OBJECTIVES:To compare long-term survival outcomes between primary debulking surgery (PDS) and neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) in patients with advanced ovarian cancer. METHODS:We conducted a retrospective cohort study of 400 patients with FIGO stage III-IV epithelial ovarian cancer between 2013 and 2024. Propensity score matching (PSM) was employed to balance baseline characteristics, resulting in 124 patients in each treatment group. Progression-free survival (PFS) and overall survival (OS) were the primary endpoints. RESULTS:In the matched cohort, PDS was associated with improved survival outcomes compared to NACT-IDS. Median PFS was 31.6 months for PDS versus 20.17 months for NACT-IDS (HR 0.6503, 95%CI 0.4734-0.8932, P = 0.0071). Median OS was 49.67 months for PDS versus 40.5 months for NACT-IDS (HR 0.6333, 95%CI 0.4425-0.9064, P = 0.0124). In multivariable analysis, NACT-IDS remained independently associated with poorer PFS (adjusted HR 1.59, 95% CI 1.14-2.22; P = 0.006) and OS (adjusted HR 1.62, 95% CI 1.11-2.37; P = 0.013). In the subgroup analysis, CC0/R0 resection was significantly associated with improved survival. CONCLUSIONS:In conclusion, in this single-institution retrospective real-world cohort, PDS was associated with longer PFS and OS than NACT-IDS after adjustment for measured baseline characteristics. Regardless of treatment strategy, CC0/R0 resection was associated with improved survival outcomes, highlighting the importance of individualized treatment selection aimed at achieving safe complete cytoreduction whenever feasible.
INTRODUCTION:Pathological T4 (pT4) renal cell carcinoma (RCC) is defined by adjacent organ invasion. The rate of pT4 and its associated clinicopathological characteristics received little attention in non-metastatic (M0) RCC. METHODS:Within the Surveillance, Epidemiology, and End Results (SEER) database (2004-2022), we identified M0 RCC nephrectomy patients and assessed pT4 rates. RESULTS:Of 129,075 M0 RCC nephrectomy patients, 733 (0.6%) harbored pT4 stage. Annual pT4 rates decreased from 1.4% in 2004 to 0.4% in 2022 (p < 0.001). According to tumor size, the pT4 rate was 0.1% in tumors <7 cm and increased from 0.7% in 7-7.9 cm tumors to 6.4% in ≥15 cm tumors (p < 0.001). In patients undergoing radical nephrectomy for tumors ≥7 cm, pT4 rate was 2.5% (578/22,981). According to histology, pT4 rates were 2.3% (376/16,703) in clear-cell RCC, 3.0% (81/2682) in papillary RCC, 1.2% (27/2274) in chromophobe RCC, 6.7% (75/1119) in sarcomatoid dedifferentiated tumors, 13.2% (7/53) in collecting duct carcinomas, and 8.0% (12/150) in other variant histologies (p < 0.001). Compared to pT2-3 patients, pT4 patients more frequently underwent lymphadenectomy (63.3% [366/578] vs. 30.0% [6724/22,403], p < 0.001). Among patients who underwent lymphadenectomy, lymph node invasion was more common in pT4 than in pT2-3 stage (83.6% [298/366] vs. 54.8% [3901/6724], p < 0.001). CONCLUSION:In M0 RCC, pT4 is rare. It is virtually non-existent in tumors <7 cm. The highest pT4 rates are observed in variant histologies. Compared to pT2-3, pT4 is associated with higher lymphadenectomy use and lymph node invasion rates. Collectively, these findings provide descriptive population-level benchmarks.
