Explore the vast range of titles available.

Purpose of ReviewGastric adenocarcinoma is the fifth most common and the third most lethal cancer worldwide. Surgery is the only chance of cure, but recurrence is common, even with complete resection.Recent FindingsAdvances in diagnosis and staging, genomic classification, surgical resection and treatment of peritoneal disease, systemic chemotherapy and chemoradiation, and targeted and immune therapies have led to the current multidisciplinary approach to gastric adenocarcinoma.SummaryTreatment of gastric cancer is rapidly evolving in an effort to combat this challenging disease.

Background Due to the increased adoption of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), patients with malignant peritoneal mesothelioma (MPM) have seen improved outcomes. We aimed to evaluate and synthesize the recent published literature. Methods The review was conducted according to the recommendation of the Meta-Analysis of Observational Studies in Epidemiology group with prespecified inclusion and exclusion criteria. The DEALE method was used to combine mortality rates, and imputation techniques were used to calculate standard errors. Meta-regression techniques were used to synthesize data. Publication bias was assessed using funnel plots. Results Of 6,528 citations collected, 20 articles reporting on 1,047 patients were included in the analysis. The median age was 51 years (interquartile range 49–55), with 59 % (54–67) female. The median peritoneal carcinomatosis index score was 19 (16–23). Complete cytoreduction (CC0, 1) was performed in 67 % (46–93 %) of patients. Pooled estimates of survival yielded a 1-, 3- and 5-year survival of 84, 59, and 42 %, respectively. Patients receiving early postoperative intraperitoneal chemotherapy [EPIC] (44 %) and those receiving cisplatin intraperitoneal chemotherapy alone (48 %) or in combination (44 %) had an improved 5-year survival. Conclusions While CRS + HIPEC has led to an improved survival for patients with MPM compared to historic data, heterogeneity of studies precludes generalizable inferences. EPIC chemotherapy and cisplatin chemoperfusion may infer survival benefit.

Colorectal cancer is the third most common cancer diagnosis in the world, and the second most common cause of cancer-related deaths. Despite significant progress in management strategies for colorectal cancer over the last several decades, metastatic disease remains difficult to treat and is often considered incurable. However, for patients with colorectal liver metastases (CRLM), surgical resection offers the best opportunity for survival, can be curative, and remains the gold standard. Unfortunately, surgical treatment options are underutilized. Misperceptions regarding resectable and unresectable CRLM likely play a role in this. The assessment of factors that impact resectability status like medical fitness, technical considerations, and disease biology can be difficult, necessitating careful multidisciplinary input and discussion. The identification of ideal operative time windows that align with the multimodal management of these patients can also be perplexing. For all patients with CRLM it may therefore be advantageous to obtain surgical evaluation at the time of discovering liver metastases to mitigate these challenges and minimize the risk of undertreatment. In this review we summarize current surgical management strategies for CRLM and discuss factors to be considered when determining resectability.

Background The benefit of chemotherapy for surgically resected intrahepatic cholangiocarcinoma (ICC) remains poorly defined. The present study sought to determine the survival impact of chemotherapy for surgically resected ICC. Methods Patients with non-metastatic ICC who underwent surgery were identified from the National Cancer Database (1998–2011) and stratified by receipt of chemotherapy. Survival outcomes were analyzed following propensity score modeling using the greedy matching algorithm. Results A total of 2751 patients were identified (median age 64 years); 985 (35.8 %) received chemotherapy. Younger age, advanced tumor stage, R1/R2 surgical margins, and lymph node metastasis were all independently associated with receipt of chemotherapy ( p  < 0.05). Following propensity score matching, advanced tumor stage, lymph node metastasis, poorly differentiated tumors, and R1/R2 surgical margins were associated with poorer overall survival (OS) ( p  < 0.05). Median OS comparing patients who received chemotherapy compared with surgery alone was 23 versus 20 months ( p  = 0.09). However, when stratified by lymph node status, chemotherapy demonstrated a significant improvement in median OS among N1 patients (19.8 vs. 10.7 months; p  < 0.001). In contrast, patients with N0 disease derived no benefit from chemotherapy (29.4 vs. 29 months; p  = 0.33). Additional tumor characteristics associated with improved survival with chemotherapy included T3/T4 tumors (21.3 vs. 15.6 months; p  < 0.001) and R1/R2 surgical margins (19.5 vs. 11.6 months; p  = 0.006). Conclusion The use of chemotherapy was associated with a survival benefit only for ICC patients with nodal metastasis, advanced tumor stage, or an inadequate surgical resection. Chemotherapy for resected ICC should be strongly considered for tumors harboring high-risk features.

