The prognostic relevance of preoperative high-resolution magnetic resonance imaging (MRI) assessment of circumferential resection margin (CRM) involvement is unknown. This follow-up study of 374 ...patients with rectal cancer reports the relationship between preoperative MRI assessment of CRM staging, American Joint Committee on Cancer (AJCC) TNM stage, and clinical variables with overall survival (OS), disease-free survival (DFS), and time to local recurrence (LR).
Patients underwent protocol high-resolution pelvic MRI. Tumor distance to the mesorectal fascia of ≤ 1 mm was recorded as an MRI-involved CRM. A Cox proportional hazards model was used in multivariate analysis to determine the relationship of MRI assessment of CRM to survivorship after adjusting for preoperative covariates.
Surviving patients were followed for a median of 62 months. The 5-year OS was 62.2% in patients with MRI-clear CRM compared with 42.2% in patients with MRI-involved CRM with a hazard ratio (HR) of 1.97 (95% CI, 1.27 to 3.04; P < .01). The 5-year DFS was 67.2% (95% CI, 61.4% to 73%) for MRI-clear CRM compared with 47.3% (95% CI, 33.7% to 60.9%) for MRI-involved CRM with an HR of 1.65 (95% CI, 1.01 to 2.69; P < .05). Local recurrence HR for MRI-involved CRM was 3.50 (95% CI, 1.53 to 8.00; P < .05). MRI-involved CRM was the only preoperative staging parameter that remained significant for OS, DFS, and LR on multivariate analysis.
High-resolution MRI preoperative assessment of CRM status is superior to AJCC TNM-based criteria for assessing risk of LR, DFS, and OS. Furthermore, MRI CRM involvement is significantly associated with distant metastatic disease; therefore, colorectal cancer teams could intensify treatment and follow-up accordingly to improve survival outcomes.
Pseudomyxoma peritonei (PMP) originating from an appendiceal mucinous neoplasm remains a biologically heterogeneous disease. The purpose of our study was to evaluate outcome and long-term survival ...after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) consolidated through an international registry study.
A retrospective multi-institutional registry was established through collaborative efforts of participating units affiliated with the Peritoneal Surface Oncology Group International.
Two thousand two hundred ninety-eight patients from 16 specialized units underwent CRS for PMP. Treatment-related mortality was 2% and major operative complications occurred in 24% of patients. The median survival rate was 196 months (16.3 years) and the median progression-free survival rate was 98 months (8.2 years), with 10- and 15-year survival rates of 63% and 59%, respectively. Multivariate analysis identified prior chemotherapy treatment (P < .001), peritoneal mucinous carcinomatosis (PMCA) histopathologic subtype (P < .001), major postoperative complications (P = .008), high peritoneal cancer index (P = .013), debulking surgery (completeness of cytoreduction CCR, 2 or 3; P < .001), and not using HIPEC (P = .030) as independent predictors for a poorer progression-free survival. Older age (P = .006), major postoperative complications (P < .001), debulking surgery (CCR 2 or 3; P < .001), prior chemotherapy treatment (P = .001), and PMCA histopathologic subtype (P < .001) were independent predictors of a poorer overall survival.
The combined modality strategy for PMP may be performed safely with acceptable morbidity and mortality in a specialized unit setting with 63% of patients surviving beyond 10 years. Minimizing nondefinitive operative and systemic chemotherapy treatments before definitive cytoreduction may facilitate the feasibility and improve the outcome of this therapy to achieve long-term survival. Optimal cytoreduction achieves the best outcomes.
Pseudomyxoma peritonei (PMP) is a complex disease with unique biological behavior that usually arises from appendiceal mucinous neoplasia. The classification of PMP and its primary appendiceal ...neoplasia is contentious, and an international modified Delphi consensus process was instigated to address terminology and definitions. A classification of mucinous appendiceal neoplasia was developed, and it was agreed that "mucinous adenocarcinoma" should be reserved for lesions with infiltrative invasion. The term "low-grade appendiceal mucinous neoplasm" was supported and it was agreed that "cystadenoma" should no longer be recommended. A new term of "high-grade appendiceal mucinous neoplasm" was proposed for lesions without infiltrative invasion but with high-grade cytologic atypia. Serrated polyp with or without dysplasia was preferred for tumors with serrated features confined to the mucosa with an intact muscularis mucosae. Consensus was achieved on the pathologic classification of PMP, defined as the intraperitoneal accumulation of mucus due to mucinous neoplasia characterized by the redistribution phenomenon. Three categories of PMP were agreed-low grade, high grade, and high grade with signet ring cells. Acellular mucin should be classified separately. It was agreed that low-grade and high-grade mucinous carcinoma peritonei should be considered synonymous with disseminated peritoneal adenomucinosis and peritoneal mucinous carcinomatosis, respectively. A checklist for the pathologic reporting of PMP and appendiceal mucinous neoplasms was also developed. By adopting the classifications and definitions that were agreed, different centers will be able to use uniform terminology that will allow meaningful comparison of their results.
