Association of body composition and survival in patients with locally advanced breast cancer: a historical cohort study.

BACKGROUND: Altered body composition has been attributed to major health problems globally, particularly in patients with cancer. To date, there have not been sufficient indices for body compositions in predicting the survival of locally advanced breast cancer (LABC). PURPOSE: To assess the association between body composition and overall survival (OS) as well as disease-free survival (DFS) in patients with LABC. MATERIAL AND METHODS: A retrospective study was conducted of patients with LABC diagnosed between 2010 and 2018. Body composition parameters, including skeletal muscle and adiposity parameters, were measured using computed tomography at the L3 vertebra using in-house software developed by MATLAB and freeware Python 3.6.13. The association between body composition and OS and DFS were analyzed using a log-rank test and multivariate Cox-proportional hazard regression. RESULTS: Of 199 patients, 72 (36%) died during the follow-up period (range = 3.8-150.7 months). Median survival was 101 months. Low visceral-to-subcutaneous ratio ≤0.3 (adjusted hazard ratio [aHR] = 2.57, 95% confidence interval [CI] = 1.51-4.37; aHR = 2.46, 95% CI = 1.33-4.56), and high composite fat (aHR = 3.26, 95% CI = 1.69-6.29; aHR = 2.19, 95% CI = 1.11-4.3) were associated with lower OS and DFS. Positive lymph nodes ≥3, progesterone receptor negative, and total radiation dose >5000 cGy significantly decreased both OS and DFS. A history of previous treatment before body composition assessment and surgery had a protective effect on OS and DFS. No association of sarcopenia, body mass index, and adiposity areas with survival outcomes was observed. CONCLUSION: Low visceral-to-subcutaneous ratio and high composite fat were independent prognostic factors for OS and DFS in patients with LABC. However, other body composition parameters showed no effect on survival.

Achievement of benchmark outcomes by a young surgical attendant performing pancreatoduodenectomies.

PURPOSE: Pancreatoduodenectomy is a challenging procedure for young general surgeons, and no benchmark outcomes are currently available for young surgeons who have independently performed pancreatoduodenectomies after completing resident training. This study aimed to identify the competency of a young surgeon in performing pancreatoduodenectomies, while ensuring patient safety, from the first case following certification by a General Surgical Board. METHODS: A retrospective review of data from the university hospital was performed to assess quality outcomes of a young surgical attendant who performed 150 open pancreatoduodenectomies between July 13, 2006, and July 13, 2020. Primary benchmark outcomes were hospital morbidity, mortality, postoperative pancreatic fistula, postoperative hospital stay, and disease-free survival. RESULTS: All benchmark outcomes were achieved by the young surgeon. The 90-day mortality rate was 2.7%, and one patient expired in the hospital (0.7% in-hospital mortality). The overall morbidity rate was 34.7%. Postoperative pancreatic fistula grades B and C were observed in 5.3% and 0% of patients, respectively. The median postoperative hospital stay was 14 days. The 1- and 3-year disease-free survival were 71.3% and 51.4%, respectively. CONCLUSION: Pancreatoduodenectomy requires good standards of care as it is associated with high morbidity and mortality. As only one surgeon could be included in this study, our benchmark outcomes must be compared with those of other institutions. CLINICAL TRIAL REGISTRATION: The study was registered at Thai Clinical Trials Registry and approved by the United Nations (registration identification TCTR20220714002).

Randomized controlled trial of intravenous sedation vs general anesthesia for esophageal dilation with percutaneous endoscopic gastrostomy in esophageal cancer patients.

BACKGROUND: Esophageal squamous cell cancer (ESCC) is mostly diagnosed in its later stages, when patients present with dysphagia and weight loss. Esophageal dilation with percutaneous endoscopic gastrostomy (PEG) is a common surgical procedure in patients with locally advanced ESCC because of tumor obstruction and enteral nutrition support during neoadjuvant or definitive concurrent chemoradiotherapy (CCRT). Esophageal dilation with PEG is widely performed under general anesthesia (GA) with endotracheal intubation. AIM OF THE STUDY: To determine the overall success rate of completing this procedure using intravenous (IV) sedation with dexmedetomidine (DEX) relative to GA and to compare its perioperative conditions, including procedure times, pain scores (visual analog scale), adverse events, and costs. SETTINGS: Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Thailand. PATIENTS AND METHODS: Prospective randomized controlled trial (RCT) of locally advanced ESCC patients who had dysphagia and needed esophageal dilation with PEG between January 2020 and December 2021. Esophageal dilation (using a Savary-Gilliard dilator) and PEG were performed using the pull technique. RESULTS: Seventy patients were randomly assigned to either the DEX group (n = 34) or the GA group (n = 36). All patients in both groups underwent successful surgery. The DEX group had a significantly shorter procedure time, lower procedure cost, and lower total hospital cost than the GA group. However, there were no significant between-group differences in pain scores or length of hospital stay. There were no serious adverse events in either group; however, the GA group had some incidences of sore throat, transient hoarseness, and atelectasis. CONCLUSION: This study found that IV sedation with DEX during esophageal dilation with PEG was as effective and safe as using GA.

