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Recent EJSO - European Journal of Surgical Oncology Articles
A meta-analysis of STAT3 and phospho-STAT3 expression and survival of patients with non–small-cell lung cancer
Available online 4 December 2013
Y. Xu | S. Lu
Abstract: BackgroundThe prognostic role of signal transducer and activator of transcription 3 (STAT3) and phospho-STAT3 in non-small-cell lung cancer (NSCLC) remains controversial. To clarify its impact on survival, we performed a meta-analysis to quantitatively assess STAT3 and phospho-STAT3 expression on the prognosis of NSCLC.MethodsPublished studies were identified using a systematic and thorough literature search. To be eligible, a study had to investigate STAT3 or phospho-STAT3 expression rates of NSCLC patients in different characteristics and provide patient survival data.ResultsA total of 17 retrospective trials were chosen for meta-analysis, including 1793 patients. The estimated pooled log HR (0.67, 95%CI: 0.57–0.77) of 9 trials (STAT3: log HR 0.71, 95%CI 0.38–1.04; phospho-STAT3: log HR 0.67, 95%CI 0.56–0.77) for NSCLC was statistically significant (P < 0.0001), suggesting that high STAT3 or phospho-STAT3 expression is a strong predictor of poor prognosis among patients with NSCLC. For the risk factors, pooled analysis of patients with STAT3 positivity, demonstrated a statistically significant OR (3.82, 95%CI: 2.37–6.16) between poorly differentiated carcinoma and well-moderately, OR (5.68, 95%CI: 3.16–10.21) between stage III–IV patients and stage I–II patients, and OR (3.41, 95%CI: 2.12–5.49) between patients with lymph node metastasis and patients without lymph node metastasis. However, pooled analysis of patients with phospho-STAT3 positivity only demonstrated a statistically significant OR (4.51, 95%CI: 1.57–12.96) between poorly differentiated carcinoma and well-moderately (P < 0.05).ConclusionsHigh STAT3 or phospho-STAT3 expression is a strong predictor of poor prognosis among patients with NSCLC. The conclusion should be confirmed by large prospective studies with long-term follow-up.
Available online 4 December 2013
J.P. Williams | S.M. Nyasavajjala | B.E. Phillips | M. Chakrabarty | J.N. Lund
Abstract: BackgroundColorectal cancer is the third most common cancer in the UK, with patients suffering declines in muscle mass and aerobic function. We hypothesised that tumour removal in non-metastatic colorectal cancer would lead to a restoration of lean muscle mass and increases in objective and subjective measures of aerobic performance.MethodsWe recruited two groups: patients with colorectal cancer (n = 30, 65.3 (51–77) y, body mass index 27.67 (4.83) kg m−2) and matched controls (n = 30, 64.6 (42–77) y, BMI 27.14 (3.51) kg m−2). Controls underwent a single study while colorectal cancer patients were studied before and 10 months after tumour resection. Aerobic performance was assessed via cardiopulmonary exercise testing and activity questionnaires. Lean muscle mass was measured via dual-energy X-ray absorptiometry.ResultsLean muscle mass was not different between groups (control: 47.82 (8.23); pre-resection: 52.41 (10.59); post-resection: 52.38 (10.52), kg). Anaerobic threshold was lower in pre-operative patients compared to controls (14.40 (3.23) vs. 19.67 (5.81) ml kg−1 min−1, p < 0.0001), increasing significantly post-resection (17.00 (3.56) ml kg−1 min−1p < 0.0001). Self reported maximal physical activity was lower after resection compared to preoperatively (pre-resection 6.0 (6.5–5 IQR), post-resection 3.75 (4–3 IQR), p < 0.0001).ConclusionIn colorectal cancer, anaerobic threshold is reached more rapidly than in matched controls, returning toward normal with tumour resection. Self-reported measures of activity do not mirror this objective change, cardiopulmonary exercise testing may therefore allow for a more accurate evaluation of pre and postoperative performance capability. The variance between objective and subjective measures of exercise capacity may be important in determining return to normal activities.
Comparison of mammographic findings after intraoperative radiotherapy or external beam whole breast radiotherapy
Available online 4 December 2013
B. Elsberger | A. Romsauerova | S. Vinnicombe | P. Whelehan | D.C. Brown | J.A. Dewar | A.M. Thompson | A. Evans
Abstract: BackgroundThe TARGIT (TARGeted Intraoperative Radiotherapy) trial was designed to compare local recurrence and complication rates in breast cancer patients, prospectively randomised to either EBRT (external beam whole breast radiotherapy) or a single dose of IORT (intraoperative radiotherapy). The aim of our study was to compare follow-up mammographic findings, ultrasound and biopsy rates in each group.MethodsFollow-up imaging and breast biopsies of women from one centre participating in the TARGIT-A trial were independently reviewed by two radiologists blinded to the radiotherapy treatment received.ResultsThe cohort consisted of 141 patients (EBRT n = 80/IORT n = 61). There was no significant difference in the patient or disease characteristics of the two groups. The number of follow-up mammograms and length of follow-up was similar (EBRT/IORT n = 2.0/2.4; 4.3yr/5.1yr; p = 0.386 χ2 test). There were no significant differences in mammographic scar or calcification appearances of the post-operative site. Generalised increase in breast density and skin thickening were more common in the EBRT compared to the IORT group (p = 0.002; p = 0.030, χ2 test respectively). A trend towards additional ultrasound at follow-up was observed in the IORT group (15 of 61 [24.6%] versus 11 of 80 [13.8%]), however this was not statistically significant (p = 0.100 χ2 test). No disease recurrence was demonstrated on any of the breast biopsies taken. Only one biopsy was reported as fat necrosis in the IORT group.ConclusionsMammographic changes were more common following EBRT, although more additional follow-up ultrasounds were performed in the IORT group. IORT is not detrimental to subsequent radiological follow up.
Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer
Available online 4 December 2013
A. Gornicki | P. Richter | W. Polkowski | M. Szczepkowski | L. Pietrzak | L. Kepka | A. Rutkowski | K. Bujko
Abstract: AimsLocal excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study.MethodsFunctional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38).ResultsIn the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%–21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group.ConclusionsOur study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.
Mesopancreas: A boundless structure, namely R1 risk in pancreaticoduodenectomy for pancreatic head carcinoma
N. Peparini | P. Chirletti
Abstract: BackgroundThe mesopancreatic resection margin after pancreaticoduodenectomy for carcinoma of the head of the pancreas is of great interest with respect to curative resection, since the neoplastic involvement of this margin was shown to be the primary site for R1 resection. In this review the current knowledges of the surgical anatomy of the so-called mesopancreas and the mesopancreas excision techniques are summarized.MethodsReferences were identified by searching Pubmed database using the search terms “mesopancreas” and “meso-pancreatoduodenum” until June 2013 and through searches of the authors' own files. Five studies were included in this review.ResultsOriginal contributions with regard to the anatomy of the retropancreatic area and specific technical descriptions of so-called “total mesopancreas excision” provided by published studies are pointed out.ConclusionsBecause there is no “meso” of the pancreas, and due to the continuity of the mesopancreatic and para-aortic areas, surgical dissection should be extended to the left of the superior mesenteric artery and include the para-aortic area to achieve the most complete possible resection of the so-called mesopancreas and minimize the rate of R1 resections due to mesopancreatic margin involvement. This extended mesopancreatic resection cannot be accomplished en bloc even if the removal of the dissected mesopancreatic tissues is performed en bloc with the head, uncus, and neck of the pancreas, i.e., with the pancreaticoduodenectomy specimen.
Radiofrequency ablation for early-stage breast cancer: Treatment outcomes and practical considerations
B.A. Grotenhuis | W.W. Vrijland | T.M.A.L. Klem
Abstract: BackgroundRadiofrequency ablation (RFA) for early-stage breast cancer has the potential advantage of being a less invasive treatment associated with improved cosmetic outcome. The aim of this review was to summarise the reported treatment outcomes of ultrasound-guided RFA for early-stage breast cancer and to highlight practical considerations with regard to this treatment.MethodsA search of the English-language literature concerning RFA for breast cancer treatment was performed.ResultsRFA is a technique that can be safely applied in patients with early-stage breast cancer, which is restricted to cT1-T2N0 ductal carcinoma with radiologically defined borders without any signs of multifocality or multicentricity. However, before RFA can be adopted as local therapy for early-stage breast cancer, more research is needed to assess the post-treatment pathological complete response and margin status, the long-term oncologic outcome in comparison to current standard breast conserving therapy and the potential cosmetic superiority of percutaneous RFA.ConclusionRFA appeared to be a feasible technique for the treatment of early-stage breast cancer, but considerable practical considerations form an obstacle to introduce RFA as a standard of care.
Treatment and prevention of peritoneal carcinomatosis from gastric cancer by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Overview and rationale
F. Roviello | S. Caruso | A. Neri | D. Marrelli
Abstract: Peritoneal carcinomatosis (PC) from gastric cancer is a condition with a very bleak prognosis. Most authors consider it to be a terminal disease and recommend palliative therapy only. Multimodal therapeutic approaches to PC have emerged in the last decades, combining cytoreductive surgery (CRS) and peritonectomy procedures with perioperative intraperitoneal chemotherapy (IPEC), including hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC).We reviewed the pertinent literature concerning the HIPEC modality both for the treatment of established PC and the prevention of peritoneal recurrence after potentially curative gastric cancer (GC) surgery. Basically, the two procedures relate to different aspects of GC and they are not comparable, since the latter has been used as an adjuvant when PC is still not macroscopically evident and the former has been exclusively used in advanced gastric cancer stages with peritoneal dissemination. Data supporting beneficial effects once gastric PC is already manifest is scarce and limited to few centres with specific experience in this field. Conversely, with regards to the peritoneal perfusion for preventing PC in high risk gastric cancer patients, there are phase III trials and meta-analysis which support beneficial effects resulting from the HIPEC procedure. To offer a baseline guide, we summarized the actual status and general outcome obtained by this multimodal technique, in association or not with CRS as treatment of advanced GC.
Periscapular amputation as treatment for brachial plexopathy secondary to recurrent breast carcinoma: A case series and review of the literature
N.K. Behnke | S.N. Crosby | C.M. Stutz | G.E. Holt
Abstract: AimsRecurrent breast carcinoma with brachial plexus involvement is often misinterpreted as a radiation- or chemotherapy-induced brachial plexopathy. We review a case series of 4 patients at our institution within a 1-year period, and describe their diagnostic workup and treatment with a palliative periscapular amputation. Our aim is to describe this entity, indications and benefits of this procedure, when required for progressive disease, with the goal of raising a collective index of suspicion to aid in earlier diagnosis.MethodsFour patients with recurrent axillary breast cancer and symptoms consistent with a brachial plexopathy were prospectively collected over a 1-year period. A Pubmed search was conducted; pertinent articles were reviewed and reported.ResultsPatients presented with intractable pain and flaccid paralysis of the ipsilateral limb. All had been previously treated with surgical resection, axillary lymph node dissection, chemotherapy, and radiation therapy. Average time from breast surgery to presentation was 78.75 months (range 11–216 months.) Workup included MRI and biopsy to confirm recurrence. Periscapular amputation was performed for each patient, all of who experienced subjective pain relief postoperatively. Three of the 4 patients are still living; one patient died of disease.ConclusionBreast cancer survivors presenting with a brachial plexopathy should raise suspicion for recurrent disease. Close evaluation with MRI is the best first step in diagnosis. Although periscapular amputation is an aggressive surgical treatment, it is an acceptable option when disease has progressed to neurovascular involvement and a functionless limb.