OBJECTIVE:Three-dimensional (3D) reconstruction model is an emerging technology that significantly enhanced perioperative metrics. This work aimed to delineate the contribution of preoperative 3D reconstruction model to robot-assisted radical nephrectomy (RARN) and IVC thrombectomy. METHODS:A retrospective cohort study was conducted on consecutive patients with RCC and IVC tumor thrombus (Mayo level 1-3) who underwent robotic surgery by a single surgeon (January 2023-January 2026). Preoperative computed tomography urography (CTU) images were used to generate 3D reconstruction models, enabling detailed visualization of tumor-vessel relationships and quantitative measurement of tumor parameters. The primary oncological endpoint was recurrence-free survival (RFS); overall survival (OS) was also evaluated as a secondary endpoint. Postoperative complications were graded using Clavien-Dindo (≥III defined as major), and renal function was assessed by eGFR. A two-sided p value < 0.05 was considered significant. RESULTS:Among 71 patients, those with preoperative 3D reconstruction (n = 27) versus without (n = 44) showed significantly shorter postoperative hospital stay (8.0 vs 10.0 days, P = 0.04) and higher postoperative estimated glomerular filtration rate (eGFR) (76.0 vs 60.0, P = 0.01). Other perioperative benefits (blood transfusion, major complications) were not statistically significant. RFS and OS did not differ significantly between groups. CONCLUSIONS:Preoperative 3D reconstruction helps facilitate RARN and IVC thrombectomy and improves perioperative outcomes. This technique holds promise for broader application in complex urological surgery.
Background Technetium-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin (99mTc-GSA) scintigraphy is a useful method for assessing liver function and its heterogeneity. We evaluated its predictive usefulness for post-hepatectomy liver failure (PHLF) in liver resection for biliary tract cancer. Methods Between 2013 and 2024, 95 patients underwent major hepatectomy with bile duct resection for biliary tract cancer and had preoperative 99mTc-GSA scintigraphy. The GSA-K value was defined using established reduction formulas of indocyanine green plasma clearance rate (ICG-K) values based on LHL15 value (99mTc-GSA uptake ratio of the liver to the liver plus heart at 15 min) from 99mTc-GSA scintigraphy. Functional remnant liver volume (f-RLV) ratio was estimated by dividing scintillation counts of the future remnant liver by total counts of the whole liver. We compared volumetric (ICG-Krem: ICG-K x RLV ratio) and functional (GSA-Krem: GSA-K x f-RLV ratio) assessment methods of the future remnant liver for predicting PHLF. Results PHLF was observed in 34 patients (35.8%) and a receiver operating characteristic curve revealed cut-off values for predicting PHLF of 0.088 for ICG-Krem and 0.086 for GSA-Krem. Positive predictive values for PHLF were 53.2% (ICG-Krem) and 87.6% (GSA-Krem). In patients with portal vein embolization (PVE), GSA-Krem showed 89.1% of positive predictive value for PHLF, and ICG-Krem was very low (53.3%). The multivariate analysis identified GSA-Krem as one of independent predictors of PHLF. Conclusions GSA-Krem derived from 99mTc-GSA scintigraphy is a valuable predictor of PHLF.
BACKGROUND:Intraoperative ultrasound-guided surgery (IOUS) is an effective technique for invasive breast cancer, offering advantages over wire localization (WL), such as smaller resection volumes, lower rates of involved margins, and better patient satisfaction. However, evidence for ductal carcinoma in situ (DCIS) is limited. This study aimed to compare specimen margins and excision volume in DCIS treated with IOUS versus WL. MATERIAL AND METHODS:From February 2018 to December 2023, women diagnosed with DCIS and eligible for breast-conserving surgery guided by IOUS or WL were prospectively recorded. For IOUS, a US-visible clip was placed at the biopsy site. During surgery, the distance between the clip and the end of mammographic microcalcifications was measured to guide excision. A specimen mammogram confirmed complete removal. Margin status, need for re-excision, and volume of excess healthy tissue-estimated through the calculated resection ratio (CRR)-were compared. RESULTS:A total of 188 patients were included: 55 (29.25%) in the IOUS group and 133 (70.75%) in the WL group. IOUS patients were younger (p = 0.01). Tumor size (p = 0.11) and grade (p = 0.46) were similar between groups. IOUS achieved higher rates of negative margins (>2mm, p = 0.005) and fewer close margins (0.1-2mm, p = 0.03). Surgical volumes did not differ (p = 0.39). Re-excision rates were lower with IOUS (p = 0.05). Multivariate analysis showed IOUS significantly reduced re-excisions (OR 0.1; 95% CI 0.01-0.6) and close/positive margins (OR 0.1; 95% CI 0.02-0.5). Disease-free survival was similar between groups. CONCLUSIONS:IOUS is an accurate localization method for DCIS surgery, reducing re-excisions by increasing rates of negative margins compared with WL.
