Posterior and Para-Aortic (D2plus) Lymphadenectomy after Neoadjuvant/Conversion Therapy for Locally Advanced/Oligometastatic Gastric Cancer.

Super-extended (D2plus) lymphadenectomy after chemotherapy has been reported in only a few studies. This retrospective study evaluates survival outcomes in a Western cohort of locally advanced or oligometastatic gastric cancer patients who underwent D2plus lymphadenectomy after neoadjuvant chemotherapy. A total of 97 patients treated between 2010 and 2022 were included. Of these, 62 had clinical stage II/III disease, and 35 had stage IV disease. Most patients (65%) received preoperative DOC/FLOT chemotherapy. The mean number of lymph nodes harvested was 39. Pathological positive nodes in the posterior/para-aortic stations occurred in 17 (17.5%) patients. Lymphovascular invasion, ypN stage, clinical stage, and perineural invasion were predictive factors for positive posterior/para-aortic nodes. Postoperative complications occurred in 21 patients, whereas severe complications (grade III or more) occurred in 9 cases (9.3%). Mortality rate was 1%. Median overall survival (OS) was 59 months (95% CI: 13-106), with a five-year survival rate of 49 ± 6%; the five-year OS after R0 surgery was 60 ± 7%. In patients with positive posterior/para-aortic nodes, the median OS was 15 months (95% CI: 13-18). D2plus lymphadenectomy after chemotherapy for locally advanced or oligometastatic gastric cancer is feasible and associated with low morbidity/mortality rates. The incidence of pathological metastases in posterior/para-aortic nodes is not negligible even after systemic chemotherapy, with poor long-term survival.

A pragmatic approach improves the clinical management of stage IV gastric cancer: Comparison between the Meta-Gastro results and the GIRCG's retrospective series.

INTRODUCTION: The Italian Research Group for Gastric Cancer developed a prospective database about stage IV gastric cancer, to evaluate how a pragmatic attitude impacts the management of these patients. MATERIALS AND METHODS: We prospectively collected data about metastatic gastric cancer patients thanks to cooperation between radiologists, oncologists and surgeons and we analyzed survival and prognostic factors, comparing the results to those obtained in our retrospective study. RESULTS: Three-hundred and eighty-three patients were enrolled from 2018 to September 2022. We observed a higher percentage of laparoscopic exploration with peritoneal lavage in the prospective cohort. In the registry only 3.6 % of patients was submitted to surgery without associated chemotherapy, while in the retrospective population 44.3 % of patients were operated on without any chemotherapy. At univariate and multivariate analyses, the different metastatic sites did not show any survival differences among each other (OS 20.0 vs 16.10 vs 16.7 months for lymphnodal, peritoneal and hepatic metastases, respectively), while the number of metastatic sites and the type of treatment showed a statistical significance (OS 16,7 vs 13,0 vs 4,5 months for 1, 2 and 3 different metastatic sites respectively, p < 0.001; 24,2 vs 12,0 vs 2,5 months for surgery with/without chemotherapy, chemotherapy alone and best supportive treatment respectively, p < 0.001). CONCLUSIONS: Our data highlight that the different metastatic sites did not show different survivals, but survival is worse in case of multiple localization. In patients where a curative resection can be achieved, acceptable survival rates are possible. A better diagnostic workup and a more accurate staging impact favorably upon survival.

Neuroendocrine tumors' patients treated with somatostatin analogue could complicate with emergency cholecystectomy.

BACKGROUND: Gastro-entero-pancreatic neuroendocrine tumors are gradually seeing their incidence increase, probably due to their low-rate mortality. Surgery and subsequent medical therapy through octeotride and somatostatin analogues is the recommended approach for hypersecretive hormonal forms, showing an effective control of symptoms and improved survival outcomes. AIM: The present study aims to evaluate the occurrence of gallbladder lithiasis, and its complications, in patients underwent upfront surgery for neuroendocrine tumors and subsequent long-term administration of somatostatin analogues. MATERIAL OF STUDY: We included four adults affected by neuroendocrine (gastric, appendiceal and ileal) tumors and without previous evidence of gallbladder stones, who needed an emergency cholecystectomy after long-term somatostatin treatment. RESULTS: The patients showed complicated conditions sustained by cholelithiasis, such as acute cholecystitis, gangrenous cholecystitis, or intestinal occlusion, which required emergency surgery. DISCUSSIONS: Somatostatin analogues may influence the cascade of enzymes that guarantee the gallbladder motility, and consequently cause the precipitation of cholesterol and calcium bilirubinate crystals. Therefore, higher and sustained levels of somatostatin may result in higher rates of gallstone development. CONCLUSIONS: The prophylactic cholecystectomy, during upfront surgery for neuroendocrine tumors, might prevent an emergency cholecystectomy for gallstones complications. KEY WORDS: Gallbladder stones, Neuroendocrine tumors, Somatostatine analogues.