The indocyanine green method is equivalent to the 99mTc-labeled radiotracer method for identifying the sentinel node in breast cancer: A concordance and validation study
B. Ballardini | L. Santoro | C. Sangalli | O. Gentilini | G. Renne | G. Lissidini | G.M. Pagani | A. Toesca | C. Blundo | A. del Castillo | N. Peradze | P. Caldarella | P. Veronesi
Abstract: AimsThe aim of this study was to assess concordance between the indocyanine green (ICG) method and 99mTc-radiotracer method to identify the sentinel node (SN) in breast cancer. Evidence supports the feasibility and efficacy of the ICG to identify the SN, however this method has not been prospectively compared with the gold-standard radiotracer method in terms of SN detection rate.MethodsBetween June 2011 and January 2013, 134 women with clinically node-negative early breast cancer received subdermal/peritumoral injection of 99mTc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for fluorescence detection of SNs using an exciting light source combined with a camera. In all patients, SNs were first identified by the fluorescence method (ICG-positive) and removed. A gamma ray-detecting probe was then used to determine whether ICG-positive SNs were hot (99mTc-positive) and to identify and remove any 99mTc-positive (ICG-negative) SNs remaining in the axilla. The study was powered to perform an equivalence analysis.ResultsThe 134 patients provided 246 SNs, detected by one or both methods. 1, 2 and 3 SNs, respectively, were detected, removed and examined in 70 (52.2%), 39 (29.1%) and 17 (12.7%) patients; 4–10 SNs were detected and examined in the remaining 8 patients. The two methods were concordant for 230/246 (93.5%) SNs and discordant for 16 (6.5%) SNs. The ICG method detected 99.6% of all SNs.ConclusionsFluorescent lymphangiography with ICG allows easy identification of axillary SNs, at a frequency not inferior to that of radiotracer, and can be used alone to reliably identify SNs.
Concordance between vacuum assisted biopsy and postoperative histology: Implications for the proposed Low Risk DCIS Trial (LORIS)
S. Soumian | E.T. Verghese | M. Booth | N. Sharma | S. Chaudhri | S. Bradley | S. Umranikar | R.A. Millican-Slater | A.M. Hanby | A. Francis
Abstract: AimThe recent Breast Cancer Screening Review has estimated that for one life saved three patients are overtreated. The dramatic increase in the diagnosis of Ductal carcinoma in-situ (DCIS) has not lead to the expected decrease in the incidence of invasive cancer. It is not clear if all DCIS progress to invasive cancer if untreated. The Low Risk DCIS Trial (LORIS) intends to compare the current treatment of low risk DCIS i.e. surgery, with active monitoring. For effective implementation, concordance between diagnostic biopsy using large volume vacuum assisted biopsy (VAB) and excision histology is vital. A two-centre UK audit was done to assess concordance in patients diagnosed with low grade DCIS diagnosed using VAB.MethodsData of DCIS diagnosed with VAB from year 2001–2010 in University Hospital Birmingham and Leeds Teaching Hospitals was retrospectively collected and concordance between diagnostic and excision histology was assessed. Low Grade DCIS diagnoses were further evaluated retrospectively with regard to their eligibility for LORIS.ResultsOf 225 DCIS diagnoses 128 (57%) were high grade, 66 (29%) intermediate grade and 31 (14%) low grade. Overall 18% were upgraded to invasive cancer. The upgrade rate to invasive cancer for high grade was 23% and for low grade DCIS was 10%. In the low grade group eligible for LORIS, there were no upgrades to invasive cancer.ConclusionThe upgrade rates to invasive cancer are comparable to series published in literature. The concordance for the low risk DCIS with zero upgrade to invasive cancer supports the stringent LORIS eligibility criteria for trial selection.
Selective axillary dissection after axillary reverse mapping to prevent breast-cancer-related lymphoedema
M. Gennaro | M. Maccauro | C. Sigari | P. Casalini | L. Bedodi | A.R. Conti | A. Caraceni | E. Bombardieri
Abstract: BackgroundIt has recently been reported that, using axillary reverse mapping (ARM), the lymphatics from the arm can be spared to reduce the incidence of breast-cancer-related lymphoedema (BCRL). The aim of this study was to assess the feasibility of selective axillary dissection (SAD) after using ARM and partially preserving arm drainage, and to assess the occurrence of BCRL.MethodsUsing a radioisotope and lymphoscintigraphy, ARM was performed in 60 patients scheduled for SAD, who were subsequently divided for the purpose of comparing the BCRL rates into: group A, comprising 45 patients who successfully underwent SAD with a residual lymphatic hot spot; and group B with 15 whose hot nodes were removed as is normally the case during complete axillary lymph node dissection (ALND).ResultsSAD was feasible in 75% of the 60 patients. SAD was completed successfully in 19 of the first 30 patients, and in 26 of the second 30 patients (p = 0.072). The median follow-up was 16 months (6–36), during which 9 patients developed a BCRL, 4 in group A (9%) and 5 in group B (33%); p = 0.035. None of the patients had nodal relapses during the follow-up.ConclusionsUsing a radioisotope enables an effective and safe SAD in a large proportion of patients. There was evidence of a trend to suggest a learning curve. The rate of BCRL after SAD was less than one third of the rate recorded after ALND, a result that should encourage the development of the former technique.
Multidisciplinary one-stage risk-reducing gynaecological and breast surgery with immediate reconstruction in BRCA-gene carrier women
M.F. Khadim | P. Eastwood | J. Price | P. Morrison | K. Khan
Abstract: Familial breast cancer accounts for 5–10% of all breast cancers. Due to BRCA1/2 tumour suppressor gene mutation, hereditary breast and ovarian syndrome is the most common form. Risk-reducing gynaecological and breast surgery is offered to such patients in ever-increasing numbers. Hence, the development of a multi-specialty combined treatment approach is called for. Twenty-two BRCA gene-mutation carrier women underwent one-stage gynaecological and breast risk-reducing surgery and immediate reconstruction between January 2005 and December 2011 at the Belfast City Hospital. Their mean age was 41.2 years (median 41 years). Nearly half of the patients were BRCA2 and a quarter were BRCA1 carriers. The rest were positive for both genes. Hormone-replacement therapy was initiated in 14 women. Average theatre time and stay in the hospital were three hours and two and a half days, respectively. Two patients developed complications unrelated to combining the procedures. Both were treated conservatively and recovered. The one-stage approach logically proves economical by limiting the time the patients are in the hospital and away from work. We describe our multidisciplinary team service that is offering safe and economical one-stage risk-reducing surgery and reconstruction to young BRCA gene-mutation carrier women in Northern Ireland.
Models predicting non-sentinel node involvement also predict for regional recurrence in breast cancer patients without axillary treatment
M.J.A.E. Pepels | J.H.M.J. Vestjens | M. de Boer | P. Bult | J.A.A.M. Van Dijck | M. Menke-Pluijmers | P.J. van Diest | G. Borm | V.C.G. Tjan-Heijnen
Abstract: BackgroundNon-SN prediction models are frequently used in clinical decision making to identify patients that may not need axillary treatment, but these models still need to be validated by follow-up data. Our purpose was the validation of non-sentinel node (SN) prediction models in predicting regional recurrences in patients without axillary treatment.MethodsWe followed a cohort of 486 women with favorable primary tumor characteristics and pN0(i+)(sn) or pN1mi(sn) for median 4.5 years. None of the patients underwent axillary treatment. Based on four published non-SN prediction models, the threshold allowing separation into low versus high-risk on non-SN involvement was set at 10%.ResultsOverall 5-year regional recurrence rate was 3.0% (SE, ±0.1%). Using the Tenon scoring system, 438 low-risk patients had a 5-year regional recurrence rate of 2.3% (±0.8%), and 48 high-risk patients a recurrence rate of 10.1% (±0.4%). The MSKCC nomogram identified 300 low-risk patients with a recurrence rate of 2.8% (±1.1%), versus 166 high-risk patients with a rate of 3.4% (±0.5%) (20 patients not assessable). The Stanford nomogram identified 21 high-risk patients without recurrence, and 465 low-risk patients with a 3.2% (±0.9%) recurrence rate. A Dutch model discriminated between 384 low-risk patients with a recurrence rate of 2.2% (±0.8%) and 102 high-risk patients with a rate of 6.3% (±2.9%).ConclusionThe Tenon scoring system outperformed the other models as it identified the largest subgroup of patients with low recurrence rate. In patients resembling our cohort we would recommend axillary treatment if they had a Tenon score above 3.5.
W.P. Andrade | E.N.P. Lima | C.A.B.T. Osório | M. do Socorro Maciel | G. Baiocchi | A.G.V. Bitencourt | M.F. Fanelli | A.S. Damascena | F.A. Soares
Abstract: PurposeNeoadjuvant chemotherapy (NAC) in breast cancer is currently used not only for locally advanced tumors, but also for large operable tumors when breast preservation is considered. It also provides the opportunity to evaluate chemotherapy tumor response. Our aim was to correlate the relative change in the standardized uptake value (SUV) of 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET/CT) with pathologic response after NAC.MethodsWe prospectively evaluated 40 patients with invasive ductal breast carcinomas from February 2010 to December 2011. FDG-PET/CT was performed at baseline and after the second cycle of NAC. All patients underwent surgery after NAC. Pathologic response was evaluated according to Residual Cancer Burden (RCB) index.ResultsThe mean age was 41.9 years. Median primary tumor size was 6 cm. Pathologic complete response (pCR) was obtained in 12 (30%) patients. The tumor baseline mean maximum SUV (SUVmax), and after second cycle were: 8.97 (sd.4.3) and 4.07 (sd.3.2), respectively. The relative change (ΔSUV) after the second course of NAC was significantly higher for patients with pCR (−81.58%) when compared to the non-pCR patients (−40.18%) (p = 0.001). The optimal ΔSUV threshold that discriminates between pCR and non-pCR was −71.8% (83.3% sensitivity; 78.5% specificity). Moreover, the optimal ΔSUV threshold to discriminate between NAC responders and non-responders was −59.1% (68% sensitivity; 75.0% specificity).ConclusionsOur data suggest that the FDG-PET/CT ΔSUV after the second course of NAC can predict pathological response in ductal breast carcinomas, and potentially identify a subgroup of non-responding patients for whom ineffective chemotherapy should be avoided.SynopsisBreast cancer is the most frequently diagnosed cancer in women. The indications for neoadjuvant chemotherapy are increasing. Early information on chemotherapy response is crucial and methods that predict the therapeutic effectiveness might avoid potentially ineffective chemotherapies in non-responding patients.