An investigation into tumor regression grade as a parameter for locally advanced rectal cancer and 5-year overall survival rate.

PURPOSE: The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiation (nCRT) followed by surgery. Several parameters are associated with patient survival in LARC. One of these parameters is tumor regression grade (TRG); however, the significance of TRG remains controversial. In this study, we aimed to examine the correlations of TRG with 5-year overall (OS) and relapse-free survival (RFS) and identify other factors that influence the survival rates in LARC after nCRT followed by surgery. METHODS: This retrospective study included 104 patients diagnosed with LARC who underwent nCRT followed by surgery at Songklanagarind Hospital from January 2010 to December 2015. All patients received fluoropyrimidine-based chemotherapy at a total dose of 45.0 to 50.4 Gy in 25 daily fractions. Tumor response was evaluated using the 5-tier Mandard TRG classification. TRG was categorized into good (TRG 1-2) and poor (TRG 3-5) responses. RESULTS: TRG (classified by either the 5-tier classification system or the 2-group classification system) was not correlated with 5-year OS or RFS. The 5-year OS rates were 80.0%, 54.5%, 80.8%, and 67.4% in patients with TRG 1, 2, 3, and 4, respectively (P=0.22). Poorly differentiated rectal cancer and systemic metastasis were associated with poor 5-year OS. Intraoperative tumor perforation, poor differentiation, and perineural invasion were correlated with inferior 5-year RFS. CONCLUSION: TRG was probably not associated with either 5-year OS or RFS; however, poor differentiation and systemic metastasis were strongly associated with poor 5-year OS.

Urogenital dysfunction after laparoscopic surgery for rectal or sigmoid colon cancer.

BACKGROUND/OBJECTIVE: Urogenital dysfunction is a common complication after surgery for sigmoid colon or rectal cancers and may result from various causes. Herein, we evaluated urogenital dysfunction and the associated factors after laparoscopic surgery at different follow-up times. METHODS: We conducted a prospective study on 91 patients who were diagnosed with sigmoid colon and rectal cancers and underwent laparoscopic surgery during 2014-2016. Voiding and male and female sexual dysfunctions following surgery were evaluated by the International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5), and Female Sexual Function Index-6 (FSFI-6), respectively. Urogenital function was compared at pre-surgery and 3 and 12 months postoperatively, and factors associated with urogenital dysfunction were identified. RESULTS: The overall urinary function after surgery was better when compared to that at pre-surgery; however, there was deterioration in both male and female sexual functions. The mean preoperative IPSS, IIEF-5, and FSFI-6 scores were 9.35, 12.18, and 6.09, respectively. The mean differences among IPSS, IIEF-5, and FSFI-6 at 12 months postoperatively and pre-surgery were -3.08 (95% confidence interval [CI] -4.77 to -1.40), -2.57 (95% CI -4.33 to -0.80), and -2.58 (95% CI -4.73 to 0.42), respectively. Multivariate analysis demonstrated that age ≤60 years (odds ratio 4.22) and postoperative complications (odds ratio 2.77) were correlated with erectile dysfunction. CONCLUSION: Voiding function improved after laparoscopic surgery in both sigmoid colon and rectal cancer patients. However, sexual function in both male and female patients was worse. Age ≤60 years and postoperative complications were strongly associated with male sexual dysfunction.

Accuracy of high-resolution rectal magnetic resonance imaging re-staging with histopathology in locally advanced rectal cancer after neoadjuvant chemoradiotherapy.

