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Dr Harsh Shah - Surgical Gastroenterologist and GI Robotic Surgeon, Ahmedabad
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Dr Harsh Shah - Surgical Gastroenterologist and GI Robotic Surgeon, Ahmedabad

Dr Harsh Shah

Surgical Intervention for Liver Metastases in Breast Cancer Patients: A Meta-Analysis

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Introduction The management of breast cancer liver metastases (BCLM) remains controversial. Traditional palliative care offers limited success, prompting investigation into more aggressive surgical interventions. A recent meta-analysis reconstructs individual patient data to evaluate the efficacy of hepatic resection in BCLM, comparing survival outcomes with non-surgical treatments.

Methods This study employed a one-stage meta-analysis approach, reconstructing patient-level survival data from four propensity-score matched studies. The analysis included 205 surgical and 291 non-surgical patients. Shared-frailty and stratified Cox models were used to compare overall survival (OS) outcomes.
Results The meta-analysis revealed significant survival benefits for patients undergoing surgery:

  • Overall Survival: Surgical intervention showed a hazard ratio (HR) of 0.40 (95% CI 0.32–0.51), indicating a substantial reduction in mortality risk.
  • Sensitivity Analyses: Consistent HRs favoring surgery were observed across hormone receptor status and type of resection performed.

Discussion The findings support the inclusion of hepatic resection in the multidisciplinary management of BCLM for select patients. Criteria for surgical candidates included good resectability, favorable response to systemic therapy, and absence of extrahepatic metastasis aside from stable bone lesions.

Conclusion This meta-analysis provides robust evidence that hepatic resection offers superior OS in BCLM patients under specific conditions. The study underscores the need for future PSM studies and potential randomized controlled trials to refine surgical indications and enhance treatment protocols.

Access the Full Study For detailed insights, access the full study here.

Frailty as a Predictor of Outcomes in Oncological Liver Resections

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Introduction Frailty has emerged as a significant predictor of surgical outcomes, particularly in the elderly undergoing complex procedures like oncological liver resections. This systematic review and meta-analysis aim to consolidate the evidence on the impact of frailty on morbidity and mortality in this patient population.

Methods This study involved a systematic review and meta-analysis of 10 studies, including 71,102 patients, comparing outcomes between frail and non-frail individuals undergoing liver resections. Frailty was assessed using various validated scores.

Results

  • Patient Characteristics: Frail patients were generally older and had lower preoperative albumin levels, indicating poorer nutritional status.
  • Morbidity and Mortality: Frail patients had significantly higher rates of overall morbidity (OR 2.9), major complications (OR 2.2), surgical complications (OR 1.4), and postoperative liver failure (OR 1.3). Mortality rates were three times higher in frail patients.
  • Readmissions and Length of Stay: Frail patients had a higher readmission rate and a longer hospital stay, though the latter showed significant interstudy heterogeneity.

Discussion The findings underscore the importance of preoperative frailty assessment in patients undergoing liver resection. Frailty, characterized by reduced physiological reserve, significantly predicts adverse outcomes. Integrating frailty scores into preoperative evaluations can aid in patient selection, improve surgical planning, and enhance postoperative care.

Conclusion Frailty is a robust predictor of morbidity and mortality in patients undergoing oncological liver resections. Incorporating frailty assessment into clinical practice can help optimize surgical outcomes and patient management.

Enhancing Lymphadenectomy in Gastric Cancer Surgery with ICG Fluorescence

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Objective:
This study evaluates the effectiveness of indocyanine green (ICG)-guided lymph node (LN) dissection during laparoscopic radical gastrectomy post-neoadjuvant chemotherapy (NAC) in locally advanced gastric cancer (LAGC) patients.

Background:
ICG fluorescence has been shown to improve LN mapping in various cancers. However, its application in LAGC post-NAC remains underexplored.

Methods:
Patients with clinical T2-4NanyM0 gastric adenocarcinoma were randomized into ICG-guided and non-ICG groups. Key secondary endpoints included the quality of lymphadenectomy and surgical outcomes.

Results:
Out of 240 patients randomized, 236 were analyzed. The ICG group had a significantly higher mean number of retrieved LNs within D2 dissection compared to the non-ICG group (48.2 vs. 38.3, P < 0.001). The ICG group also showed a significantly reduced LN noncompliance rate (33.9% vs. 55.1%, P = 0.001). Additionally, in patients without baseline measurable LNs, ICG significantly increased the number of retrieved LNs and decreased the LN noncompliance rate. Surgical outcomes were comparable between the groups.

Conclusion:
ICG-guided lymphadenectomy improves LN dissection quality in LAGC patients undergoing laparoscopic radical gastrectomy post-NAC, without compromising surgical outcomes. This technique is particularly beneficial in patients without baseline measurable LNs and those achieving complete response post-NAC.

DOI: Read here

Prediction Model for Lung Metastases in Colorectal Cancer Patients with Indeterminate Pulmonary Nodules

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Introduction: The management of indeterminate pulmonary nodules (IPNs) in newly diagnosed colorectal cancer (CRC) patients poses a significant clinical challenge. This study aimed to develop and validate a prediction model to estimate the risk of IPNs being lung metastases, aiding in the decision-making process for follow-up imaging strategies.