Debulking surgery followed by intraarterial 5-fluorouracil chemotherapy plus subcutaneous interferon alfa for massive hepatocellular carcinoma with multiple intrahepatic metastases: A pilot study
K. Tanaka | Y. Yabushita | K. Nakagawa | T. Kumamoto | K. Matsuo | M. Taguri | I. Endo
Abstract: BackgroundThe prognosis in advanced hepatocellular carcinoma (HCC) with multiple intrahepatic metastases is extremely poor. Combination therapy with subcutaneous interferon (IFN) alfa and intraarterial 5-fluorouracil was reported to be effective against such advanced HCC. We describe results of debulking surgery followed by combination therapy with IFN alfa and 5-FU for massive HCC with multiple intrahepatic metastases.MethodsIn 27 HCC patients with massive tumors and multiple intrahepatic metastases, we performed combination therapy with IFN alfa and 5-FU after maximal liver tumor resection.ResultsMean patient age was 63.3 years. Including intrahepatic metastases, tumors numbered 5 or more in 17 patients (63%). Portal or hepatic vein branches were invaded in 22 (81%). The mean maximum tumor diameter was 102 mm. Among 24 patients whose results were analyzed, an objective response by residual intrahepatic metastases was observed in 13 (54%; complete response in 12, and partial response in 1). Overall 1-, 3-, and 5-year survival was 73.2%, 38.7%, and 38.7%, respectively; 1-, 3-, and 5-year progression-free rates were 38.2%, 22.3%, and 22.3%.ConclusionsDebulking surgery followed by IFN alfa and 5-FU combination chemotherapy offers possibility of long-term survival despite massive HCC with multiple intrahepatic metastases.
Outcomes following liver resection and clinical pathologic characteristics of hepatocellular carcinoma occurring in patients with chronic hepatitis B and minimally fibrotic liver
H.S. Kadri | S. Blank | Q. Wang | K.W. Kim | M.I. Fiel | W. Luan | S.P. Hiotis
Abstract: AimsThe intent of this analysis is to assess clinico-pathologic and prognostic characteristics of HCC in patients with minimal liver fibrosis (Ishak stage 1–2) after primary surgical liver resection as compared to patients with moderate to severe fibrosis (Ishak stage 3–6) in order to improve screening and treatment of HCC.MethodsData were obtained from 200 patients with HBV-related HCC who underwent primary surgical liver resection at a single North American medical institution between 1988 and 2012. A dedicated liver pathologist performed fibrosis staging for each resection specimen using the modified Ishak method. Univariate and multivariate analyses of clinico-pathologic variables were performed to determine those associated with prognosis.ResultsTwenty-two percent of patients had minimal fibrosis defined as Ishak stage 1 or 2. Kaplan–Meier analysis of 5-year survival showed a non-significant trend toward better outcome among Ishak 1–2 patients compared to Ishak 3–6 (p = 0.09). Ishak 1–2 was associated with lower hazard of death compared to Ishak 3–6 (adjusted HR = 0.38, 95% CI = 0.15–0.99). Ishak 1–2 retained statistical significance after multivariate analysis for overall survival (p = 0.05), but not recurrence-free survival.ConclusionsA significant proportion of HBV–HCC cases arise in the minimally fibrotic liver. Patients with Ishak 1–2 fibrosis have better overall survival compared to those with Ishak 3–6, indicating that minimally fibrotic patients should be treated as a separate cohort. There is a need to better understand the mechanisms underlying hepatocarcinogenesis and to formulate unique diagnostic and therapeutic algorithms for minimally fibrotic HCC patients.
Liver metastases from breast cancer: Surgical resection or not? A case-matched control study in highly selected patients
P. Mariani | V. Servois | Y. De Rycke | S.P. Bennett | J.G. Feron | M.M. Almubarak | F. Reyal | B. Baranger | J.Y. Pierga | R.J. Salmon
Abstract: AimTo determine whether, in a highly selected patient population, medical treatment combined with surgical resection of liver metastases from breast cancer is associated with improved survival compared with medical treatment alone.Patients and methodsBetween 1988 and 2007, 100 liver resections for metastatic breast cancer were performed at Institut Curie, 51 of which met the criteria for inclusion in this case-control study. With the exception of bone metastases, patients with other distant metastasis sites were excluded. Surgery was only performed in patients with stable disease or disease responding to medical treatment evaluated by imaging evaluation. Surgical cases were individually matched with 51 patients receiving medical treatment only. All patients had 4 or fewer resectable liver metastases. The study group was matched with the control group for age, year of breast cancer diagnosis, time to metastasis, TNM stage, hormone receptor status and breast cancer tumour pathology.ResultsUnivariate analysis confirmed a survival advantage for patients lacking bone metastases and axillary lymphadenopathy at the time of breast cancer diagnosis and for surgically treated patients. Multivariate analysis indicated that surgery and the absence of bone metastases were associated with a better prognosis. A multivariate Cox model adapted for paired data showed a RR = 3.04 (CI: 1.87–4.92) (p < 0.0001) in favour of surgical treatment.ConclusionSurgical resection of liver metastases from primary breast cancer appears to provide a survival benefit for highly selected patients.
A.A.P. Slesser | M. Chand | R. Goldin | G. Brown | P.P. Tekkis | S. Mudan
Abstract: IntroductionThe aim of this study was to determine the outcomes associated with simultaneous resections compared to patients undergoing sequential resections for synchronous colorectal liver metastases.MethodConsecutive patients undergoing hepatic resections between 2000 and 2012 for synchronous colorectal liver metastases were identified from a prospectively maintained database.ResultsOf the 112 hepatic resections that were performed, 36 were simultaneous resections and 76 were sequential resections. There was no difference in disease severity: number of metastases (P 0.228), metastatic size (P 0.58), the primary tumour nodal status (P 0.283), CEA (P 0.387) or the presence of extra-hepatic metastases (P 1.0). Major hepatic resections were performed in 23 (64%) and 60 (79%) of patients in the simultaneous and sequential groups respectively (P 0.089). Intra-operatively no differences were found in blood loss (P 1.0), duration of surgery (P 0.284) or number of adverse events (P 1.0). There were no differences in post-operative complications (P 0.161) or post-operative mortality (P 0.241). The length of hospital stay was 14 (95% CI 12.0–18.0) and 18.5 (95% CI 16.0–23.0) days in the simultaneous and sequential groups respectively (P 0.03). The 3-year overall survival was 75% and 64% in the simultaneous and sequential groups respectively (P 0.379). The 3-year hepatic recurrence free survival was 61% and 46% in the simultaneous and sequential groups respectively (P 0.254).ConclusionSimultaneous resections result in similar short-term and long-term outcomes as patients receiving sequential resections with comparable metastatic disease and are associated with a significant reduction in the length of stay.
Impact of hepatectomy margin on survival following resection of colorectal metastasis: The role of adjuvant therapy and its effects
N.A. Mbah | C. Scoggins | K. McMasters | R. Martin
Abstract: IntroductionThe optimal width of microscopic margin and the use of adjuvant therapy after a positive margin for hepatic resection for colorectal liver metastasis (CRCLM) has not been conclusively determined. The aim of the current study is to evaluate the influence of width of surgical margin and adjunctive therapy upon disease free and overall survival.MethodsAll patients undergoing hepatectomy for CRCLM from 1997 to 2012 were identified from a prospectively maintained, IRB approved database. Patients were divided into four subgroups based on the parenchymal margin: positive, <0.1 cm, 0.1 cm–1 cm, and >1 cm.ResultsA total of 373 patients were included for analysis with a median follow up of 26 months (range 9–103 months) and a median overall survival of 53 months. The resection margin was positive (26 patients median OS 24 months), <0.1 cm (48 patients median OS 36 mon), 0.1 cm–1 cm (82 patients median OS 44 months), and >1 cm (217 patients median OS 64 months). The most common adjunctive therapy was chemotherapy, hepatic arterial therapy, or local. Patients with positive margins also had the shortest disease free survival (DFS), 16 months. The DFS was similar amongst the other margin groups (<0.1 cm: 21 months, 0.1–1 cm: 22 months, >1 cm 25 months). Hepatectomy margin independently influenced survival (p = 0.017) and disease free survival (p = 0.034). Patients with negative margins has similar overall recurrence rates (p = 0.36) and survival rates (p = 0.89).ConclusionsA positive surgical margin indicates a worse overall biology of disease for patients undergoing hepatectomy for CRCLM, and appropriate multi-disciplinary therapy should be considered in this high risk patient population. Marginal width if a complete resection has been achieved does not adversely effect overall surgical in patients with CRCLM.
S. Evrard | V. Brouste | P. McKelvie-Sebileau | G. Desolneux
Abstract: BackgroundLiver metastases (LM) in close contact to hepatic veins (HV) are a frequent cause of unresectability. Reconstruction of hepatic veins is technically difficult and outcomes are poor. Intra-operative radiofrequency ablation (IRFA) with vascular exclusion (VE) may be a useful approach.MethodsOut of 358 patients operated for LM, 22 with LM close to a HV treated by IRFA under VE with at least one year of follow-up were included in this retrospective study. Technical success was evaluated at four months by CT scan of the ablated lesion. Complications; local, hepatic and extra-hepatic recurrence rates, and overall survival are reported.ResultsThe median number of metastases was 4.5 [range: 1–12]. Seventeen patients had bilateral metastases. The median size of ablated lesions was 2 cm [range: 1–5.5]. Seven complications occurred (1 Grade 1, 2 Grade 3b and 4 Grade IVa), with no mortality. No recurrence of ablated lesions was detected at four months or during follow-up. Seventeen patients had new or extra-hepatic lesions. Median overall survival for colorectal patients was 40 months 95%CI[17.5-not reached].ConclusionsIRFA plus VE for LM in close contact to a HV is a novel approach, appearing to be a safe and effective technique which can extend the applications of liver metastases surgery.