BACKGROUND/OBJECTIVE: Re-staging of locally advanced rectal cancer (LARC) following neoadjuvant chemoradiotherapy (NCRT) is a crucial step in surgical decision-making. Currently, MRI is the imaging of choice for evaluation of LARCs, however, the diagnostic accuracy of this modality is inconsistent. In this study, we evaluated the diagnostic accuracy of MRI in LARC and analyzed the factors that influenced the accuracy. METHODS: The records of 133 patients diagnosed with LARC who were operated on during 2011-2018 were retrospectively reviewed. All patients received NCRT followed by re-staging based on high-resolution rectal MRI. The MRI results were analyzed for their yT and yN accuracy and anal sphincter involvement and compared with the related histopathological studies after definitive surgery. RESULTS: Re-staging MRIs gave overall accuracy in both the yT stage and yN evaluation of 85% (K 0.45 and 0.21, respectively). The MRI tended to overstaging for tumor invasion and understaging for lymph node involvement (sign test p-values = 0.017 and 0.022, respectively.) The highest accuracy of the yT stage was yT4b (93%, K 0.71). The study found that larger tumors (>3 cm) were associated with significantly higher accuracy in the yT readings while lack of lymphovascular invasion was associated with higher accuracy in the yN readings. The negative predictive value for anal sphincter involvement was 100%. CONCLUSION: MRI has limited accuracy in post-NCRT re-staging in LARC, tending to give overstaged yT readings and understaged yN readings. An MRI exclusion of sphincteric involvement is highly reliable.

Pretreatment Esophageal Wall Thickness Associated with Response to Chemoradiotherapy in Locally Advanced Esophageal Cancer.

PURPOSE: A multimodality approach using concurrent chemoradiotherapy (CRT) followed by esophagectomy has been the standard treatment in patients with locally advanced esophageal squamous cell carcinoma (ESCC). Computed tomography (CT) is widely utilized to evaluate esophageal cancer before and after CRT. This study evaluated the utility of pretreatment maximal esophageal wall thickness on CT scans to predict treatment outcomes after CRT in patients with locally advanced ESCC. METHODS: Eighty-one patients with T3 locally advanced ESCC, whom were treated completely with CRT with and without surgery, and had available CT scans before and after CRT at a university hospital between 2005 and 2015, were retrospectively reviewed. RESULT: Twenty patients (24.7%) had esophagectomy after neoadjuvant CRT and sixty-one patients (75.3%) had definitive CRT. The maximal esophageal wall thicknesses were measured retrospectively and correlated with the response and survival after treatment. A total of 40% of neoadjuvant CRT patients achieved a pCR. There was a significant difference in pretreatment maximal esophageal wall thickness between the pCR and non-pCR groups (mean 11.9 ± 5.3 mm versus 16.9 ± 3 mm; p = 0.01). Pretreatment maximal esophageal wall thickness < 10 mm was significantly related to better overall survival than ≥ 10 mm (median survival 79 months versus 15 months; HR 3.21, 95%CI 1.14-9; p = 0.02). The neoadjuvant CRT group had significantly better survival than the definitive CRT group (median survival 51 months versus 14.5 months; HR 0.46; 95%CI 0.25-0.85; p = 0.01). CONCLUSION: In our study, pretreatment esophageal wall thickness of T3 locally advanced ESCC is a useful indicator for predicting survival and pCR after treatment.

Costs and benefits of different methods of esophagectomy for esophageal cancer.

Background A minimally invasive approach to esophagectomy is being used increasingly, but concerns remain regarding the feasibility, safety, cost, and outcomes. We performed an analysis of the costs and benefits of minimally invasive, hybrid, and open esophagectomy approaches for esophageal cancer surgery. Methods The data of 83 consecutive patients who underwent a McKeown's esophagectomy at Prince of Songkla University Hospital between January 2008 and December 2014 were analyzed. Open esophagectomy was performed in 54 patients, minimally invasive esophagectomy in 13, and hybrid esophagectomy in 16. There were no differences in patient characteristics among the 3 groups Minimally invasive esophagectomy was undertaken via a thoracoscopic-laparoscopic approach, hybrid esophagectomy via a thoracoscopic-laparotomy approach, and open esophagectomy by a thoracotomy-laparotomy approach. Results Minimally invasive esophagectomy required a longer operative time than hybrid or open esophagectomy ( p = 0.02), but these patients reported less postoperative pain ( p = 0.01). There were no significant differences in blood loss, intensive care unit stay, hospital stay, or postoperative complications among the 3 groups. Minimally invasive esophagectomy incurred higher operative and surgical material costs than hybrid or open esophagectomy ( p = 0.01), but there were no significant differences in inpatient care and total hospital costs. Conclusion Minimally invasive esophagectomy resulted in the least postoperative pain but the greatest operative cost and longest operative time. Open esophagectomy was associated with the lowest operative cost and shortest operative time but the most postoperative pain. Hybrid esophagectomy had a shorter learning curve while sharing the advantages of minimally invasive esophagectomy.