BACKGROUND:The incidence of colorectal cancer (CRC) in adults under 50 is increasing worldwide, with young-onset rectal cancer (YORC) projected to represent up to 25% of rectal cancers by 2030. This study compared clinical presentation, tumor characteristics, and staging between YORC and late-onset rectal cancer (LORC) in a tertiary referral center. The primary objective was to assess differences in baseline disease stage, with secondary outcomes including short-term oncological endpoints. METHODS:All patients diagnosed with rectal adenocarcinoma between 2017 and 2024 were retrospectively analyzed and classified as YORC (<50 years) or LORC (≥50 years). Clinical, pathological, and radiologic staging features were compared. Mismatch repair (MMR) status was determined by immunohistochemistry, with MSI testing for MMR-deficient tumors. Overall survival (OS) and disease-free survival (DFS) in non-metastatic patients were calculated using Kaplan-Meier analysis. Median potential follow-up was estimated using the reverse Kaplan-Meier method. RESULTS:Of 705 patients, 86 (12.2%) were YORC and 619 (87.8%) LORC. YORC patients more often presented with symptoms (91.9% vs 70.9%; p < 0.001), had better WHO performance status (score 0: 98.8% vs 82.5%; p = 0.002), and more frequently showed dMMR/MSI tumors (7.0% vs 1.3%; p = 0.001). Younger patients had higher rates of metastatic disease (22.1% vs 11.6%; p = 0.007), lymph-node involvement (73.8% vs 60.7%; p = 0.020), and extramural vascular invasion (40.1% vs 26.0%; p = 0.004), with no significant differences in T-stage or mesorectal fascia involvement. At the first MDT, YORC patients were more often selected for total neoadjuvant therapy or chemotherapy alone. Among non-metastatic patients, 3-year OS (93.6% vs 87.1%; p = 0.259) and DFS (77.8% vs 77.2%; p = 0.923) was not statistically different with a median potential follow-up of 3.85 years. CONCLUSION:YORC presents more often with symptoms and advanced disease (M+, N+, EMVI+), yet short-term survival in non-metastatic patients tended to parallel that of older individuals. These findings underscore the need for earlier diagnosis, tailored management, and increased clinical awareness.
BACKGROUND:Cytoreductive surgery is central to the management of advanced ovarian cancer. As the extent of surgery varies widely, assessment of postoperative risk is challenging. The Karolinska Surgical Extent and Complexity Score (K-SECS) was developed to quantify surgical extent and has previously been associated with survival. This study evaluated whether K-SECS is also associated with major postoperative complications (MPC). METHODS:We conducted an observational study using two Swedish databases (2009-2023) including women with FIGO stage III-IV ovarian cancer undergoing cytoreductive surgery. K-SECS was classified as Intermediate (0-9), High (10-18), or Very High (≥19). The primary outcome was MPC (Clavien-Dindo grade ≥ III). Multivariable logistic regression adjusted for relevant covariates was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS:A total of 399 patients were included; 25% experienced an MPC. The risk of MPC increased with increasing surgical extent: 15% (Intermediate), 33% (High), and 52% (Very High). Compared with Intermediate scores, High (OR 2.69, 95% CI 1.62-4.52) and Very High K-SECS (OR 5.92, 95% CI 2.03-18.3) were associated with higher odds of MPC. Absolute adjusted risk differences confirmed a clinically meaningful stepwise increase in morbidity across K-SECS categories, with a 34% higher risk in the Very High versus Intermediate group (95% CI 11-57). CONCLUSION:K-SECS is associated with MPC. When considered alongside its previously demonstrated association with survival, K-SECS may support a more structured assessment of the balance between oncologic benefit and surgical risk in advanced ovarian cancer.