Role of bursectomy for advanced gastric cancer: Result of a case–control study from a large volume hospital
B.W. Eom | J. Joo | Y.W. Kim | J.M. Bae | K.B. Park | J.H. Lee | K.W. Ryu | M.C. Kook
Abstract: AimsAccording to the recent Japanese Gastric Cancer Association's gastric cancer treatment guidelines, bursectomy is recommended for tumors penetrating the serosa of the posterior gastric wall. However, there is still little data to show whether bursectomy improves patient survival. The aim of this study is to evaluate the efficacy of bursectomy for subserosa or serosa-positive gastric cancer in terms of overall survival.MethodFrom April 2001 to December 2006, 470 patients underwent curative resection for macroscopically subserosa or serosa-positive gastric cancer. These patients were grouped according to whether bursectomy was performed or not (bursectomy+/bursectomy−). Clinicopathological characteristics and incidence of complications were compared between the groups. The overall survival rates were analyzed using a Cox proportional hazards model.ResultsThere was no significant difference in morbidity and mortality between the bursectomy+ and bursectomy− groups. In the multivariable analysis for overall survival, bursectomy was not a significant independent factor (p = 0.978). In the subgroup analysis for clinical and pathological stage III and IV, and tumors penetrating the serosa of the posterior gastric wall, bursectomy did not have significant effect on overall survival as well (p = 0.582, 0.453, and 0.532, respectively). In the propensity score-matched patients, bursectomy still showed no significant effect on overall survival (p = 0.804).ConclusionsBursectomy is unlikely to improve overall survival in patients with macroscopically subserosa or serosa-positive gastric cancer.
A.A. Bajwa | J. Peck | A. Loktionov | A. Obichere
Abstract: AimsColorectal cancer (CRC) sheds viable cells in the mucocelluar layer overlaying the colonic mucosa which travels distally alongside the faecal stream. These cells can be retrieved from the surface of the rectal mucosa. DNA quantification of these cells may be a marker of CRC, assessment of which was aim of this study.MethodsA prospective double-blinded study of 467 consecutive patients referred with symptoms suggestive of CRC. Cells were collected from the surface of the rectal mucosa and total DNA quantified. DNA scores were compared with outcome after subjects had completed bowel investigations. Analysis of receiver operating characteristic (ROC) curves was performed to determine the optimum cut-off point for a positive result.Results107 of the 467 patients were excluded due to; excessive faecal contamination of samples (n = 84); declined investigations (n = 17); inappropriate referral (n = 5); unfit (n = 1). 263 patients had lower GI endoscopy; 89 CT colonography and 8 barium enema. The diagnosis were; CRC (n = 23), inflammatory bowel disease (IBD) (n = 7), adenomatous polyps (AP) (n = 20) and no significant abnormality detected (n = 310).ROC analysis revealed that sensitivities at a specificity of 60% for detecting CRC were 91.3%; for CRC and IBD 86.7%; and for CRC, IBD and AP 72.0%.ConclusionIn symptomatic patients DNA quantification of cells retrieved from the surface of the rectal mucosa is sensitive for the detection of CRC. Although faecal contamination is a limitation of this technique, refinement and application of other molecular tests hold promise for a better non invasive method for the detection of CRC.
The role of VEGFR-2 expression in outcomes and survival of patients with peritoneal carcinomatosis from appendiceal cancer
W.A. Jimenez | A. Sardi | P. Ledakis | C. Nieroda | M. Sittig | V. Gushchin
Abstract: BackgroundVascular endothelial growth factor (VEGF) is a prognostic factor and target treatment for metastatic colorectal and ovarian cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival on peritoneal carcinomatosis (PC) from appendiceal cancer. We hypothesize that tumoral high expression of VEGF receptor 2 (VEGFR-2) is a negative prognostic factor for survival in patients with PC from appendiceal cancer.MethodsA retrospective study of a prospective database revealed 89 patients with PC from appendiceal cancer who underwent 127 CRS/HIPECs. Surgical specimens from 59 patients were tested to identify high vs. low VEGFR-2 expression. Patient outcomes and survival were analyzed.ResultsThere were 26 males and 33 females. Mean age was 51 years. Forty-seven VEGFR-2 high expressers and 15 low expressers were identified. Mean follow-up of high and low expressers was 25.1 and 26.6 months, respectively (p = 0.806). At follow-up, 33 (70%) high expressers were alive and 14 (30%) deceased, while 11 (92%) low expressers were alive and 1 (8%) deceased. Recurrence, use of bevacizumab, CC score, PCI, and LN status showed no differences between high and low expressers. OS for high expressers was 90.5%, 59.8%, and 47.1% at 1-, 3-, and 5-years, respectively, while OS for low expressers remained stable at 91.7% at 1-, 3-, and 5-years (p = 0.133).ConclusionThere is a trend towards better outcomes and survival in patients with PC from appendiceal cancer who have low expression of VEGFR-2 compared to high expression. More studies are encouraged to confirm this trend.
Evaluation and impact of residual disease in locally advanced cervical cancer after concurrent chemoradiation therapy: Results of a multicenter study
D. Hequet | E. Marchand | V. Place | V. Fourchotte | A. De La Rochefordière | S. Dridi | C. Coutant | F. Lecuru | A-S. Bats | M. Koskas | J-J. Bretel | A. Bricou | Y. Delpech | E. Barranger
Abstract: BackgroundThe aim of this study was to evaluate the diagnosis and impact of residual disease (RD) after concurrent chemoradiation therapy (CRT) in locally advanced cervical cancer (FIGO IB2-IVA).MethodsThis retrospective multicenter study included 159 patients who were treated with completion surgery after CRT between 2006 and 2012. Magnetic resonance imaging (MRI) was performed 4–6 weeks after CRT and compared to pathological evidence of residual disease. Kaplan–Meier survival curves were plotted and univariate/multivariate analyses were performed to assess the association between RD and the outcome.ResultsResidual disease was present in 45.3% of the patients and detected by MRI in 57.1%. The MRI had a 29.2% false positive rate and an 11.1% false negative rate. The overall survival (OS) rates at 3 and 5 years were 78.6% (CI 95% [71%–86.9%]) and 76.5% (CI 95% [68.2%–85.7%]), respectively. The disease free survival (DFS) rates at 3 and 5 years were 73.4% (CI 95% [65.6%–82%]) and 71.1% (CI 95% [62.7%–80.1%]), respectively. RD greater than 10 mm decreased DFS (HR = 4.84, p = 0.03), whereas RD between 1 and 10 mm (HR = 0.31, p = 0.58) and less than 1 mm (HR = 0.37, p = 0.54) had no impact on DFS. The OS was not changed by RD.DiscussionThe MRI accuracy value is not sufficient to select patients who might benefit from completion surgery. Residual disease over 10 mm decreased DFS but did not impact OS.
Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: A French multicentre retrospective cohort study of 566 patients
N. Bakrin | J.M. Bereder | E. Decullier | J.M. Classe | S. Msika | G. Lorimier | K. Abboud | P. Meeus | G. Ferron | F. Quenet | F. Marchal | S. Gouy | P. Morice | C. Pomel | M. Pocard | F. Guyon | J. Porcheron | O. Glehen
Abstract: BackgroundDespite a high response rate to front-line therapy, prognosis of epithelial ovarian carcinoma (EOC) remains poor. Approaches that combine Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) have been developed recently. The purpose of this study was to assess early and long-term survival in patients treated with this strategy.Patients and methodsA retrospective cohort multicentric study from French centres was performed. All consecutive patients with advanced and recurrent EOC treated with CRS and HIPEC were included.ResultsThe study included 566 patients from 13 centres who underwent 607 procedures between 1991 and 2010. There were 92 patients with advanced EOC (first-line treatment), and 474 patients with recurrent EOC. A complete cytoreductive surgery was performed in 74.9% of patients. Mortality and grades 3 to 4 morbidity rates were 0.8% and 31.3%, respectively. The median overall survivals were 35.4 months and 45.7 months for advanced and recurrent EOC, respectively. There was no significant difference in overall survival between patients with chemosensitive and with chemoresistant recurrence. Peritoneal Cancer Index (PCI) that evaluated disease extent was the strongest independent prognostic factor for overall and disease-free survival in all groups.ConclusionFor advanced and recurrent EOC, curative therapeutic approach combining optimal CRS and HIPEC should be considered as it may achieve long-term survival in patients with a severe prognosis disease, even in patients with chemoresistant disease. PCI should be used for patient's selection.
Quality of life and female sexual function after skinning vulvectomy with split-thickness skin graft in women with vulvar intraepithelial neoplasia or vulvar Paget disease
V. Lavoué | A. Lemarrec | N. Bertheuil | S. Henno | H. Mesbah | E. Watier | J. Levêque | K. Morcel
Abstract: ObjectiveVulvar intraepithelial neoplasia (VIN) and vulvar Paget disease are managed with either vulvectomy, destructive treatments (laser, antimitotic drugs) or immunostimulants. All these options are associated with functional complications. The purpose of this study was to evaluate the surgical technique consisting of skinning vulvectomy with split-thickness skin graft, and its effect on overall quality of life and sexual function.MethodsA retrospective study was conducted on thirteen patients who underwent skinning vulvectomy with split-thickness skin graft between 1999 and 2009. Overall quality of life and sexual function were assessed with the Medical Outcome Study Short Form 36 (MOS SF-36) and Female Sexual Function Index (FSFI), respectively.ResultsThe median age of patients was 54 (range: 33–77) years. Three patients had Paget disease and 10 patients had VIN lesions. The excision margins were clear in 46% of cases. The incidence of occult cancer was 31%. The mean follow-up period was 77 (±35) months. Four patients experienced a relapse of their intraepithelial disease. The mean disease-free survival was 58 (±44) months. There was no significant difference in MOS SF-36 scores between the study population and the general population. The patients assessed with the FSFI regained normal sexual function after the surgical procedure.ConclusionSkinning vulvectomy with split-thickness skin graft is a feasible technique yielding good results in terms of quality of life and sexual function. It enables occult cancer to be diagnosed in patients with VIN or Paget disease.
Available online 28 November 2013
L.G. Campana | G. Bertino | C.R. Rossi | A. Occhini | M. Rossi | Sara Valpione | M. Benazzo
A differential intraoperative molecular biological test for the detection of sentinel lymph node metastases in breast carcinoma. An extended experience from the first UK centre routinely offering the service in clinical practice
Available online 21 November 2013
M. Babar | R. Madani | L. Thwaites | P.A. Jackson | H.L. Devalia | A. Chakravorty | T.E. Irvine | G.T. Layer | M.W. Kissin
Abstract: IntroductionOne-Step Nucleic acid Amplification (OSNA) is a molecular biological assay of cytokeratin-19 (a breast epithelial marker) mRNA. It can be employed intra-operatively for detection of lymph node metastases in breast carcinoma. Patients with positive sentinel nodes may proceed to axillary lymph node dissection (ALND) level I or higher dependent upon the OSNA quantitative result, during the same surgical procedure, avoiding a second operation and eliminating the technical difficulties possibly associated with delayed ALND.AimsOur Breast Unit was the first in the UK to implement this novel technique in routine practice. This study reviews our first 44 month data following introduction of OSNA “live” on whole sentinel nodes following an extensive validation study.9MethodsData was collected prospectively from the period of introduction 01/12/2008 to 30/08/2012. All patients eligible for sentinel node biopsy were offered OSNA and operations were performed by five consultant breast surgeons. On detection of macro-metastasis a level II/III and for a micro-metastasis a level I ALND was performed.ResultsA total of 859 patients (1709 sentinel lymph nodes) were analysed. All except one were females. The majority underwent wide local excision (73.4%, n = 631) or mastectomy 25% (n = 215) and 1.6% (13) underwent SLN biopsy alone. IDC was seen in 79% (n = 680) of the patients and 53.5% (n = 460) had grade II tumours. One third (30.8%, n = 265) had positive sentinel nodes and had further axillary surgery at the time of SLN biopsy. Of these, 47% (n = 125/265) had macro-metastases, 38% (n = 101/265) had micro-metastases and 14.7% (n = 39/265) had “positive but inhibited” results. Positive non-sentinel lymph nodes (NSLN) were seen in 35% (44/125) of those with macro-metastases; 17.8% (18/101) of the patients with micro-metastases and 10.2% (4/39) of the “positive but inhibited” group.ConclusionIn our series over a third of our patients had positive lymph nodes detected with OSNA allowing them to proceed directly to axillary surgery at the same operation. This technique eliminates the need for a second operation in sentinel lymph node positive patients and avoids the anxiety waiting for histological results.