The Pre-Treatment Neutrophil-Lymphocyte Ratio: a Useful Tool in Predicting Non-Sentinel Lymph Node Metastasis in Breast Cancer Cases

Background: The sentinel lymph node (SLN) biopsy is a highly accurate predictor of overall axillary nodal status in early breast cancer patients. There is however, still a debate on which patients with a positive SLN can benefit from axillary lymph node dissection (ALND). Numerous studies have been designed to identify variables that are predictive of non-SLN metastasis to avoid a complete ALND. The aim of this study was to determine whether the pre-treatment neutrophil-lymphocyte ratio (NLR) can be a predictive factor of non-SLN metastasis in early breast cancer patients. Materials and Methods: The records of 214 consecutive patients with cT1-3N0 invasive breast cancer who had undergone intraoperative SLN evaluation at Songklanagarind Hospital between the 1stof March 2011 and the 30thof May 2016 were examined. Data on patient demographics, tumor variables and NLR were collected and factors for non-SLN metastasis were analyzed using multivariate logistic regression. The power of the NLR was quantified with receiver operating characteristics (ROC) curves as measured by the areas under curves (AUC). Results: Multivariate analysis established presence of lymphovascular invasion (OR 8.4, 95%CI 2.3-31.3, p=0.002), macrometastasis (OR 6.6, 95%CI 1.8-24.7, p=0.005), and NLR (OR 2.3, 95%CI 1.1-4.8, p=0.033) as predictive factors of non-SLN metastasis with statistical significance. The AUC for NLR was 0.7 (95%CI 0.6-0.8) with an optimal cut-off of 2.6 giving a sensitivity of 62%, a specificity of 83.8%, a positive predictive value of 77.3% and a negative predictive value of 70.5%. Conclusion: Pre-treatment NLR is a useful diagnostic aid for predicting additional non-SLN metastasis.

The efficacy of cefazolin in reducing surgical site infection in laparoscopic cholecystectomy: a prospective randomized double-blind controlled trial.

BACKGROUND: A prophylactic antibiotic is recommended in open cholecystectomy surgeries, but in laparoscopic cholecystectomies such prophylaxis is controversial. Recent reviews have not found conclusive evidence that routine prophylaxis, especially in low risk patients, is effective. This clinical trial was undertaken to evaluate the efficacy of cefazolin in reducing surgical site infection SSI in laparoscopic cholecystectomies in a sample not screened for high or low risk patients. METHODS: A randomized double-blind controlled trial was conducted in a single university hospital. Scheduled cholecystectomy patients without selection for patient risk factors were randomized into two groups. Pre-operatively, group A patients received a placebo of 10 ml isotonic sodium chloride, and group B patients received 1 g of cefazolin as a prophylactic antibiotic. All patients underwent a standard laparoscopic cholecystectomy, and were followed up for at least 30 days. RESULTS: Two hundred ninety-nine patients were randomized (149 in group A and 150 in group B). SSI occurred in seven patients (2.34 %), five (1.67 %) in the placebo group, and two (0.67 %) in the prophylactic antibiotic group. The difference was not statistically significant (p value = 0.512), and no specific risk factors for post-operative infection were identified. CONCLUSIONS: A single dose of preoperative prophylactic cefazolin has no significant benefit in reducing the incidence of SSI in laparoscopic cholecystectomy. Whether or not to use a prophylactic depends on the individual patient, and the consideration of the attending surgeon.

Randomized study of antiinflammatory and immune-modulatory effects of enteral immunonutrition during concurrent chemoradiotherapy for esophageal cancer.

