We report patient outcomes from esophageal resection with respect to morbidity and cancer survival comparing open thoracotomy and laparotomy (Open), with a thoracoscopic/laparotomy approach ...(Thoracoscopic-Assisted) and a total thoracoscopic/laparoscopic approach (Total MIE).
From a prospective database of all patients managed with cancer of the esophagus or esophagogastric junction, patients who had a resection using one of three techniques were analyzed to assess postoperative variables, adequacy of cancer clearance, and survival.
The number of patients for each procedure was as follows: Open, 114; Thoracoscopic-Assisted, 309; and Total MIE, 23. The groups were comparable with respect to preoperative variables. The differences in the postoperative variables were: less median blood loss in the Thoracoscopic-Assisted (400 mL) and Total MIE (300 mL) groups versus Open (600 mL); longer time for Total MIE (330 minutes) versus Thoracoscopic-Assisted (285 minutes) and Open (300 minutes); longer median time in hospital for Open (14 days) versus Thoracoscopic-Assisted (13 days), Total MIE (11 days) and less stricture formation in the Open (6.1%) versus Thoracoscopic-Assisted (21.6%), Total MIE (36%). There were no differences in lymph node retrieval for each of the approaches. Open had more stage III patients (65.8%) versus Thoracoscopic-Assisted (34.4%), Total MIE (52.1%). There was no difference in survival when the groups were compared stage for stage for overall median or 3-year survival.
Minimally invasive techniques to resect the esophagus in patients with cancer were confirmed to be safe and comparable to an open approach with respect to postoperative recovery and cancer survival.
OBJECTIVE:The aim of this study was to assess long-term health-related quality of life (HRQL) in patients after thoracoscopic and open esophagectomy.
SUMMARY OF BACKGROUND DATA:Trials comparing ...minimally invasive with open transthoracic esophagectomy have shown improved short-term outcomes; however, long-term HRQL data are lacking. This prospective nonrandomized study compared HRQL and survival after thoracoscopically assisted McKeown esophagectomy (TAMK) and open transthoracic Ivor Lewis esophagectomy (TTIL) for esophageal or gastroesophageal junction (GEJ) cancer.
METHODS:Patients with esophageal or GEJ cancer selected for TAMK or TTIL completed baseline and follow-up HRQL assessments for up to 24 months using the EORTC generic and disease-specific measures, QLQ-C30 and QLQ-OES18. Baseline clinical variables were examined between the treatment groups and changes in mean HRQL scores over time estimated and tested using generalised estimating equations with propensity score (generated by boosted regression) adjustment.
RESULTS:Of the 487 patients, 377 underwent TAMK and 110 underwent TTIL. Most clinical variables were similar in the 2 groups; however, there were significantly more patients with AJCC stage 3 disease who underwent TTIL than TAMK (54% vs 32%, P < 0.01) and this was reflected in the survival data.Mean symptom scores for pain were significantly higher in the TTIL group than in TAMK for 2 years postoperatively (P = 0.036). In addition, mean constipation scores were significantly higher for the TTIL group, with a 15-point difference in mean score at 3 months postoperatively (P = 0.037).
CONCLUSIONS:This large comprehensive nonrandomized analysis of longitudinal HRQL shows that TTIL is associated with more pain and constipation than TAMK.
Background
Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant ...treatment mandate analysis of more contemporary cohorts.
Methods
Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models.
Results
A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio OR 1.47,
P
= 0.016; OR 1.35,
P
= 0.001) and pneumonia (OR 2.29,
P
= 0.002; 1.56,
P
= 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4,
P
= 0.035). Respiratory comorbidities (OR 3.81,
P
= 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51,
P
= 0.032) or respiratory failure (OR 8.7,
P
< 0.001), but not anastomotic leak (OR 2.22,
P
= 0.074), were independent risk factors for death. MIE (OR 0.11,
P
< 0.001) and thoracic epidural analgesia (OR 0.12,
P
= 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications.
Conclusions
Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.