Extended Lymphadenectomy for Gastric Cancer in the Neoadjuvant Era: Current Status, Clinical Implications and Contentious Issues.

Despite its decreasing incidence, gastric cancer remains an important global healthcare problem due to its overall high prevalence and high mortality rate. Since the MAGIC and FNLCC/FFCD trials, the neoadjuvant chemotherapy has been recommended throughout Europe in gastric cancer. Potential benefits of preoperative treatments include a higher rate of R0 resection achieved by downstaging the primary tumor, a likely effect on micrometastases and isolated tumor cells in the lymph nodes, and, as a result, improved cancer-related survival. Nevertheless, distortion of anatomical planes of dissection, interstitial fibrosis, and sclerotic tissue changes may increase surgical difficulty. The collection of at least twenty-five lymph nodes after neoadjuvant therapy would seem to ensure removal of undetectable node metastasis and reduce the likelihood of locoregional recurrence. It is not what you take but what you leave behind that defines survival. Therefore, para-aortic lymph node dissection is safe and effective after neoadjuvant chemotherapy, in both therapeutic and prophylactic settings. In this review, the efficacy of adequate lymph node dissection, also in a neoadjuvant setting, has been investigated in the key studies conducted to date on the topic.

Immunohistochemical Markers of the Epithelial-to-Mesenchymal Transition (EMT) Are Related to Extensive Lymph Nodal Spread, Peritoneal Dissemination, and Poor Prognosis in the Microsatellite-Stable Diffuse Histotype of Gastric Cancer.

Background: Although the prognostic value of the epithelial-to-mesenchymal transition (EMT) in gastric cancer has been reported in several studies, the strong association with the diffuse type may represent a confounding factor. Our aim is to investigate potential correlations among EMT status, tumor advancement, and prognosis in diffuse gastric cancer. Methods: Between 1997 and 2012, 84 patients with microsatellite-stable (MSS) diffuse-type tumors underwent surgery. The EMT phenotype was assessed with the E-cadherin, CD44, and zinc finger E-box binding homeobox 1 (ZEB-1) immunohistochemical markers. Results: Forty-five out of 84 cases (54%) were EMT-positive; more advanced nodal status (p = 0.010), pTNM stage (p = 0.032), and vascular invasion (p = 0.037) were observed in this group. The median numbers of positive nodes (13 vs. 5) and involved nodal stations (4 vs. 2) were higher in the EMT-positive group. The cancer-related survival time was 26 months in EMT-positive cases vs. 51 in negative cases, with five-year survival rates of 17% vs. 51%, respectively (p = 0.001). The EMT status had an impact on the prognosis of patients with <70 years, R0 resections, or treatment with adjuvant chemotherapy. Tumor relapses after surgery and peritoneal spread were significantly higher in the EMT-positive tumors. Conclusions: EMT status, when assessed through immunohistochemistry, identified an aggressive phenotype of MSS diffuse-type tumors with extensive lymph nodal spread, peritoneal dissemination, and worse long-term outcomes.

Some Concerns from a Radiological Point of View. Comment on Huang et al. Outcomes of Conversion Surgery for Metastatic Gastric Cancer Compared with In-Front Surgery Plus Palliative Chemotherapy or In-Front Surgery Alone. J. Pers. Med. 2022, 12, 555.

We read, with great interest, the article by Huang Ruo-Yi and colleagues entitled "Outcomes of Conversion Surgery for Metastatic Gastric Cancer Compared with In-Front Surgery Plus Palliative Chemotherapy or In-Front Surgery Alone", published on 1 April 2022 [...].

Long-Term Function of Kidneys From an Acute Renal Failure Donor on Continuous Venovenous Hemofiltration: A Case Report.

The organ shortage has induced many transplant centers to use suboptimal grafts, such as those from expanded criteria donors and donors after cardiac death. Acute renal failure donors, sometimes present in intensive therapy units, have been used in a very low number of cases due to the fear of primary nonfunction of this type of graft. There are few published studies about the utilization of donors with severe acute renal failure and there is no general consensus identifying unequivocal criteria for their use by different transplant centers. We transplanted 2 kidneys from a 67-year-old donor who suffered from acute renal failure as a consequence of extracorporeal circulation in cardiac surgery and died of a massive cerebral edema with cistern obliteration. The kidneys were discarded by other transplant centers due to the patient's acute renal failure, treated by continuous venovenous hemofiltration. Both transplants were successful and both grafts showed very good renal function after 6 months. One recipient suffered from delayed graft function and renal drug toxicity, which resolved 1 month post transplant. The long-term graft function at 10 years is acceptable, with very low proteinuria. As a growing gap between the inadequate supply and constantly high demand for kidney transplantation has led doctors to explore novel policies to increase the number of available organs over the last 2 decades, acute renal failure treated by continuous venovenous hemofiltration does not seem to be a contraindication for the utilization of grafts.