Concurrent chemoradiotherapy (CCRT) induces toxicities from inflammation and immunological suppression. Omega-3 fatty acids, glutamine, and arginine are therapeutic factors that can attenuate such inflammation and promote cellular immunity. The question is whether immunonutrition (IN) during CCRT reduces inflammation and improves the immune function in patients with esophageal squamous cell carcinoma (ESCC). Seventy-one locally advanced ESCC patients being treated with CCRT (5-FU and cisplatin) were randomized into 2 groups. The IN group received a combination of omega-3 fatty acids, glutamine, and arginine, whereas the control group received standard formula. The levels of C-reactive protein (CRP), tumor necrosis factor (TNF), interferon-gamma (IFN), interleukin (IL-6, IL-10), CD3, CD4, CD8, white blood cells, neutrophils, and total lymphocytes were measured before and during treatment. The levels of CRP (P = 0.001) and TNF (P = 0.014) increased more during treatment in the control group than the treatment group, whereas IFN, IL-6, and IL-10 were similar but not significantly. CD3, CD4, CD8, white blood cells, neutrophils, and total lymphocytes decreased more in the control group than in the treatment group, but not significantly. Enteral IN during CCRT reduced the increase of inflammatory cytokine levels.

Evaluating synchronous esophageal cancer in head and neck cancer patients using Lugol dye chromoendoscopy.

OBJECTIVE: Routine screening for esophageal cancer in head and neck cancer patients in Thailand is controversial, because of concerns regarding the screening methods and cost effectiveness. Since Lugol dye chromoendoscopy is an effective technique for early detection of squamous cell carcinoma of the esophagus, the objectives of the present study are to evaluate the synchronous esophageal cancer in head and neck cancer patients and the effectiveness of Lugol dye chromoendoscopy for routine screening. MATERIAL AND METHOD: All diagnosed patients with head and neck cancer between September 1, 2009 and June 30, 2011 were enrolled into the study. Both conventional esophagoscopy and Lugol dye chromoendoscopy were done. The incidence of esophageal cancer was calculated. A diagnostic statistical analysis was done to compare the diagnostic properties between conventional esophagoscopy and Lugol dye chromoendoscopy. Univariate and multivariate logistic regression analyses were used to find significant factors associated with esophageal cancer in this study. RESULTS: Eighty-nine head and neck cancer patients were enrolled in this study. The incidence of esophageal cancer in head and neck cancer patients was 12.4% (11/89). Conventional esophagoscopy found a highly suspicious malignant lesion in only six patients, while the Lugol dye chromoendoscopy detected all 11 esophageal cancers. The sensitivity and specificity for conventional esophagoscopy were 54.5% and 100%, respectively, andfor Lugol dye chromoendoscopy were 100% and 70.5%, respectively. The three significant factors that increased the likelihood of synchronous esophageal cancer from univariate analysis were age less than 50 years, presence of dysphagia, and an unstained Lugol dye area ≥10 mm. Howeve, these factors were not statistically significant by multivariate analysis. CONCLUSION: Lugol dye chromoendoscopy is a promising tool to enhance the diagnosis of esophageal cancer among head and neck cancer patients.

Prediction of major postoperative complications and survival for locally advanced esophageal carcinoma patients.

BACKGROUND: Predicting the major complications after esophagectomy is important and may help in preselecting patients who are most likely to benefit from surgery, especially in locally advanced esophageal cancer patients who have poor prognosis. OBJECTIVE: To identify the factors associated with the development of pneumonia and anastomotic leakage complications, and the survival characteristics in locally advanced esophageal cancer patients. METHODS: A consecutive series of 232 locally advanced esophageal cancer patients (183 men and 49 women, median age 63 years) who underwent esophagectomy at Prince of Songkla University Hospital between 1998 and 2007 was analyzed. RESULTS: There were nine (3.8%) 30-day mortalities. Pneumonia occurred in 53 patients (22.8%) and anastomotic leakage in 37 patients (15.9%). Multivariate analyses showed that low body mass index was related to leakage (p = 0.015), while soft-diet dysphagia (p = 0.009), forced expiratory volume in 1 second <75% (p = 0.0005), type of surgery (McKeown technique) (p = 0.019), and long operative time (p = 0.006) were related to pneumonia. The median survival rate was 13.0 months. Stage 2b patients had longer survival than stages 3 and 4a patients (p = 0.0001). CONCLUSION: Patient body mass index, dysphagia, spirometry, type of surgical technique, and operative time can help predict the likelihood of pulmonary or leak complications after esophagectomy. TNM (Tumor, Node, Metastasis) staging can help predict the overall survival after resection in locally advanced cases.