Demographic and lifestyle factors, in particular tobacco smoking and alcohol, are well established causes of esophageal squamous cell carcinoma (ESCC); however, little is known about the effect of ...these factors on survival. We included all 301 patients with incident ESCC, recruited into a population‐based case–control study of esophageal cancer in Australia. Detailed information about demographic and lifestyle factors was obtained at diagnosis, and deaths were identified using the National Death Index. Median follow‐up for all‐cause mortality was 6.4 years. Hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated from Cox proportional hazards models, adjusted for age, sex, pretreatment AJCC tumor stage, treatment and presence of comorbidities. Two hundred and thirteen patients (71%) died during follow‐up. High lifetime alcohol consumption was independently associated with poor survival. Relative to life‐long nondrinkers and those consuming <1 drink/week, the HRs for those with average consumption of 7–20 drinks/week or ≥21 drinks/week were 2.21 (95% CI = 1.27–3.84) and 2.08 (95% CI = 1.18–3.69), respectively. There was a suggestion of worse survival among current smokers (HR = 1.42, 95% CI = 0.89–2.28); however, the risk of early death was greatest among current smokers who reported regularly (≥7 drinks/week) consuming alcohol (HR = 3.84, 95% CI = 2.02–7.32). Other lifestyle factors putatively associated with risk of developing ESCC were not associated with survival. In addition to increasing disease risk, heavy alcohol consumption may be independently associated with worse survival among patients with ESCC. Future clinical follow‐up studies should consider alcohol as a potential prognosticator, in addition to known clinicopathologic factors.
Background
High hospital‐volume and service capability are associated with improved mortality following complex cancer surgery. Using a population‐based study in Queensland, we assessed differences ...in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high‐ and low‐volume hospitals stratified by service capability.
Methods
Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; ‘low‐volume (<6) with high service capability' and ‘low‐volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30‐ and 90‐day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time‐period.
Results
For oesophagectomy, adjusted 90‐day mortality was higher in low‐volume compared with high‐volume hospitals, regardless of service capability (low‐volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74–8.57; low‐volume, low service: IRR 3.40, 95% CI 1.16–10.00). For pancreaticoduodenectomy, mortality was higher in low‐volume compared with high‐volume centres regardless of service capability: 30‐day mortality (low‐volume, high service: IRR 2.32, 95% CI 1.07–5.03; low‐volume, low service: IRR 3.92, 95% CI 1.45–10.61); 90‐day mortality (low‐volume, high service: IRR 2.36, 95% CI 1.29–4.30; low‐volume, low service: IRR 3.32, 95% CI 1.64–6.71).
Conclusion
High hospital resection volumes are associated with lower post‐operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high‐volume centres.
Post‐operative mortality is lower following oesophagectomy and pancreaticoduodenectomy performed in high‐volume (six or more procedures annually) when compared with low‐volume centres, regardless of hospital service capability.
Abstract
Retroperitoneal lipoma is exceedingly rare, and due to the difficulty in distinguishing between retroperitoneal lipoma and well-differentiated liposarcoma (WDLS), recommendation is en-bloc ...resection. A 58-year-old male was investigated for scrotal swelling, ultrasound and computed tomography showed a well-defined lipomatous mass occupying much of the left side of the lower abdomen. At laparotomy, a large left-sided retroperitoneal mass was found. Histology reported a 160 mm × 150 mm × 90 mm fatty tumour weighing 1540 g. MDM2 gene amplification was not present on fluorescence in situ hybridization. No significant somatic signatures were identified on whole exome sequencing. Retroperitoneal fatty tumours represent a diagnostic dilemma. Sampling via core biopsy has been recorded at 85% accuracy for WDLS. Positive amplification of the MDM2 gene supports a diagnosis of WDLS; however, a negative biopsy does not exclude the diagnosis due to varied amplification among different cells in the same tumour.
Abstract
Mixed epithelial-stromal tumours (MESTs) are a rare biphasic tumour that frequently arise in women from the renal and urogenital tract. They are also seen in men but are exceptionally ...uncommon with only few cases reported to originate from the seminal vesicles. Malignant transformation of its epithelial or stromal components is possible; however, by in large, these tumours are benign in nature. We report the case of a 48-year-old man with no remarkable medical or surgical history who presented with a huge expanding pelvic and intra-abdominal mass that required extensive surgical management including a pelvic exenteration. Histopathological analysis concluded the diagnosis of benign MEST originating from the seminal vesicles with no malignant features. No further systemic therapy was recommended for our patient. Given the technical intricacy in the operative resection of this tumour, we aim to present our findings and surgical management of this complex MEST.