INTRODUCTION:Most studies recommend a treatment sequence involving neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy (NAC first) for osteosarcoma, yet direct comparisons with upfront surgery (surgery first) are lacking, and previous comparative analyses revealed no significant difference in overall survival (OS) between the two strategies. MATERIALS AND METHODS:Using the target trial emulation (TTE) framework and the Surveillance, Epidemiology, and End Results (SEER) database, we compared NAC first versus surgery first in patients with osteosarcoma. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to control for baseline confounding. The primary analysis aimed to estimate the intention-to-treat (ITT) effect to evaluate the comparative effectiveness of which initial treatment strategy is associated with a better prognosis. RESULTS:Among 831 eligible patients, 152 were assigned to the surgery-first group, and 679 were assigned to the NAC-first group. After PSM (121 pairs), the NAC-first group had significantly higher 5-year OS (77.7% [95% CI: 70.6%-85.5%] versus 61.3% [95% CI: 53.0%-70.8%], p = 0.006) and an increased risk of death in the surgery-first group (HR = 1.907, 95% CI: 1.172-3.103; p = 0.009). ITT and per-protocol (PP) analyses consistently corroborated these findings. IPTW analysis of the entire cohort showed a non-significant trend toward improved survival with NAC first (HR = 1.084, 95% CI: 0.992-1.186; p = 0.076). CONCLUSION:This study is the first to employ the TTE framework to compare treatment sequences for osteosarcoma. Our findings suggest that initiating treatment with NAC is associated with increased OS rates compared with initiating treatment with upfront surgery, providing empirical evidence that aligns with current recommendation in the National Comprehensive Cancer Network (NCCN) guidelines.
Introduction Total gastrectomy (TG) is associated with comparable survival outcomes but poorer short-term postoperative outcomes than distal gastrectomy (DG) in the general population with gastric cancer. However, evidence regarding these outcomes in the older population with early gastric cancer remains limited. This study compared long-term treatment outcomes after TG and DG, including longitudinal nutritional indicators, in this cohort. Materials and methods Patients aged ≥75 years with pathologically confirmed stage I gastric cancer were included. Among the 534 enrolled patients, 450 underwent DG and 84 underwent TG. Propensity score matching was performed to minimize baseline differences between the two groups. Results After 1:1 matching, 84 patients were included in each treatment group. Surgical outcomes, including hospital days and readmission rates, did not show significant differences. The overall complication rate was higher in the TG group (34.5% vs. 25.0%), although not significantly. 5-year overall survival rates were 79.8% in the DG group and 69.9% in the TG group. Body weights and hemoglobin levels declined more significantly in the TG group over time. Conclusion TG showed a numerically lower 5-year overall survival than DG, and was accompanied by less favorable longitudinal nutritional outcomes, although postoperative complication rates did not differ significantly between the two groups. The oncological benefit of TG may be expected primarily in disease-specific rather than overall survival in this age group, where non-cancer mortality contributes substantially. These observations may suggest that, in older adults with early gastric cancer at relatively low oncological risk, surgical strategies that minimize functional loss without compromising oncological adequacy deserve further investigation. Our findings could indirectly support stomach-preserving approaches in selected older patients with early gastric cancer.
OBJECTIVE:To investigate the distribution patterns and dissection efficacy of lymph node metastasis in thoracic esophageal cancer, providing a theoretical basis for standardized lymphadenectomy during esophageal cancer surgery. METHODS:A total of 703 patients who underwent radical resection for thoracic esophageal cancer via the right thoracic approach at the Fourth Hospital of Hebei Medical University between January 2014 and March 2023 were analyzed. According to tumor location, patients were classified into upper, middle, and lower thoracic groups. Lymph nodes were categorized anatomically into three regions: upper mediastinum, lower mediastinum, and upper abdomen. Stratified analyses were performed according to tumor invasion depth (T stage) and histological differentiation grade. Metastasis rates and efficacy index (EI) values were calculated for each lymph node station to clarify correlations between tumor characteristics and nodal involvement and to assess the impact of metastatic stations on patient survival. RESULTS:Overall metastasis rates to the upper mediastinal, lower mediastinal, and upper abdominal lymph nodes were 37.55%, 18.07%, and 23.33%, respectively. Among all stations, the right recurrent laryngeal nerve lymph nodes (Station 106recR) exhibited the highest metastasis rate (22.62%) and EI (11.22). Metastasis to lymph nodes along the hepatic artery (Station 