Study Summary:

  • Incidence of IPNs: In a cohort of 2111 CRC patients, 9.6% had IPNs detected on chest CT scans at diagnosis.
  • Lung Metastases Incidence: Among these, 26% were confirmed to have lung metastases within two years.
  • Predictive Factors Identified:
    • Primary tumor location in the rectum.
    • Pathological nodal stage (pN2).
    • Size of the largest nodule (>10 mm).
    • Presence of extrapulmonary synchronous metastases (ESM).

Model Development: The model was derived from patients diagnosed between November 2011 and June 2014 and validated with patients from July 2014 to December 2018. It demonstrated robust discrimination with an AUC of 0.83 in the derivation sample and 0.79 in the validation sample.

Clinical Application: A nomogram was created to facilitate the clinical application of the risk score. This tool can assist multidisciplinary teams in stratifying
For more detailed information, you can read the full study here.

Prophylactic Hyperthermic Intraperitoneal Chemotherapy in T4 Colorectal Cancer: Can it Improve the Oncologic Prognosis?

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Introduction
Colorectal cancer (CRC) is a prevalent malignancy of the digestive system. Approximately 7% of CRC cases present with synchronous peritoneal metastases (PM), significantly reducing patient survival rates. The study aimed to determine if prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) could improve the prognosis for patients with T4 CRC.

Study Overview
This retrospective propensity score matching (PSM) cohort study included 220 patients with cT4N0-2M0 CRC treated at Zhejiang University School of Medicine between 2014 and 2018. The primary outcomes assessed were 3-year disease-free survival (DFS) and 3-year PM rate.

Methods
Patients were divided into two groups: those who received HIPEC (n = 45) and those who did not (n = 135). HIPEC was performed using either mitomycin C or oxaliplatin, administered through an extracorporeal circulation system at a constant temperature of 43°C for 60 minutes, either intraoperatively or within three days post-surgery.
Results

  • 3-Year DFS: The HIPEC group demonstrated a significantly better 3-year DFS (83.9%) compared to the non-HIPEC group (67.2%).
  • 3-Year PM Rate: The incidence of PM was significantly lower in the HIPEC group (2.2%) compared to the control group (11.1%).
  • Subgroup Analysis: HIPEC improved DFS for T4N0-1M0 patients but not for T4N2M0 patients. Laparoscopic surgery followed by HIPEC did not increase the risk of PM.

Discussion
The findings suggest that prophylactic HIPEC may enhance the prognosis of patients with T4N0-1M0 CRC without significantly increasing surgery-related complications. However, HIPEC did not show a significant benefit for T4N2M0 patients, who have a higher propensity for distant metastasis. This highlights the importance of careful patient selection for HIPEC treatment.

Conclusion
Prophylactic HIPEC appears to provide significant benefits for certain CRC patients, particularly those with T4N0-1M0 staging. This treatment may lead to better long-term outcomes and lower recurrence rates, although further large-scale, randomized controlled trials are necessary to confirm these results and refine patient selection criteria.
DOI: 10.1016/j.ejso.2024.107958

Validation of PERI-Gastric Models for Predicting Peritoneal Recurrence Post-Gastrectomy

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Gastric cancer remains a significant global health issue, with radical gastrectomy being a common curative approach. However, peritoneal recurrence poses a major challenge post-surgery. This study aimed to validate the PERI-Gastric 1 and PERI-Gastric 2 prediction models using a large Korean cohort.

Study Design and Methods: The study retrospectively analyzed data from 8564 patients who underwent gastrectomy for stage Ib-IIIc gastric cancer at the Yonsei Cancer Center between 1998 and 2018. The performance of the PERI-Gastric models was evaluated through AUROC, calibration plots, and decision curve analysis.

Results:

  1. Discrimination: PERI-Gastric 1 and PERI-Gastric 2 models demonstrated AUROC values of 0.766 and 0.767, respectively, indicating good discriminatory power.
  2. Calibration: The models exhibited satisfactory calibration, particularly within the risk range of 24-33% for PERI-Gastric 1 and 35-47% for PERI-Gastric 2.
  3. Clinical Utility: Decision curve analysis confirmed a positive net benefit within specific risk ranges (10-42% for PERI-Gastric 1 and 15-45% for PERI-Gastric 2).

Discussion: The external validation study confirms that the PERI-Gastric models are robust tools for predicting peritoneal recurrence in Eastern populations. The models’ ability to identify high-risk patients allows for tailored therapeutic strategies, potentially incorporating more aggressive perioperative treatments and stringent postoperative surveillance.

Conclusion: The PERI-Gastric 1 and 2 models provide reliable risk stratification for peritoneal recurrence after radical gastrectomy. Their implementation in clinical practice can enhance prognostic accuracy and guide treatment decisions, ultimately improving patient outcomes.

For detailed insights, refer to the full study here.

Dr Harsh Shah - Surgical Gastroenterologist and GI Robotic Surgeon, Ahmedabad

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