IntroductionDespite increasing palliative care capabilities in the USA, utilisation rates remain low for patients with advanced cancer, particularly among African American patients. To address this gap, a theory-driven, stakeholder-informed community health worker (CHW) palliative care intervention for African American patients with advanced cancer and their informal caregivers is currently being assessed through a hybrid type 1 effectiveness-implementation trial at four cancer centres across the USA. To improve the quality and efficiency of palliative care delivery, inform resource allocation and guide broad-scale implementation, it is essential to generate evidence on the economic value of palliative care programmes. The objectives of this study are to evaluate the cost-effectiveness and estimate the social value of a CHW palliative care intervention for African American patients with advanced cancer and their caregivers.Methods and analysisWe will conduct cost-effectiveness analyses (CEAs) and a social return-on-investment (SROI) analysis to assess the value of the CHW palliative care intervention compared with enhanced standard of care. Standard, extended and distributional CEAs will be performed from the perspectives of an adopting organisation or payer (eg, Medicaid), the US healthcare sector and society. An SROI analysis will also be conducted to assess the social value of the intervention. These analyses will focus on estimating the costs, health and distributional impacts of the intervention.Ethics and disseminationThis study protocol was approved by the Johns Hopkins Medicine Institutional Review Board (IRB00372476). All methods will be carried out in accordance with relevant guidelines and regulations. Written informed consent will be obtained from all subjects prior to study participation. This manuscript does not contain participant-level data. The full protocol will be available from the corresponding author on reasonable request. The dissemination of findings from the clinical trial and accompanying economic evaluation outlined in this manuscript will be multifaceted to maximise reach and impact. Research findings will be presented at relevant scientific conferences, submitted for publication in peer-reviewed journals and shared with community stakeholders, including hospital leaders and administrators, providers, CHWs and patient advocacy groups.Trial registration number NCT05407844.

Patients with unresectable Colorectal Liver Metastases (CRLM) are increasingly being managed using Hepatic Artery Based Therapies (HAT), including Hepatic Arterial Infusion (HAI), Radioembolization (RE), and Transcatheter Arterial Chemoembolization (TACE). Limited data is available on the comparative effectiveness of these options. We hypothesized that outcomes in terms of survival and toxicity were equivalent across the three strategies. A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013003861) that utilized studies from PubMed (2003-2013). Primary outcome was median overall survival (OS). Secondary outcomes were treatment toxicity, tumor response, and conversion of the tumor to resectable. Additional covariates included prior or concurrent systemic therapy. Of 491 studies screened, 90 were selected for analyses-52 (n = 3,000 patients) HAI, 24 (n = 1,268) RE, 14 (n = 1,038) TACE. The median OS (95% CI) for patients receiving HAT in the first-line were RE 29.4 vs. HAI 21.4 vs. TACE 15.2 months (p = 0.97, 0.69 respectively). For patients failing at least one line of prior systemic therapy, the survival outcomes were TACE 21.3 (20.6-22.4) months vs. HAI 13.2 (12.2-14.2) months vs. RE 10.7 (9.5-12.0). Grade 3-4 toxicity for HAT alone was 40% in the HAI group, 19% in the RE group, and 18% in the TACE groups, which was increased with the addition of systemic chemotherapy. Level 1 evidence was available in 5 studies for HAI, 2 studies for RE and 1 for TACE. HAI, RE, and TACE are equally effective in patients with unresectable CRLM with marginal differences in survival.