8a), celiac axis (Station 9), and proximal splenic artery (Station 11p) was extremely low (≤0.85%). Stratified analysis showed that in upper and middle thoracic cancers, metastasis was most frequent at Station 106recR, with both the metastasis rates and EI increasing with greater tumor invasion invasion (T3-T4 vs. T1-T2) and poorer differentiation. For example, in upper thoracic cancer with T3-T4 poorly differentiated tumors, Station 106recR had a metastasis rate of 44.44% and an EI of 22.22. In lower thoracic cancers, perigastric lymph nodes (Stations 1-4) had the highest metastasis rate (24.71%) and EI (10.08). Among T1-T2 tumors, moderately-to-well differentiated cases metastasized predominantly to Station 106recR (7.69%, EI 5.13), whereas poorly differentiated tumors primarily involved the left gastric artery nodes (Station 7; 33.33%, EI 12.50). In T3-T4 poorly differentiated lower thoracic tumors, perigastric nodes showed the highest metastasis (59.46%, EI 22.31). CONCLUSION:Lymph node metastasis in thoracic esophageal cancer exhibits distinct, site-specific patterns. Upper and middle thoracic tumors predominantly metastasize upward to recurrent laryngeal nerve nodes, whereas lower thoracic tumors primarily involve the perigastric region. The risk and extent of lymph node metastasis-including the number of involved nodes, nodal stations, and EI values-increase with deeper invasion and poorer differentiation. Although distant lymph node metastasis occurs frequently in advanced disease, an EI of zero indicates no survival benefit from extended lymphadenectomy. Surgical lymphadenectomy should therefore be individualized based on tumor location, invasion depth, differentiation, and nodal metastatic patterns.
BACKGROUND:Three-dimensional virtual modeling (3DVM) is increasingly used in robot-assisted partial nephrectomy (RAPN), yet its true clinical utility remains uncertain because prior studies rarely accounted for surgeon experience or relied on unmatched cohorts. This study aimed to evaluate the association of 3DVM with Trifecta achievement and perioperative performance after accounting for tumor complexity and surgeon experience. METHODS:We retrospectively analyzed 80 RAPN cases (27 with 3DVM). Propensity-score matching (1:1) was performed using demographic and anatomical variables, while surgeon-related confounding was addressed using mixed-effects regression with surgeon included as a random effect. The primary endpoint was Trifecta (negative margin, warm ischemia time ≤25 min, and no 30-day complications). Mixed-effects logistic regression was used to evaluate independent predictors. RESULTS:Propensity score matching was used to balance patient and tumor characteristics between groups, while surgeon-related effects were further addressed using mixed-effects regression models. In the matched cohort, 3DVM use resulted in significantly shorter warm ischemia time (20.3 ± 9.3 vs 28.5 ± 7.1 min; p = 0.001) and more frequent arterial-only clamping (81.5% vs 18.5%; p < 0.001). Trifecta was achieved more often with 3DVM (74.1% vs 37.0%; p = 0.014). In mixed-effects logistic regression analyses accounting for surgeon-level random effects and continuous surgeon experience, the association between 3D virtual modeling and trifecta achievement was not statistically significant (OR 2.25, 95% CI 0.44-11.45, p = 0.33). CONCLUSIONS:These findings suggest that while 3D virtual modeling is associated with improved perioperative outcomes in matched comparisons, its independent effect on trifecta achievement remains uncertain after accounting for surgeon-level heterogeneity.
Objectives To establish and externally validate a preoperative MRI-based risk scoring system for MVI prediction in IMCC≤5 cm, and to evaluate its prognostic value. Methods This multicenter retrospective study enrolled 171 patients with pathologically confirmed IMCC (≤5 cm) from four institutions who underwent curative surgical resection. Patients were divided into training (n = 122) and external validation (n = 49) cohorts. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of MVI. A scoring system was established by incorporating the independent predictors based on logistic regression coefficients. According to this scoring system, patients were stratified into low- and high-risk MVI groups and disease-free survival (DFS) was analyzed by Kaplan-Meier survival analysis. Results In the multivariable analysis, non-smooth tumor margin (OR = 4.140; p = 0.005), arterial phase (AP) peritumoral enhancement (OR = 6.589; p < 0.001), and arterial edge enhancement ratio (AEER; OR = 0.916; p < 0.001) were included as independent predictors of MVI. The scoring system demonstrated high predictive accuracy, with AUCs of 0.837 in the training cohort and 0.813 in the external validation cohort. IMCC patients at high risk exhibited significantly shorter DFS compared to those at low risk for MVI in both cohorts (p < 0.05). Conclusion The preoperative MRI-based scoring system incorporating tumor margin, AP peritumoral enhancement, and AEER can effectively predict MVI in patients with IMCC ≤5 cm, providing a valuable predictive tool for risk stratification and prognosis assessment.