MicroRNA-30a-3p inhibits tumor proliferation, invasiveness and metastasis and is downregulated in hepatocellular carcinoma
Available online 19 November 2013
W. Wang | H. Lin | L. Zhou | Q. Zhu | S. Gao | H. Xie | Z. Liu | Z. Xu | J. Wei | X. Huang | S. Zheng
Abstract: BackgroundMicroRNAs (miRNAs) are small non-coding RNAs that regulate physiological and pathological processes by suppressing target gene expression. Altered expression of miR-30a-3p has been demonstrated in several cancers. However, little about how miR-30a-3p functions in these cancers has been reported, and the role of miR-30a-3p in hepatocellular carcinoma (HCC) is unknown. The purpose of this study was to identify the role and underlying molecular mechanism of action of miR-30a-3p in HCC.MethodsA total of 110 HCC patients, primarily treated by surgical removal of tumors, were involved in the study. HCC cell line Bel-7402 was selected to characterize the function of miR-30a-3p in vitro.ResultsOur results showed that in 83.6% of the 110 HCC patients, expression of miR-30a-3p was significantly downregulated (P < 0.0001) in tumors compared to adjacent normal tissues. In a clinicopathological correlation analysis, downregulation of miR-30a-3p correlated with a significantly higher incidence of portal vein tumor thrombus (PVTT, P = 0.009). Moreover, miR-30a-3p markedly inhibited the invasion and migration of Bel-7402 HCC cells in vitro. Furthermore, miR-30a-3p overexpression had an inhibitory effect on cell proliferation, induced apoptosis and increased arrest of cells in the S phase. We further demonstrated that miR-30a-3p regulates HCC cell function by a mechanism involving reduced vimentin and MMP3 expression and restoration of E-cadherin expression.Conclusionsour data suggest that miR-30a-3p is downregulated in HCC and acts as a tumor suppressor in vitro. Regulation of vimentin, E-cadherin and MMP3 by miR-30a-3p suggests a useful therapeutic strategy for tumors with reduced miR-30a-3p expression.
Risk factors for double primary malignancies and their clinical implications in patients with sporadic gastric cancer
Available online 15 November 2013
I. Cho | J.Y. An | I.G. Kwon | Y.Y. Choi | J.H. Cheong | W.J. Hyung | S.H. Noh
Abstract: AimsWe carried out a large scale study to identify the risk factors for double primary malignancy (DPM) development in gastric cancer patients and to evaluate the clinical implications for these patients.MethodsA total of 2593 patients who underwent gastrectomy for primary gastric cancer from January 2005 to November 2010 were reviewed with regard to DPM. We compared the clinicopathological characteristics, risk factors for developing DPM, and prognosis between the DPM(+) group and the DPM(-) group.ResultsOf the 2593 patients, 152 (5.9%) were diagnosed with DPM. The most common accompanying malignancies were colorectal, lung and thyroid. Multivariate analysis indicated that age (p=0.016) and MSI status (p=0.002) were associated with a higher frequency of DPM. 30.3% of patients were diagnosed with DPM within 1 year around perioperative period and 53.3% of patients had DPM detected during 5 years of post-operative follow up periods. Although there was no significant difference in overall survival between the DPM(+) and DPM(-) group, DPM(+) patients had a worse prognosis than DPM (-) patients in stage I gastric cancer.ConclusionsGastric cancer patients over the age of 60 or with a MSI-high status had an increased risk for developing DPM. Further, in stage I gastric cancer, the presence of DPM was associated with a worse prognosis. Therefore, careful pre- and postoperative surveillance is especially important in these patients.
Available online 15 November 2013
I. Grossmann | P.M. Doornbos | J.M. Klaase | G.H. de Bock | T. Wiggers
Abstract: BackgroundDue to changes in staging, (neo)-adjuvant treatment and surgical techniques for colorectal cancer (CRC), it is expected that the recurrence pattern will change as well. This study aims to report the current incidence of, and time to recurrent disease (RD), further the localization(s) and the eligibility for successive curative treatment.MethodsA consecutive cohort of CRC patients, whom were routinely staged with CT and underwent curative treatment according to the national guidelines, was analyzed (n = 526).ResultsAfter a mean and median FU of 39 months, 20% of all patients and 16% of all AJCC stage 0–III patients had developed RD. The annual incidences were the highest in the first two years but tend to retain in the succeeding years for stage 0–III patients. The majority of RD was confined to one organ (58%) and 28% of these patients were again treated with curative intent.ConclusionsIn follow-up nowadays, less recurrences are found than reported in historical studies but these can more often be treated with curative intent. A main cause for the decreased incidence of RD, next to improvements in treatment, is probably stage shift elicited by pre-operative staging. The outcomes support continuation of follow-up in colorectal cancer.
FDG-PET-CT is effective in selecting patients with poor long term survivals for colorectal liver metastases
Available online 15 November 2013
V.S. Yip | G.J. Poston | S.W. Fenwick | H. Wieshmann | T. Athwal | H.Z. Malik
Abstract: AimsHaving incorporated PET-CT as part of the staging process for colorectal liver metastases (CRLM) in our unit since 2008, this study aims to evaluate the survival outcomes of all patients managed by our specialist multi-disciplinary team (MDT).MethodsAll patients with colorectal liver metastases referred to a single liver MDT between 2008 and 2011 were examined. Overall survival (OS) for palliative groups due to occult extrahepatic disease detected by PET-CT (A) and those upfront palliative patients with extensive multi-site disease as identified on baseline CT or disease progression during chemotherapy (B), and resected (C) groups were evaluated and compared. Different extents of occult extrahepatic disease as characterised by PET-CT were also compared.Results532 patients were included in the study. Median OS for group A (n = 80), B (n = 161) and C (n = 291) were 10.9, 12.0 and 46.7 months, with a 5-year OS approaching 6.5%, 6.1% and 43.0% respectively. There were significant differences in OS of C vs. A & B (p < 0.001). Single compartment metastases had a significant better survival outcomes than non-torso metastases (p = 0.04).ConclusionThis is the first report of OS of patients with CRLM excluded from surgery on the basis of PET-CT. We have confirmed that PET-CT is effective in selecting patients with occult extrahepatic disease, which has poor survival outcomes. However, a subgroup with single compartment extrahepatic disease has a better than expected outcome.
Available online 13 November 2013
T. Fardoun | D. Chaste | E. Oger | R. Mathieu | B. Peyronnet | N. Rioux-Leclercq | G. Verhoest | J.J. Patard | K. Bensalah
Abstract: ObjectivesTo identify the predictive factors of hemorrhagic complications (HC) in a contemporary cohort of patients who underwent partial nephrectomy (PN).Materials and methodsRecords of 199 consecutive patients who underwent PN between 2008 and 2012 at our institution were retrospectively analyzed. HC was defined as a hematoma requiring transfusion, an arterio-veinous fistula, a false aneurysm or a post-operative decrease of hemoglobin >3 g/dl. Patients with or without HC were compared using Wilcoxon and Fisher exact tests for continuous and categorical variables, respectively. We performed a univariate and multivariate analysis with a logistic regression model using the occurrence of an HC as the dependent variable.Results54% of the patients were male with a median age of 61 (22–86) years. Median BMI was 26 (18–47) kg/m2. Surgery was done open, laparoscopically or with robotic assistance in 106, 54 and 39 cases, respectively. Global complication rate was 40% including 21.6% HC. There were more complex tumors (75.6% vs. 66.5%, p = 0.04) and median length of stay was increased (11 days compared to 7 days, p < 0.0001) in case of a HC. In univariate analysis, imperative indication (p = 0.08), RENAL score (p = 0.07), operating time (p = 0.07) and operative blood loss > 250 ml (p = 0.002) were statistically relevant. In multivariate analysis, only operative blood loss >250 ml was identified as a predictive factor of HC (p = 0.0007).ConclusionPatients who underwent a procedure with estimated blood loss >250 ml should be carefully monitored in the postoperative course.
Bowel obstruction in recurrent gynecologic malignancies: Defining who will benefit from surgical intervention
Available online 13 November 2013
T. Perri | J. Korach | G. Ben-Baruch | A. Jakobson-Setton | L. Ben-David Hogen | S. Kalfon | M. Beiner | L. Helpman | D. Rosin
Abstract: AimTo define factors that could help select, in a cohort of gynecologic cancer patients with malignant gastro-intestinal obstruction, those most likely to benefit from palliative surgery.MethodsIn this retrospective study of patients with malignant gastro-intestinal obstruction who underwent palliative surgery in our institute over 7 years, outcome measures were oral intake, chemotherapy, and 30-day, 60-day and overall survival. Based on Cox proportional-hazards regression models and Kaplan–Meier curves with log-rank tests, a prognostic score was developed to identify those most likely to benefit from surgery.ResultsSixty-eight palliative surgeries were performed in 62 patients with ovarian (69.1%), primary-peritoneal (8.8%), cervical (11.8%) or uterine (10.3%) malignancies. Procedures were colostomy (26.5%), ileostomy (39.7%), colonic stent (1.5%), gastrostomy (7.3%), gastroenterostomy (5.9%) and bypass/resection and anastomosis (19.1%). Eighteen patients died prior to discharge, within 3–81 days (median 25 days). The 30-day and 60-day mortality rates were 14.7% and 29.4%, respectively. Postoperative oral-intake and chemotherapy rates were 65% and 53%, respectively, with albumin level identified on multivariate analysis as the only significant predictor of both. Median postoperative survival was 106 days (3–1342). Bypass/resection and anastomosis was associated with improved survival. Ascites below 2 L, younger age, ovarian primary tumor, and higher blood albumin correlated with longer postoperative survival. A prognostic index based on these factors was found to identify patients with increased 30-day and 60-day mortality.ConclusionsOur proposed prognostic index, based on age, primary tumor, albumin and ascites, might help select those gynecological cancer patients most likely to benefit from palliative surgery.