Ulcerated primary melanomas are associated with an inflammatory tumor microenvironment. We hypothesized that systemic proinflammatory states and anti-inflammatory medications are also associated with ...a diagnosis of ulcerated melanoma. In a cross-sectional study of 787 patients with newly diagnosed clinical stage IB or II melanoma, we estimated odds ratios for the association of proinflammatory factors (high body mass index, diabetes, cardiovascular disease, hypertension, and smoking) or the use of anti-inflammatory medications (statins, aspirin, corticosteroids, and nonsteroidal anti-inflammatory drugs), with ulcerated primary melanoma using regression models and subgroup analyses to control for melanoma thickness and mitotic rate. On the basis of information from 194 patients with ulcerated and 593 patients with nonulcerated primary melanomas, regular statin users had lower likelihood of a diagnosis of ulcerated primary melanoma (odds ratio 0.67, 95% confidence interval 0.45–0.99), and this association remained after adjusting for age, sex, thickness, and mitosis. When analysis was limited to melanomas that were ≤2 mm thick and had ≤2 mitoses/mm2 (40 ulcerated; 289 without ulceration), patients with diabetes had significantly raised odds of diagnosis of ulcerated melanoma (odds ratio 2.90, 95% confidence interval 1.07–7.90), adjusted for age, sex, body mass index, and statin use. These findings support our hypotheses that statin use is inversely associated, and diabetes is positively associated, with ulcerated melanoma.
Background
Isolated limb infusion (ILI) offers a minimally invasive treatment option for locally advanced extremity melanoma.
Objective
The aim of the current study was to evaluate the safety and ...efficacy of ILI in elderly patients in an Australian multicenter setting.
Methods
The results of 316 first ILI procedures, performed between 1992 and 2008 in five Australian institutions, were identified and analyzed, with the main focus on elderly patients (≥75 years of age). All institutions used the same protocol: melphalan was circulated in the isolated limb for 20–30 min (±actinomycin D), and toxicity, responses, and survival were recorded.
Results
Characteristics of patients aged ≥75 years (
n
= 148) were similar to those aged <75 years (
n
= 168), except that older patients had more melanoma deposits (median 4 vs. 5;
p
= 0.035) and lower limb volumes (5.4 vs. 6.5 L;
p
= 0.001). Median drug circulation times were lower in the older group (21 vs. 24 min;
p
= 0.04), and older patients experienced less limb toxicity (grade III/IV in 22 and 37% of patients, respectively;
p
= 0.003). A complete response (CR) was seen in 27% of patients aged ≥75 years and in 38% of patients aged <75 years (
p
= 0.06), while overall response rates were 72 and 77%, respectively (
p
= 0.30). No difference in survival was seen (
p
= 0.69).
Conclusions
The ILI technique proved safe and effective in elderly patients. When present, toxicity was localized, and lower compared with younger patients, possibly due to shorter drug circulation times. CR rates were higher in younger patients, although not significantly, while overall response and survival were equal. Optimization of perioperative factors in elderly patients may allow response rates to be raised further, while maintaining low toxicity.
Neoadjuvant therapy (NAT) for oesophageal cancer may reduce cardiopulmonary function, assessed by cardiopulmonary exercise testing (CPEX). Impaired cardiopulmonary function is associated with ...mortality following esophagectomy. We sought to assess the impact of NAT on cardiopulmonary function using CPEX and assessing the clinical relevance of any change in particular if changes were associated with post-operative morbidity.
This was a prospective, cohort study of 40 patients in whom CPEX was performed before and after NAT. Thirty-eight patients underwent surgery and follow-up with perioperative outcomes measured. The primary variables derived from CPEX were the anaerobic threshold (AT) and peak oxygen uptake (V˙O2peak).
There were significant reductions in the AT (pre-NAT: 12.4 ± 3.0 vs. post-NAT 10.6 ± 2.0 mL kg−1.min−1; p = 0.001). This reduction was also evident for V˙O2peak (pre-NAT: 16.6 ± 3.6 vs. post-NAT 14.9 ± 3.7 mL kg−1.min−1; p = 0.004). The relative reduction in V˙O2peak was greater in chemotherapy patients who developed any peri-operative morbidity (p = 0.04). For patients who underwent chemoradiotherapy, there was a significantly greater relative reduction in AT (p = 0.03) for those who encountered a respiratory complication.
Cardiopulmonary function significantly declined as a result of NAT prior to oesophagectomy. The reduction in AT and V˙O2peak was similar in both the chemotherapy and chemoradiotherapy groups.
•Neoadjuvant therapy reduces a patient's anaerobic threshold (AT) by 14.5%.•Neoadjuvant therapy reduces a patient's peak oxygen uptake (V˙O2peak) by 10.2%.•The reduction in cardiopulmonary function is similar with neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy.
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