Background Historically, malignant peritoneal mesothelioma (MPM) has been considered an aggressive and lethal neoplasm. However, contemporary series have demonstrated improved outcomes following a combination of cytoreductive surgery and intraperitoneal chemotherapy. We sought to assess the trends in management and survival of patients with MPM in the United States. Methods The Surveillance, Epidemiology, and End Results database was used to identify all patients diagnosed with malignant peritoneal mesothelioma from 1973 to 2010. Overall survival (OS) was studied with Kaplan–Meier curves and Cox regression analyses. Results We identified 1,591 patients with MPM. Median age at diagnosis was 64 years (IQR 53–74 years) with the majority of patients presenting with metastatic disease ( n  = 962, 60.5 %). A total of 980 patients (61.6 %) did not receive surgical therapy. Receipt of radical cytoreduction for patients with metastatic MPM demonstrated a significant improvement in OS compared with patients not receiving surgery (20 vs. 4 months, p  < 0.01). A temporal increase was observed in OS for patients receiving surgery (1991–1995: 15 vs. 2006–2010: 38 months, p  = 0.1). In multivariate models, limited (HR 0.55; 95 % CI 0.48–0.63; p  < 0.01) and radical (HR 0.66; 95 % CI 0.54–0.80; p  < 0.01) surgery were independently associated with improved survival. Conclusions In the current era, approximately three of every five patients do not receive surgery when diagnosed with MPM, although a significant survival benefit is noted in select patients. The opportunity to improve patient survival with surgical therapy is lost in a significant number of MPM patients.

Background Duodenal gastrointestinal stromal tumors (GISTs) are a small subset of GISTs, and their management is poorly defined. We evaluated surgical management and outcomes of patients with duodenal GISTs treated with pancreaticoduodenectomy (PD) versus local resection (LR) and defined factors associated with prognosis. Methods Between January 1994 and January 2011, 96 patients with duodenal GISTs were identified from five major surgical centers. Perioperative and long-term outcomes were compared based on surgical approach (PD vs LR). Results A total of 58 patients (60.4 %) underwent LR, while 38 (39.6 %) underwent PD. Patients presented with gross bleeding ( n  = 25; 26.0 %), pain ( n  = 23; 24.0 %), occult bleeding ( n  = 19; 19.8 %), or obstruction ( n  = 3; 3.1 %). GIST lesions were located in first ( n  = 8, 8.4 %), second ( n  = 47; 49 %), or third/fourth ( n  = 41; 42.7 %) portion of duodenum. Most patients ( n  = 86; 89.6 %) had negative surgical margins (R0) (PD, 92.1 vs LR, 87.9 %) ( P  = 0.34). Median length of stay was longer for PD (11 days) versus LR (7 days) ( P  = 0.001). PD also had more complications (PD, 57.9 vs LR, 29.3 %) ( P  = 0.005). The 1-, 2-, and 3-year actuarial recurrence-free survival was 94.2, 82.3, and 67.3 %, respectively. Factors associated with a worse recurrence-free survival included tumor size [hazard ratio (HR) = 1.09], mitotic count >10 mitosis/50 HPF (HR = 6.89), AJCC stage III disease (HR = 4.85), and NIH high risk classification (HR = 4.31) (all P  < 0.05). The 1-, 3-, and 5-year actuarial survival was 98.3, 87.4, and 82.0%, respectively. PD versus LR was not associated with overall survival. Conclusions Recurrence of duodenal GIST is dependent on tumor biology rather than surgical approach. PD was associated with longer hospital stays and higher risk of perioperative complications. When feasible, LR is appropriate for duodenal GIST and PD should be reserved for lesions not amenable to LR.