Available online 12 November 2013
S. Fegrachi | I.Q. Molenaar | J.H. Klaessens | M.G. Besselink | J.A. Offerhaus | R. van Hillegersberg
Abstract: ObjectiveTo determine the impact of radiofrequency ablation (RFA) in pancreas after two-week follow-up.BackgroundRFA is a novel treatment strategy in patients with unresectable locally advanced pancreatic cancer. The histological effect and risk of postoperative complications has not been systematically addressed in an in-vivo animal model.MethodsIn a porcine model (n = 6), RFA was performed via laparotomy with previously determined optimal settings using a bipolar probe with 30 mm active length, at 30 W until a total energy of 15 KJ was administered. The probe was inserted in the pancreas at 10 mm distance from duodenum and portomesenteric vessels (PMV). RFA nearby duodenum was performed under continuous duodenal cooling using 100 ml/min saline of 5 °C. During two weeks the clinical condition was evaluated daily including blood analyses. After two weeks, total pancreatoduodenectomy was performed and the obtained tissue histopathologically assessed.ResultsNo mortality occurred during or after RFA. Two animals had a serum amylase increase more than threefold the pre-intervention value without clinical manifestations. Histopathologic assessment showed total ablation within the ablation zone, with loss of normal pancreatic acinar cell outlines and necrosis. In one animal, focal necrosis of duodenal submucosa was seen and in another animal focal fibrosis in the muscular layer of the superior mesenteric vein without clinical manifestations.ConclusionNo major morbidity and no mortality was seen during a period of two weeks after RFA with previously validated RFA settings including duodenal cooling and 10 mm distance to PMV. Future clinical studies should confirm safety of RFA using the settings established here.
Adjuvant chemotherapy improves overall survival after TME surgery in mucinous carcinoma of the rectum
Available online 12 November 2013
M. Chand | S. Rasheed | A. Bhangu | G.W.H. Stamp | R.I. Swift | P.P. Tekkis | G. Brown
Abstract: IntroductionMucinous tumours of the rectum are characterised by an abundance of extracellular mucin within the tumour complex. They are known to have a poor prognosis compared to non-mucinous adenocarcinomas. The effect of adjuvant chemotherapy on the survival outcomes of patients with mucinous cancer remains unclear. This study evaluated the 5-year overall survival of patients with mucinous rectal cancer following optimal TME surgery to determine whether adjuvant chemotherapy conferred a survival benefit.MethodsAn analysis of a prospectively-maintained database was conducted of patients presenting with mucinous rectal cancer between 2000 and 2010. Patients with mucinous tumours were identified from final pathology reports of the surgical resection specimens. The primary outcome was 5-year overall survival; univariate and multivariate analysis was performed using Cox proportional hazards regression models.ResultsA total of 191 patients were included for analysis with mean age of presentation 64.6 years (36–88 ± 11). On the fully adjusted multivariate model, EMVI status (HR 1.853, 95% CI 1.081–3.175) and not being given adjuvant chemotherapy (HR 2.888, 95% CI 1.801–4.633) were significant for disease recurrence. The 5-year overall survival for patients that had undergone adjuvant chemotherapy was 66.1% compared with 35.2% (Mantel Cox log-rank test – p < 0.0001).ConclusionThis study demonstrates that adjuvant chemotherapy is an independent factor for improvement in overall survival in patients with mucinous adenocarcinoma. Therefore, patients who have undergone TME surgery for mucinous carcinoma of the rectum should be offered adjuvant chemotherapy even in the absence of other high-risk features for poor outcomes.
Available online 12 November 2013
B. Posteraro | R. Persiani | V. Dall'Armi | A. Biondi | D. Arzani | F. Sicoli | S. Bonassi | D. D'Ugo | W. Ricciardi | S. Boccia
Abstract: BackgroundSurvival of patients after curative surgical resection for gastric cancer (GC) remains poor, thus emphasizing the need for better definition of prognostic factors to improve the long-term course of disease.MethodsFrom 1999 to 2009, 110 patients had curative-intent gastrectomy for adenocarcinoma. Clinicopathological features, Helicobacter pylori infection, dietary habits and lifestyle, and the presence of proinflammatory gene polymorphisms were evaluated.ResultsAt the end of follow-up, 55 deaths had occurred, 48 of them due to GC, whereas the median overall survival (OS) and disease-free survival (DFS) were 62 and 51 months, respectively. From the Kaplan–Meier analysis and log-rank test, statistically significant differences in OS and DFS were found for tumor site (only for DFS), tumor size, lymph node metastasis ratio (NR), and tumor-node-metastasis stage, but not for age, comorbidity, H. pylori infection, cigarette smoking, and IL1B or TNFA polymorphisms. Multivariable Cox regression analysis revealed NR was an independent prognostic factor for OS and DFS. Cardia tumor and patient age 65 years or older were also independent prognostic factors for OS and DFS.ConclusionsTumor-related factors remain strongest predictors of survival in GC patients after surgery. Particularly, NR was an effective feature in identifying patients at high risk for adverse outcome.
Transuretral resection of the bladder (TURB): Analysis of complications using a modified Clavien system in an Italian real life cohort
Available online 11 November 2013
C. De Nunzio | G. Franco | L. Cindolo | R. Autorino | A. Cicione | S. Perdonà | M. Falsaperla | M. Gacci | C. Leonardo | R. Damiano | M. De Sio | A. Tubaro
Abstract: IntroductionTo evaluate the applicability of a modified Clavien classification system (CCS) in grading postoperative complications of transurethral resection of bladder tumours (TURB).Materials and methodsA series of patients undergoing monopolar TURB from April 2011 to March 2012 at five Italian centers were enrolled. All complications occurring within the first 30-day postoperative period were prospectively recorded and graded according to the CCS.ResultsOverall, 275 patients were included. Median age was 71 (63/78) years; median BMI was 28 (25.4/30.8) Kg/m2, median tumour size was 2 (1–3) cm; median number of tumour lesions was 1 (1–3). Median operative time was 30 (20/45) min. Fifty-seven complications were recorded in 43 patients. Overall postoperative morbidity rate was 16%. Most of the complications were not serious and classified as Clavien type I (42 cases; 74%) or II (8 cases, 14%). Higher grade complications were scarce: CCS IIIa in 1 case (2%) and CCS IIIb in six cases (10%). No TURB related death was reported. Six patients were re-operated due to significant bleeding or clot retention on postoperative days 2–7. On univariate (73.5 ± 38 versus 36.7 ± 21.6 min) and multivariate analysis longer operative time was an independent predictor of complications (OR: 1.06 per min, 95%CI 1.04–1.08, p = 0.001).ConclusionsA modified CCS can be used as a standardized tool to objectively define the complications of TURB which confirms to be a safe procedure with a low surgical morbidity. This tool can be used to aid in patient counselling and to facilitate scientific assessment.
Available online 8 November 2013
C.J.H. van de Velde | P.G. Boelens | P.J. Tanis | E. Espin | P. Mroczkowski | P. Naredi | L. Pahlman | H. Ortiz | H.J. Rutten | A.J. Breugom | J.J. Smith | A. Wibe | T. Wiggers | V. Valentini
Abstract: The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process.Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer.Surgery is the cornerstone curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?
Available online 6 November 2013
S.T. Ward | C.J. Weston | E. Hepburn | S. Damery | R.K. Hejmadi | D.G. Morton | G. Middleton | T. Ismail | D.H. Adams
Abstract: AimsLysyl oxidase (LOX) expression is elevated in colorectal cancer (CRC) tissue and associated with disease progression. A blood test may form a more acceptable diagnostic test for CRC although LOX has not previously been measured in the serum. We therefore sought to determine the clinical usefulness of a serum LOX test for CRC in a symptomatic population.MethodsAdult patients referred to a hospital colorectal clinic with bowel symptoms completed a questionnaire and provided a blood sample for serum LOX measurement. Associations between presenting symptoms, serum LOX concentrations and outcomes of investigations were tested by univariate and multivariate analyses to determine if serum LOX was clinically useful in the prediction of CRC. LOX expression in CRC and adjacent colon biopsies was evaluated by ELISA and immunohistochemistry.ResultsThirty-one cases of colorectal cancer and 16 high-risk polyps were identified from a total of 962 participants. There was no association between serum LOX concentration and the presence of CRC, high-risk polyps or cancers at any site. LOX expression was significantly increased in CRC tissue compared to adjacent colon.ConclusionDespite overexpression of LOX in CRC tissue, elevated serum levels could not be demonstrated. Serum LOX measurement is therefore not a clinically useful test for CRC.
A systematic review of surgical biopsy for LCIS found at core needle biopsy – Do we have the answer yet?
Available online 6 November 2013
E.S. Buckley | F. Webster | J.E. Hiller | D.M. Roder | G. Farshid
Abstract: BackgroundThe natural history of lobular carcinoma in-situ (LCIS) suggests that women are at increased risk of subsequent invasive breast cancer. Questions of effective management for women with this lesion have led to the need for evidence-based guidance and, in particular, guidance regarding management after LCIS is found at core needle biopsy (CNB).MethodsA systematic review was conducted to determine the most appropriate management for women with LCIS found at CNB. A comprehensive search of the scientific literature was conducted to identify the literature pertaining to this population. Critical appraisal of the literature, data extraction and a narrative synthesis of the results were conducted. The outcome of interest was upgrade of diagnosis to invasive breast cancer or ductal carcinoma in-situ (DCIS).ResultsSparse data, with limited generalisability and considerable uncertainty, are available for women with LCIS at CNB. Nine studies were identified that met pre-specified inclusion criteria. The reported estimates of upgrade of diagnosis from LCIS to invasive breast cancer or DCIS ranged from 2% to 25%. The body of evidence was limited by its retrospective nature, risk of selection bias and poor generalisability to all women with LCIS at CNB. Further, higher quality research is required to determine the best approach for women with LCIS at CNB with any certainty.
Advanced age is not a contraindication for liver resection in cases of large hepatocellular carcinoma
Available online 5 November 2013
H.-L. Fan | C.-B. Hsieh | W.-C. Chang | S.-H. Huang | D.-C. Chan | J.-C. Yu | C.-H. Chu | T.-W. Chen
Abstract: BackgroundThe role of surgery in the management of large hepatocellular carcinomas (HCCs) is controversial. Advanced age and comorbidities are taken into account when major surgery is considered.PurposeTo compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) for resectable HCC in patients aged 70 years or older.Patients and materialsThis study included 70 patients aged 70 years or older treated for large HCCs (≥5 cm) between January 2007 and December 2012: 37 underwent LR and 33 underwent TACE. The outcomes of these patients were retrospectively analyzed. Univariate and multivariate Cox proportional hazard models were established. Kaplan–Meier survival curves were generated, and survival data were compared using the log-rank test.ResultsHospital stay was significantly longer in the LR group than in the TACE group (10 days vs 8.5 days; P = 0.003). Treatment-related complications were more frequent in the TACE group, but this difference was not statistically significant. LR was associated with a better disease-free survival rate, median survival rate and cumulative overall survival rate.ConclusionOur results showed that LR could be a safe and effective treatment option for HCC tumors ≥5 cm in patiets aged 70 years or older.