INTRODUCTION:Current guidelines recommend achieving negative margins ≥2 mm for ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) and radiotherapy (RT). However, the need for re-excision in cases with close (<2 mm), but negative margins remain controversial. We evaluated the prognostic impact of close margins on locoregional recurrence (LRR) and identified factors associated with recurrence. MATERIAL AND METHODS:We retrospectively analyzed 672 patients with pure DCIS who underwent BCS and adjuvant RT between 2004 and 2020. Patients were categorized into negative- and close-margin groups (n = 611 and 61, respectively). A subgroup analysis was performed on 175 patients with microinvasive carcinoma. Predictors of LRR were assessed using Cox proportional hazards models, and survival outcomes were compared using Kaplan-Meier analysis. RESULTS:During a median follow-up of 88 months, 12 patients (1.8%) developed LRR. In pure DCIS, margin status was not significantly associated with recurrence. Younger age (≤50 years) and omission of hormonal therapy were risk factors for LRR. However, in microinvasive carcinoma, close margins were significantly associated with shorter LRR-free survival. On ultrasonography, lesion size ≥2 cm and non-mass-like appearance were associated with close margin status. CONCLUSION:Close margins were not associated with an increased risk of LRR in pure DCIS patients treated with BCS and RT, suggesting that routine re-excision may be unnecessary. However, in microinvasive carcinoma, close margins were associated with a higher recurrence risk, indicating the need for wider excision. Ultrasonographic features may help to predict close margins and assist in preoperative surgical planning.
BACKGROUND:Venous congestion and small bowel edema after venous reconstruction during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) may compromise anastomotic safety. A two-stage approach with delayed gastrointestinal reconstruction may offer a protective strategy. We refer to this concept as the TARP procedure (Two-stage Anastomotic Reconstruction after Pancreatectomy). MATERIALS AND METHODS:This retrospective single-center study analyzed all consecutive patients who underwent TARP between February 2023 and February 2025. Tumor resection and venous reconstruction were completed in an initial operation, followed by deferred reconstruction within 24-72 h. Baseline characteristics and perioperative outcomes were analyzed descriptively. RESULTS:Nine patients underwent TARP during the study period. The median age was 72 years and the primary indication for a two-stage reconstruction was small bowel edema due to venous congestion. Median operation time was 401 min, median ICU stay 9 days, and median hospital stay 28 days. No patient developed an anastomotic leak or clinically relevant postoperative pancreatic fistula. Six patients (66.7%) experienced Clavien-Dindo grade ≥ IIIb complications. One patient (11.1%) died within 30 days. CONCLUSIONS:Two-stage PD with delayed reconstruction appears to be a feasible approach in selected patients with intraoperative risk factors such as bowel edema or instability. Avoiding anastomosis under unfavorable conditions may reduce early morbidity.
Pancreatic cancer with peritoneal metastases is associated with a particularly poor prognosis under standard systemic therapy. This systematic review evaluates the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in this patient population, focusing on survival, recurrence, and treatment-related morbidity and mortality. Following PRISMA guidelines, a systematic search was conducted across MEDLINE, Web of Science, and SCOPUS. Study quality was assessed using the Methodological Index for Non-randomised Studies (MINORS). Three retrospective studies met the inclusion criteria. Median overall survival ranged from 12 to 26 months. In the only comparative study, median overall survival from diagnosis was 41 months in the CRS-HIPEC group versus 19 months in the control group (systemic chemotherapy). Complete cytoreduction (CC-0) was consistently associated with better outcomes, with a median progression-free survival of 17 months after CC-0 compared with 5 months after CC-1 resection. Major complication rates ranged from 20% to 43%, and perioperative mortality ranged from 0% to 16.7%, although estimates were imprecise owing to small sample sizes. Overall, outcomes appeared highly contingent on careful patient selection based on biological criteria. CRS-HIPEC represents a potential therapeutic strategy for a carefully selected subgroup of pancreatic cancer patients with peritoneal metastasis. However, current evidence is limited to small cohorts. Adequately powered clinical trials are required before definitive clinical recommendations can be established.
