of the patients in the robotic group was comparable to that of the open group (64.7 ± 9.2 versus 62.8 ± 12.9, P = 0.685). Endoscopic tumor size was smaller in the robotic group (24.3 ± 10.4 mm versus 43.1 ± 27.0 mm, P = 0.081). Blood loss was significantly smaller with the robotic approach (185 ± 180 mL versus 425 ± 257 mL, P = 0.038). Pathologic tumor stage included stages pT1–pT4b in the open group, while stages pT1–pT3 were operated by robotic approach. Fewer tumors were localized in the upper body in the robotic group (0, 0%) than in the open group (12, 28.6%). The length of the proximal margin was comparable in the two groups (104.29 ± 50.29 versus 86.88 ± 64.66, P = 0.516). The mean number of retrieved lymph nodes was comparable in the robotic group and the open group (42.89 ± 12.119 versus 43.22 ± 20.271, P = 0.963). The mean number of metastatic nodes was significantly lower in the robotic group (0.33 ± 0.707 versus 7.02 ± 14.313, P = 0.171). Diffuse-type cancers were significantly more frequent in the robotic group (3 (33.3%) versus 3 (8.6%), P = 0.040). Significantly fewer high-grade complications (Clavien>3a) appeared in the robotic group (0 (0%) versus 2 (4.8%), P = 0.019). Length of hospital stay was comparable in the two groups.
Conclusion
The gold standard of oncologic gastrectomy is still the open approach. The minimally invasive approach must show comparable pathohistological results in regards to lymph node harvest and proximal tumor margins to be accepted in future European guidelines.
Zusammenfassung
Hintergrund
Da die Therapie der ersten Wahl und die Prognose des Adenokarzinoms des ösophagogastralen Übergangs (AEG) signifikant mit dem TNM-Stadium korreliert, ist ein möglichst ...exaktes, prätherapeutisches Staging prognoserelevant und für die Entscheidung der individuellen Therapie obligat.
Fragestellung
Der Beitrag ist eine Übersichtsarbeit zum primären Staging der AEG.
Material und Methode
Es erfolgte eine Auswertung der aktuellen Literatur sowie der aktuell publizierten Deutschen S3-Leitlinien zum Ösophagus- und Magenkarzinom.
Ergebnisse
Die topographisch-anatomische Klassifikation erfolgt nach Siewert (AEG Typ I, II, III). Die Diagnosesicherung erfolgt durch Ösophagogastroduodenoskopie (ÖGD) mit Biopsien. Für das initiale Staging sind eine Endosonographie (EUS) und Computertomographie (CT) notwendig. Die Autoren empfehlen zusätzlich bei lokal fortgeschrittenen Karzinomen eine diagnostische Laparoskopie (AEG II und III) und ein PET-CT (intestinaler Typ). Des Weiteren muss eine Risikoanalyse bezüglich der Komorbiditäten erfolgen. Alle Patienten, auch mit Frühbefunden, müssen in einem interdisziplinären Tumorboard besprochen werden.
Schlussfolgerung
Das primäre Staging des AEG vor Einleitung therapeutischer Maßnahmen hat eine überragende Bedeutung für die Therapie der ersten Wahl und damit auch für die Prognose der Erkrankung.
Expression of MMP‐2 is associated with progression and lymph node metastasis of gastric carcinoma
Aims: One important step in tumour invasion is the penetration of the basement membrane. Matrix ...metalloproteinases (MMPs) play a key role in the migration of normal and malignant cells through the basement membrane. The aim of this study was to investigate correlations between matrix metalloproteinase 2 (MMP‐2) immunoreactivity and currently used classification systems and possible relationships between lymph node metastasis and MMP‐2 expression.
Methods and results: This prospective study analysed specimens obtained from 114 gastric cancer patients (mean age 64 years; range 33–86 years) who underwent gastrectomy with extended lymphadenectomy. All specimens were categorized according to UICC classification, WHO classification, tumour differentiation, Laurén classification, Ming classification and Goseki classification. Formalin‐fixed paraffin‐embedded tumour specimens were stained using an avidin–biotin complex peroxidase assay. MMP‐2 expression in the tumour epithelium was studied by immunohistochemistry with semiquantitative (score 0–3) evaluation. The MMP‐2 staining pattern was positive (score 1–3) in 93 (81.6%) specimens and negative (score 0) in 21 (18.4%) samples. No significant correlations were found between MMP‐2 expression and other variables such as age, tumour differentiation, WHO, Lauren, Goseki, and Ming classifications. In contrast, the intensity of MMP‐2 staining in tumour cells correlated significantly with depth of tumour infiltration (T‐stage), lymph node metastasis (N‐stage), distant metastasis (M‐stage), and UICC stage.
Conclusions: Expression of MMP‐2 is strongly associated with tumour progression and lymph node metastasis in gastric cancer. Therefore MMP‐2 staining may be clinically useful as predictor of tumour progression, especially for lymph node metastasis.
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