Sentinel lymph node biopsy in patients with microinvasive breast cancer: A systematic review and meta-analysis
Available online 5 November 2013
H. Gojon | D. Fawunmi | A. Valachis
Abstract: BackgroundThe aim of this meta-analysis is to evaluate the role of sentinel lymph node biopsy (SLNB) in patients with microinvasive breast cancer.MethodsWe searched MEDLINE and ISI Web of Science to identify studies including patients with microinvasive breast cancer who underwent SLNB and reported the rate of sentinel-node positivity. We performed proportion meta-analysis using either fixed or random-effects model based on the between-study heterogeneity.FindingsA total of 24 studies including 968 patients met the eligibility criteria. The summary estimate for the sentinel-node (SN) positivity rate was 3.2% (95% Confidence Interval (CI): 2.1%–4.6%), 4.0% (95% CI 2.7%–5.5%), and 2.9% (95% CI: 1.6%–4.6%) for macrometastasis, micrometastasis and isolated tumor cells (ITC) respectively. Significant between-study heterogeneity was observed only in the meta-analysis of ITC positivity rate.InterpretationThe amount of positive sentinel node in patients with proven microinvasive breast cancer is relatively low. As a result, the indications for SLNB in these patients should be probably individualized.
Available online 5 November 2013
W. Faber | M. Stockmann | C. Schirmer | A. Möllerarnd | T. Denecke | M. Bahra | F. Klein | E. Schott | P. Neuhaus | D. Seehofer
Abstract: ObjectiveHepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide.The majority of patients with HCC have cirrhosis. Beside liver transplantation the resection is an established curative treatment option for patients with HCC in cirrhosis. However, the long term success is limited by a high tumor recurrence rate. Furthermore, by many patients surgical resection is restricted by poor liver function.The purpose of this study was to investigate the influence of patient age on long term outcome after liver resection in patients with HCC in cirrhotic liver. Further purpose was to define the potential prognostic factors.Patients and methodsThe outcome of 141 patients with liver cirrhosis after curative resection was analyzed using a prospective database. Only patients with postoperative histological assurance of HCC were included in the database. Patients with fibrolamellar HCC were excluded.ResultsBy patients below 70 years of age the 1-, 3- and 5-year survival rates were 78.5%, 56.5% and 47.1%. By patients over 70 years the 1-, 3- and 5-year survival rates were 59.9%, 40.3% and 6.7%. Cumulative survival of the total collective was significant influenced by patient age, Clavien grade, positive lymph vessels, mechanical ventilation and BMI. The overall postoperative morbidity was 44.7%. No intraoperative deaths were observed, but 11 patients (8 older than 70 and 3 younger than 70 years) died during the hospital stay. Clavien grade correlated with preoperative increased GGT, need for intraoperative blood and fresh frozen plasma transfusion.ConclusionsPatient age and postoperative complications are more relevant for the outcome than many tumor factors, especially by patients over 70 years of age. In contrast, the prognosis of patients below 70 years of age is significantly better and a 5 year survival rate above 50% could be shown in our patients. However, by carefully selected elderly patients with HCC in cirrhosis an acceptable long term survival is reachable.
Available online 5 November 2013
F. Coccolini | E. Cotte | O. Glehen | M. Lotti | E. Poiasina | F. Catena | Y. Yonemura | L. Ansaloni
Abstract: IntroductionAn important component of treatment failure in gastric cancer (GC) is cancer dissemination within the peritoneal cavity and nodal metastasis. Intraperitoneal chemotherapy (IPC) is considered to give a fundamental contribute in treating advanced GC. The purpose of the study is to investigate the effects of IPC in patients with advanced GC.Material and methodsA systematic review with meta-analysis of randomized controlled trials (RCTs) of IPC + surgery vs. control in patients with advanced GC was performed.ResultsTwenty prospective RCTs have been included (2145 patients: 1152 into surgery + IPC arm and 993 into control arm). Surgery + IPC improves: 1, 2 and 3-year mortality (OR = 0.31, 0.27, 0.29 respectively), 2 and 3-year mortality in patients with loco-regional nodal metastasis (OR = 0.28, 0.16 respectively), 1 and 2-year mortality rate in patients with serosal infiltration (OR = 0.33, 0.27 respectively). Morbidity rate was increased by surgery + IPC (OR = 1.82). The overall recurrence and the peritoneal recurrence rates were improved by surgery + IPC (OR = 0.46 and 0.47 respectively). There was no statistically significant difference in lymph-nodal recurrence rate. The rate of haematogenous metastasis was improved by surgery + IPC (OR = 0.63).Conclusions1, 2 and 3-year overall survival is incremented by the IPC. No differences have been found at 5-year in overall survival rate. 2 and 3-year mortality rates in patients with nodal invasion and 1 and 2-year mortality rates in patients with serosal infiltration are improved by the use of IPC. IPC has positive effect on peritoneal recurrence and distant metastasis. Morbidity rate is incremented by IPC. Loco-regional lymph-nodes invasion in patients affected by advanced gastric cancer is not a contraindication to IPC.
Available online 5 November 2013
B.H.M. Williams | N.A. Alzahrani | D.L. Chan | T.C. Chua | D.L. Morris
Abstract: PurposeTo clarify the role of repeat CRS for recurrent colorectal carcinoma (CRC) through: (i) Systematic review of the literature (ii) Analysis of survival outcomes in a prospective cohort.Methods(i) Pubmed and MEDLINE from 1980 to July 2013 searched using terms: colorectal carcinoma, peritonectomy, cytoreductive surgery, heated intraperitoneal chemotherapy (HIPEC), redo, repeat, and iterative. (ii) Kaplan-Meir Survival analysis of consecutive patients undergoing repeat CRS at St George Hospital between Jan 2000 and July 2013.Results(i) The search strategy yielded 309 articles, 5 meeting inclusion criteria, reporting on 91 patients. Median overall survival from first CRS ranged from 39 to 57.6 months with 3-yr survival of 50%, and 5-year survival of 30%. Median survival from second CRS was 20-months with 1-yr survivals of 72% and 66% and 2-year survivals of 50% and 44%. (ii) Repeat CRS performed on 18 patients found median survival from first CRS was 59 months, with 1, 3, and 5-year survival of 100%, 52% and 26% respectively. Median survival from repeat CRS was 22.6 months with 1, 2, and 3-year survival of 94%, 48% and 12% respectively.ConclusionThe current data on repeat CRS in CRC is relatively immature and more data is required before drawing clear conclusions. Patient selection should be on a case by case basis conducted through a MDT process with emphasis on surrogate markers for favourable outcomes.

domain: literature


text: Impact of Taxes and Inflation Estimate the potential impact taxes and inflation can have on the purchasing power of an investment. You are viewing this website at a small screen resolution which doesn't support calculators. Click here to view this calculator. Have A Question About This Topic? Name Email Address Message Thank you! Oops! Related Content How Will the Economy React to AI? What do concerns or uncertainty about AI mean for your future and your financial strategy? Estimate Your RMD Help determine the required minimum distribution from an IRA or other qualified retirement plan. Putting a Price Tag On Your Health Being healthy not only makes you feel good, it may also help you financially.

domain: economics


text:
This book develops an original and comprehensive theory of political liberalism. It defends bold new accounts of the nature of autonomy and individual liberty, the content of distributive justice, and the justification for the authority of the State. The theory that emerges integrates contemporary progressive and pluralistic liberalism into a broadly Aristotelian intellectual tradition.
The early chapters of the book challenge the traditional conservative idea of individual liberty-the liberty to dispose of one's property as one wishes-and replace it with a new one, according to which liberty is of equal value to all persons, regardless of economic position.
The middle chapters present an original theory of socio-economic justice, arguing that a society in which every citizen enjoys an equal share of liberty should be the distributive goal of the State. It is argued that this goal is incompatible with the existence of large disparities in wealth and economic power, and that (contra conservative and libertarian economic arguments) such disparities are harmful to the overall health of national and global economies.
The final chapters provide an original argument that the State has both a moral duty and a moral right to pursue this program of socio-economic justice (contraconservative and libertarian moral arguments), and that only the measures necessary to implement this program lie within the morally justifiable limits on the State's authority.
Though primarily a political work, it spans most areas of practical philosophy-including ethical, social, and legal theory; and meta-ethics, moral psychology, and action theory. And though fundamentally a philosophical work, it incorporates research from a number of fields-including decision theory, economics, political science, and jurisprudence; primatology, neuroscience, and psychology; and history, anthropology, sociology, and ecology-and is sure to be of interest to a wide range of scholars and students.
This volume brings together contemporary position statements and research reviews which were originally presented as Plenary Addresses to the Biennial International Conference on Task-Based Language Teaching, between 2005 and 2013. It thus assembles up-to-date reflections, critiques, and recommendations from influential researchers working within the TBLT paradigm over the last 30 years, thereby also highlighting most of the major theoretical perspectives so far developed. While the plenarists structured their chapters around their original presentations, they have been invited to update their thinking as they feel appropriate and in response to recent developments in the field. The collection thus offers representative and accessible coverage of a range of approaches to the overall philosophy of TBLT, to the relationship between TBLT and the study of second language acquisition, and to the development and implementation of TBLT as a comprehensive approach to language education, curriculum, and pedagogy.
Domain Today Articles
Domain Today Books

domain: library


text:
Doctor of Philosophy
Chemical and Biochemical Engineering
Paul A. Charpentier
In order to enhance both the photoactivity and physical/mechanical properties of titania/polyurethane (PU) nanocomposites, in-situ polymerization and film casting were investigated. Both self-degrading PU foams and self-cleaning PU coatings were prepared. Functional monomers were prepared usingDMPA (2,2-dimethylolpropionic acid) functionalized anatse TiO2 and P25 for integration into polyurethane foam with a "grafting-from" synthetic method. This technique was found to successfully reduce the agglomeration effect of titania nanoparticles inside the foams. In addition, the photodegradation rate was enhanced by > 120% over unmodified foam at an optimized loading of 3wt% DMPA functionalized anatase TiO2. The presence of DMPA functionalized P25 nanoparticles produced an increase in the degradation rate of 66% over the unmodified foam at an optimized 1wt% loading.