Introduction: Achieving clear surgical margins is essential for treating soft tissue sarcomas (STS), as expected margins influence both prognosis and treatment decisions. When prognostic tools such as the Personalized Sarcoma Care (PERSARC) app are used for treatment planning, a preoperative estimate of expected surgical margins is required. The accuracy of these margin predictions and how margin uncertainty is communicated remain unclear. Methods: We conducted a retrospective secondary analysis using PERSARC app data, electronic patient records, and audio-recorded treatment decision-making consultations. Preoperative margin predictions were compared with postoperative histopathology in 134 patients. Communication of uncertainty was analyzed in a subset of 37 consultations. Results: Predicted and observed margins differed for 42/134 patients, resulting in a sensitivity of 2.3% for predicting positive margins. Prediction accuracy was not associated with patient and tumor characteristics. Inaccurate margin predictions substantially altered PERSARC-based estimations for overall survival, local recurrence, and distant metastasis. During consultations, the possibility of positive margins was discussed with 22/37 patients. When discussed, surgeons frequently expressed high confidence in achieving negative margins. Communication of margin uncertainty did not differ between patients with negative versus positive postoperative margins. Conclusion: Preoperative margin prediction in STS patients shows low accuracy for positive margins and is often accompanied by high expressed confidence and limited discussion of uncertainty. Treatment decisions were unlikely to be affected in this cohort, however inaccurate margin predictions may affect prognostic counseling. Increasing awareness of prediction limitations and transparent communication of uncertainty may support more realistic patient expectations and better informed decision making.
Recent surgical studies have renewed interest in the oncological relevance of proximal resection margin length in gastric and oesophagogastric junction cancer. While some data suggest that the absolute length of a negative proximal margin does not independently influence survival, other observations indicate that unexpected microscopic proximal tumour extension may predict adverse outcomes despite margin negativity. These findings challenge a purely distance-based surgical doctrine and suggest that horizontal intramural spread may reflect tumour biology rather than technical inadequacy. Alterations in adhesion molecules such as E-cadherin and CD44v6 have been associated with infiltrative growth and nodal dissemination and may partly explain unpredictable microscopic extension. In parallel, evolving perioperative strategies and increasing response rates further question a strictly anatomy-driven approach to resection planning. Integrating biological and response-based considerations into surgical decision-making may represent a logical next step in refining the extent of gastrectomy.
BACKGROUND:Anastomotic leakage (AL) remains a major complication after colorectal cancer surgery (CCS). Intraoperative indocyanine green (ICG) fluorescence angiography is widely used to assess bowel perfusion, but interpretation is largely subjective. Quantitative analysis of fluorescence kinetics combined with machine learning (ML) may enable more objective, physiology-based risk stratification. MATERIALS AND METHODS:In this single-centre retrospective feasibility study, 81 patients undergoing colorectal cancer resection with ICG perfusion assessment were analysed. Intraoperative fluorescence videos were post-processed to extract four quantitative perfusion metrics. Eight clinical variables with plausible relevance to microvascular health were included. Intraoperative hypoperfusion (n = 12, 15%) was defined by delayed fluorescence propagation judged by the operating surgeon. Logistic regression with elastic-net regularisation and three non-linear algorithms (random forest, XGBoost, support vector machine) were trained using perfusion metrics-only, clinical variables-only, and combined feature sets. Performance was evaluated with repeated stratified 5-fold cross-validation and bootstrap confidence intervals. RESULTS:Using perfusion-only features, elastic-net logistic regression achieved a ROC-AUC of 0.76 (95% CI 0.62-0.88). Clinical-only models reached a ROC-AUC of 0.77 (95% CI 0.59-0.93) with random forest. The combined model (perfusion + clinical) yielded the highest discrimination (ROC-AUC 0.81, 95% CI 0.63-0.94) with good calibration (Brier score 0.14). SHAP analysis identified increased latency and lower plateau intensity ratio (PIR) as the strongest predictors of hypoperfusion. CONCLUSION:Quantitative ICG perfusion indices, particularly latency and PIR, combined with interpretable ML models, can predict surgeon-assessed intraoperative hypoperfusion during colorectal cancer surgery with good discrimination. These findings support further development of explainable, perfusion-guided decision-support tools to reduce anastomotic risk.