In arid and semiarid regions, persistent hydrological imbalances illuminate the considerable gaps in our spatiotemporal understanding of fundamental catchment‐scale governing mechanisms. The Salar de ...Atacama basin is the most extreme example of groundwater‐dominated continental basins and therefore is an ideal place to probe these unresolved questions. Geochemical and hydrophysical observations indicate that groundwaters discharging into the basin reflect a large regional system integrated over 102–104 year timescales. The groundwater here, as in other arid regions, is a critical freshwater resource subject to substantial demand from competing interests, particularly as development of its world‐class lithium brine deposit expands. Utilizing a uniquely large and comprehensive set of H and O isotopes in water, we demonstrate that much of the presumed recharge area on the Altiplano‐Puna plateau exhibits isotopic signatures quite distinct from waters presently discharging within the endorheic Salar de Atacama watershed. δ18O values of predicted inflow source waters are 3.6‰ to 5.6‰ higher than modern plateau waters, and 3H data from 87 discrete samples indicate that nearly all of this inflow is composed of premodern recharge (i.e., fossil water). Under plausible conditions, these distinctions cannot be explained solely by natural variability in modern meteoric inputs or by steady state groundwater flow. We present a conceptual model revealing the extensive influence of transient draining of fossil groundwater storage augmented by regional interbasin flow from the Andes. Our analysis provides robust constraints on fundamental mechanisms governing this arid continental groundwater system and a framework within which to address persistent uncertainties in similar systems worldwide.
Plain Language Summary
Groundwater in the driest places on Earth is a vital resource for both humans and ecosystems, yet fundamental characteristics of this water such as where it originates and how it moves in the ground remain unresolved. This water often lies deep underground and flows across great distances and over long periods of time; as a result, it is quite difficult to study. Using the 1,000 water samples in the Salar de Atacama basin in northern Chile at the border of the driest desert on Earth, we trace the origin and traveltime of water across a large region. Groundwater in the Salar de Atacama region is fundamental to sustaining natural and human systems; therefore, developing a better understanding of how this water moves will be critical for their management, particularly as development of its world‐class lithium brine deposit expands. We find that “fossil water,” which entered the ground hundreds or thousands of years ago, makes up most of the water now flowing into the basin. Our analysis also defines the area that contributes water to the basin, much of which incorporates flow through mountains and from other higher‐elevation basins. By improving our understanding of how these large flow systems develop and function, this work will aid efforts to sustainably manage these critical freshwater resources for all who rely on them.
Key Points
Analysis of tritium in water discharging within Salar de Atacama basin shows that it is composed predominantly of water >60 years old
Water entering the Salar de Atacama basin is spatially distinct and decoupled from recharge on the Altiplano‐Puna plateau
Analysis of stable O and H isotope ratios in 900 water samples constrains the spatiotemporal dimensions of modern and fossil groundwaters
This multi-institutional registry study evaluated cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for diffuse malignant peritoneal mesothelioma (DMPM).
A ...multi-institutional data registry that included 405 patients with DMPM treated by a uniform approach that used CRS and HIPEC was established. The primary end point was overall survival. The secondary end point was evaluation of prognostic variables for overall survival.
Follow-up was complete in 401 patients (99%). The median follow-up period for the patients who were alive was 33 months (range, 1 to 235 months). The mean age was 50 years (standard deviation SD, 14 years). Three hundred eighteen patients (79%) had epithelial tumors. Twenty-five patients (6%) had positive lymph nodes. The mean peritoneal cancer index was 20. One hundred eighty-seven patients (46%) had complete or near-complete cytoreduction. Three hundred seventy-two patients (92%) received HIPEC. One hundred twenty-seven patients (31%) had grades 3 to 4 complications. Nine patients (2%) died perioperatively. The mean length of hospital stay was 22 days (SD, 15 days). The overall median survival was 53 months (1 to 235 months), and 3- and 5-year survival rates were 60% and 47%, respectively. Four prognostic factors were independently associated with improved survival in the multivariate analysis: epithelial subtype (P < .001), absence of lymph node metastasis (P < .001), completeness of cytoreduction scores of CC-0 or CC-1 (P < .001), and HIPEC (P = .002).
The data suggest that CRS combined with HIPEC achieved prolonged survival in selected patients with DMPM.
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