SiO2 encapsulated anatase and rutile TiO2 nanoparticles were successfully synthesized via a modified Stöber process, and integrated into polyurethane coatings. The SiO2 encapsulation enhanced the anatase TiO2 nanoparticle distribution as well as the photocatalytic activity of the polyurethane nanocomposites when the loading weight of SiO2 was lower than 3.25wt%. By increasing the SiO2 amount on the titania surface, the contact angle of the coatings increased from 75 to 87 for anatase phase and 70 to 78 for rutile phase. The Young's Modulus was also increased from 1.06GPa to 2.77GMPa for anatase phase and 1.06GPa to 2.17GPa for rutile phase, attributed to the silica layer giving better integration. The thermal conductivity of the polyurethane coatings was also successfully decreased by encapsulating SiO2 on the titania surface, which has applications for next generation high performance coatings.
In addition to nanospheres, TiO2 nanofibers were synthesized via an environmental friendly supercritical CO2 method and nanotubes were prepared via a hydrothermal reaction. They were encapsulated with silica via the modified Stöber process, then integrated into polyurethane coatings. With more of SiO2 coated on the nanofibers’ surface, the photocatalytic activity, UV absorbance, and hydroxyl radical formation decreased due to the shielding effect of the SiO2 layers. In contrast, with more SiO2 coated on the nanotubes’ surface, the formed material was more photoactive at first and then became less active later. These effects in part are attributed to the surface area changes. With these modified nanofibers and nanotubes, the polyurethane coatings were found to exhibit similar photoactivity trend. The mechanical strength was enhanced and the hydrophobicity of coatings was maintained upon exposure to UV irradiation.
Nanofiber shaped TiO2 xerogel was synthesized via environmental friendly approach with supercritical CO2 (ScCO2), which when mixed within polyurethane coatings through film casting method and the coatings remain transparent. The coordination between Ti and the carboxylic acid group was investigated showing a bidentate coordination. The TiO2 xerogel nanofibers were found to possess high UV absorbance with high UV shielding properties when integrated into polyurethane coatings. They also were found to influence the thermicity while increasing the reflective index, hence allowing more IR transfer through the coatings faster.
Chen, Chao, "Photoactive Properties of Nanostructured Titania Modified Polyurethanes" (2017). Electronic Thesis and Dissertation Repository. 4495.


text:
Older Americans are at high risk for a severe to deadly case of coronavirus. Older Americans are also the primary age group that volunteers to serve as poll workers. Consequently, there has been a shortage of poll workers for elections since the COVID-19 pandemic began.
In Georgia, elections chief Brad Raffensperger is hoping a new partnership will bring younger poll workers into the fray for the November Election.
Raffensperger is partnering with GeorgiaForward to recruit poll workers for elections in November and to educate voters about the how, when, and why of elections in Georgia. The secretary says he is spearheading this partnership with GeorgiaForward to ensure county elections officials have the staff they need on and in the weeks before election day.
“Partnering with GeorgiaForward will help us connect with civic-minded young professionals around the state to help staff the polls on election day,” said Secretary of State Brad Raffensperger. “When COVID-19 swept through Georgia, Georgia’s vulnerable elderly poll workers stayed home to stay safe from the pandemic. Through these public-private partnerships, like the one with Georgia Forward, we will fill the gaps with younger poll workers and help provide a smooth and efficient experience for Georgia’s voters in November.”
“At GeorgiaForward we understand that statewide solutions to statewide problems are solved one community, one citizen, one act of civic engagement at a time. We’re excited to partner with the Secretary on this initiative not only for how it will help Georgia’s voters in November, but also how each poll worker will go back into his or her community that much more knowledgeable, engaged, and empowered,” said A.J. Robinson, Chairman of the GeorgiaForward Board.
Secretary Raffensperger is also partnering with GeorgiaForward and the Georgia Municipal Association for a deep dive discussion on voting in Georgia. The Secretary will present at “Let Your Voice Be Heard: How, When, and Why to Vote” on Tuesday, September 15, 2020 at 6:00pm. He will be joined by Jason Carter of the Carter Center, Andra Gillespie of Emory University, and Janet Lee of the U.S. Census Bureau. Visit www.georgiaforward.org to register and learn more.
By working with a wide array of private and nonprofit organizations, Raffensperger says he is hoping to reach new areas of Georgia to pull people off of the sidelines.
Georgia poll workers were on average above 65 years old. When the COVID-19 pandemic swept through the United States, this particularly vulnerable population understandably opted to stay home and avoid the risk of exposure to the virus. As a result, polling locations across the state were short-staffed on election day and limited in their ability to train new poll workers due to the constraints of the pandemic.
To fill this gap, Secretary Raffensperger is partnering with numerous organizations in the state to help recruit younger, less-at-risk populations to staff the polls on election day.
On June 9, Georgia saw record turnout for a statewide general primary election. Notwithstanding a state record for absentee ballots cast by mail, Georgia saw over 800,000 people vote on election day itself. More than 300,000 voted early, in person, during Georgia’s three weeks of early voting.
In-person voting remains as important as ever. In November, turnout is expected to be as much as three times as high. This means, county officials need a stable of young poll workers to step up and help their communities on election day.

domain: sociology


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“Headed to the Good Life” is a story of remembering your roots and that life isn’t always easy, but it is good. For me, it took getting back to our family farm and ranch where for generations, we’ve carved out our character, work ethic and faith in this ever-changing world. For you, it could be something different but our hope is for the music to inspire you to take the good in your life and build on it everyday. —Blan Scott
Music video by Blan Scott Band performing Headed To The Good Life. (C) 2015.
Vocals, Harmonica and Acoustic Guitar: Blan Scott
Lead Guitarist: Pete Westfall
Bass Guitarist: Tom Lehr
Drummer heard on the music: Steve Sorg
Drummer in video: Tim Thayer
Video Production: Creative Owl Productions, LLC.
Cover Photo: Savanah Bond
Song Recording: Marfa Recording Studio– music recorded 2016
Music mixed by Chico Jones July 2017
Mastered by Max Lorenzen Oct. 2017

domain: artistic


text:
Monday, 16 April 2012
Join the campaign to save the Remploy factory in Penzance
Remploy is the largest and the oldest employer of disabled people in Britain. It is not only a workplace but a way of life for thousands of disabled people who want sustainable employment of their choice. Employees now face the threat of closure with little prospect of a job elsewhere.
Shoppers were angry at the way people with disabilities are being targeted by the Tory-led government, not only losing their jobs through the planned closure of Remploy, but also losing benefits as a result of the Welfare Reform Act. Around 400 people signed the petition in less than two hours, about the same amount that had signed it the previous week.
The petitioners were joined by Colin Grey, the GMB trade union rep. at the Longrock Remploy factory. Colin said: “Remploy in employing us, gives us dignity, a living wage, a reason to get up in the morning, support not only at work but in our personal lives, and most of all, a life. We have for many years worked for a living and not stayed at home on benefits as most, if not all, could have.
“To take Remploy away would subject many, many hundreds to live on benefits and never work again, and to languish in poverty and despair. I urge all to do what they can to stop this government making a huge mistake in destroying Remploy, because when it’s gone, it’s gone.”
Penwith Anti-Cuts Alliance have organised a public meeting on the issue of the planned closure of the Remploy factories on Tuesday 1 May at 7pm. It is to be held at the Lugger Hotel on the Promenade in Penzance. Colin Grey and the regional GMB rep. will speak and representatives of Disability Cornwall and Cornwall Disabled People Against the Cuts are expected to speak. Everyone is welcome to come along and have their say.

domain: news


text:
Elaine Zamansky, 609-343-5974, email@example.com
CRDA Board Acts to Strengthen Atlantic City’s Landmarks
(Atlantic City, NJ, July 16, 2014) – The Board of the Casino Reinvestment Development Authority (CRDA) yesterday acted on several measures to ensure continued operation of some of Atlantic City’s landmarks. According to CRDA Board Chairman James Kehoe these are, “part of the city’s history, and an important part of the non-gaming attractions that play a large role in our tourism industry.”
The Board authorized a $100,000 grant over a three-year period to assist with operational costs of historic Absecon Lighthouse. “It is important that this Atlantic City tourism amenity and registered historic site continue to operate on a year round basis,” said John Palmieri, CRDA executive director said.
Likewise, the Board authorized $58,000 to repair the Historic Brighton Park Fountain’s water and electrical systems, which were damaged last winter due severe winter weather. A portion of the funds will be repaid when the City of Atlantic City receives reimbursement from insurance claims. The historic “Fountain of Light” was a gift to the city from General Electric Company in 1929, commemorating the 50th anniversary of the invention of the light bulb and the 75th anniversary of Atlantic City’s founding.
Action was also taken on one of Atlantic City’s newer – and most popular — attractions. CRDA agreed to provide Tanger Outlets “The Walk” retail outlet shopping district with a $1.84 million advance, provided as a loan against their guaranteed annual payment to CRDA. The loan will help finance fit-out costs associated with the relocation of Ralph Lauren and Michael Kors to larger retail space within The Walk. The total estimated project cost is up to $6.9 million, of which Tanger will invest up to $4.6 million in equity.
A potential new attraction also received CRDA attention. The Board authorized $50,000 for a feasibility study to open a New Jersey Hall of Fame flagship museum at Boardwalk Hall.
In other action, the Board agreed to a $21,800 Supplemental Fund Reservation for the LEAD Atlantic City Tomorrow (LEAD ACT) for 2015, the program’s third year. Through seminars, guest speakers, case studies and topical readings, participants explore the issues that affect the general well-being of Atlantic City and recognize the need for collaborations and partnerships. The 10-month program is conducted in collaboration with The Richard Stockton College of New Jersey.
According to Palmieri, “The actions taken today by the CRDA Board will strengthen Atlantic City’s non-gaming tourism offerings and lay the groundwork for additional attractions in the future.”
Board actions will take effect following the expiration of the Governor’s statutory review period.
# # #
About the Casino Reinvestment Development Authority (CRDA) www.njcrda.com
The only agency of its kind nationwide, the CRDA has used Atlantic City casino reinvestments as a catalyst for meaningful, positive improvement in the lives of New Jersey residents statewide, investing nearly $2 billion in more than 400 projects statewide since 1984. Under the 2011 Tourism District Act, CRDA’s mission evolved from statewide projects to becoming the state’s key economic development agency for Atlantic City. CRDA responsibilities expanded to include Land Use Regulation, Clean and Safe initiatives, group and leisure tourism marketing, attracting and retaining conventions and meetings at the Atlantic CityConvention Center and Boardwalk Hall, and partnership with the Atlantic City Alliance to brand and market Atlantic City. Atlantic City Convention & Visitors Authority division of CRDA is the first destination marketing organization in New Jersey to achieve prestigious Destination Marketing Accreditation by the Destination Marketing Association International.


Ruoff Home Mortgage Music Center
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An outdoor music venue, located in Indianapolis IN.
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An outdoor amphitheater located just a mile down the road. Sit on our lovely back patio and listen to live summer music concerts.
2019 season includes Goo Goo Dolls, Slayer, Hootie & the Blowfish, and Kiss