Introduction Approximately 5-10% of rectal cancer diagnoses are locally advanced (LARC) at presentation and between 4 and 8% recur locally after initial treatment, locally recurrent rectal cancer (LRRC). For patients diagnosed with LARC/LRRC pelvic exenteration (PE) may be potentially curative, but is likely to impact on subsequent quality of life (QoL). To make optimal decisions about their treatment options patients need high quality detailed comprehensible information. To date there are no validated patient decision aids (PtDA) to facilitate the process of shared decision making (SDM) for PE patients. The aim of this study was to develop a PtDA in line with international minimum standards. Methods and analysis A national, multi-centre mixed methods study was designed in keeping with guidance from the International Patient Decision Aids Standard (IPDAS). Ethical approval was obtained. A PtDA was developed by a multidisciplinary committee of clinicians and patient advocates using Agile Cycle Development (ADM). Content was informed by literature review and qualitative patient and clinician interviews. Face validity and field testing were undertaken using mixed-methods of interviews and questionnaires; QQ-10, EORTC PATSAT-C33 and Preparation for Decision-Making Scale (Prep-DM). Results Six sprint cycles were used to develop the content of the PtDA. Qualitative interviews were undertaken with 19 patients and 9 clinicians resulting in 50 changes. Mean scores for value and burden were 89% (SD=12.1) and 8% (SD=8.5), respectively, suggesting high value and low burden for most patients. PtDA use resulted in improved satisfaction in all domains (p<0.05). Pre and post implementation Prep-DM score was 66.8% (SD=11.8) and 91.5% (SD=8.9%), respectively (p<0.001). Discussion This validated PtDA supports SDM for patients considering PE. A future study on implementation once the PtDA is used in routine practice will determine any further barriers to implementation.
BACKGROUND:Although gross total resection (GTR) is the standard treatment for meningiomas, its application in the cerebellopontine angle (CPA) remains controversial. Previous studies have not systematically compared long-term tumor control and functional outcomes between surgical resection and Gamma Knife radiosurgery (GKRS) for CPA meningiomas. MATERIALS AND METHODS:CPA meningioma cases were extracted from a cohort of 10,392 patients diagnosed with meningiomas. Two strategies were used: a tumor-free approach (GTR) to ensure complete tumor resection, and a tumor-reduced approach (upfront GKRS or subtotal resection plus adjuvant GKRS) to reduce tumor burden. Outcomes were assessed by progression-free survival, Karnofsky Performance Status (KPS) scores, and neurological function recovery. RESULTS:This study followed 158 patients for a median of 85.4 months. The tumor-free group had a progression rate of 5.7%, significantly lower than the 22.7% (p = 0.002) in the tumor-reduced group. Kaplan-Meier analysis showed significantly better tumor control in the tumor-free group (p = 0.043), especially in posterior tumors (p = 0.008). Regarding functional outcomes, the overall cranial nerve improvement rate was 54.2%, with a neurological deterioration rate of 7.6%. ΔKPS indicated better functional recovery in the tumor-reduced group (+12.95 vs. tumor-free group: +7.57, p = 0.005), especially for anterior tumors (+14.76 vs. +0.71, p < 0.001). CONCLUSION:For posterior CPA meningiomas, prioritizing surgical GTR may lead to optimal tumor control. For anterior meningiomas, a tumor-reduced approach (either upfront GKRS or STR followed by adjuvant GKRS) may be preferred to achieve a better functional outcome. The selection between upfront GKRS and STR + GKRS should be guided by tumor size and the presence of neural compression symptoms.
