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Background:Fifty percent of patients with sentinel lymph node (SLN) metastases have no metastatic disease in non-SLNs on axillary lymph node dissection (ALND). The goal of this study is to determine which patients have metastatic disease limited to the SLN, and, therefore, may not require completion ALND. Methods:Of the first 1000 patients undergoing SLN biopsy at Memorial Sloan-Kettering Cancer Center, using a combined blue dye and isotope technique, 231 (26%) had positive SLN. Of these, 206 underwent completion ALND. They are the study group for this report. Results:The likelihood of non-SLN metastasis was inversely related to three clinicopathologic variables: tumor size ≤ 1.0 cm; absence of lymphovascular invasion (LVI); and SLN micrometastases (≤ 2 mm). None of 24 patients with all three predictive factors had non-SLN metastases, whereas 58% of patients with none of the factors had disease in the non-SLN. Conclusion:Patients with small breast cancers, no LVI, and SLN micrometastases have a low risk of non-SLN metastases, and may not require completion ALND.

BackgroundWith the introduction of new molecular-targeted agents, an increasing number of patients with advanced hepatocellular carcinoma (HCC) are benefiting from salvage interventions; however, the actual rate of conversion surgery and its prognostic advantages remain unclear.MethodsThe clinical outcomes of 107 consecutive patients who underwent lenvatinib treatment for advanced HCC were reviewed and the efficacy of additional therapy, including surgery, was investigated.ResultsOf the 107 patients who were initially unsuitable for curative-intent therapy or transarterial chemoembolization (TACE), 54 (50.5%) received further therapy after lenvatinib treatment (surgery [n = 16] and TACE or other treatments [n = 38]). Of the 16 patients who received surgical intervention, R0 resection was achieved in 9 (8.4%) patients. Survival analysis confirmed that successful conversion to R0 resection was associated with a longer time to treatment failure (hazard ratio [HR] 0.04, 95% confidence interval [CI] 0.01–0.29; p = 0.002) and better disease-specific survival (HR 0.04, 95% CI 0.01–0.30; p = 0.002) compared with no additional treatment, while additional treatment other than surgery or R2 resection was associated with only a marginal or no prognostic advantage. Multivariate analysis confirmed that a decrease in plasma des-gamma-carboxyprothrombin levels compared with baseline levels (odds ratio 22.22, 95% CI 3.42–144.29; p = 0.001) was significantly correlated with successful R0 resection after lenvatinib treatment, irrespective of the tumor response as assessed by imaging analysis.ConclusionsIn selected patients with advanced HCC, conversion surgery after lenvatinib treatment may offer significant survival benefit as long as R0 resection is achieved.

BackgroundRecurrent esophageal cancer after radical therapy usually is thought to be incurable and treated with palliative-intent systemic therapy. However, it is empirically known that surgical resection may be effective for selected patients, although no consensus exists on the efficacy of surgery for recurrent esophageal cancer. This study sought to identify a group of patients for whom surgical resection is considered effective.MethodsThe study enrolled 206 patients at a single center who had recurrence after radical therapy for esophageal cancer. Prognostic factors after recurrence were identified, and efficacy of surgery was analyzed according to whether the recurrent lesions were oligometastases (i.e., ≤ 5 lesions in a single domain) or not.ResultsIn the multivariate analysis, oligometastatic presentation was the only factor associated with survival after recurrence (hazard ratio 6.29; 95% confidence interval, 4.10–9.71). The actuarial survival rates for the patients with oligometastases were 59.5% at 3 years and 51.7% at 5 years. The survival rates at 3 and 5 years were significantly higher for the patients who underwent resection (64.3% and 55.6%, respectively) than for those who did not (both 100%) and for the patients with multiple metastases (9.8% and 0%, respectively). The survival rates for the patients who had oligometastases without resection were comparably lower than for the patients with multiple metastases.ConclusionOligometastatic presentation at recurrence was associated with better survival outcomes for the patients who experienced recurrence after radical treatment for esophageal cancer, and surgical resection could be a choice of treatment for this group of patients.

Background Currently used treatment algorithms were originally established based on the clinical outcomes of the initial treatment for primary hepatocellular carcinoma (HCC), and no strong evidence exists yet to suggest if these algorithms could also be applicable to patients with recurrent HCC after surgery. As such, this study sought to explore an optimal risk stratification method for cases of recurrent HCC for better clinical management. Methods Among the 1616 patients who underwent curative resection for HCC, the clinical features and survival outcomes of 983 patients who developed recurrence were examined in detail. Results Multivariate analysis confirmed that both the disease-free interval (DFI) from the previous surgery and tumor stage at recurrence were significant prognostic factors. However, the prognostic impact of DFI seemed different according to the tumor stages at recurrence. While curative-intent treatment showed strong influence on survival [hazard ratio (HR), 0.61; P < 0.001] regardless of the DFI in patients with stage 0 or stage A disease at recurrence, early recurrence (< 6 months) was a poor prognostic marker in patients with stage B disease. The prognosis of patients with stage C disease was exclusively influenced by the tumor distribution or choice of treatment than by the DFI. Conclusions The DFI complementarily predicts the oncological behavior of recurrent HCC, with its predictive value differing depending on the tumor stage at recurrence. These factors should be considered for selection of the optimal treatment in patients with recurrent HCC after curative-intent surgery.

BackgroundOptimal choice of surgical procedure for hepatocellular carcinoma (HCC) remains inconclusive. This study seeks to investigate the oncological superiority of anatomic resection (AR) of the tumor-bearing portal territory and potential mechanism of survival benefit for patients undergoing AR.Patients and MethodsIn 203 patients who underwent curative resection for primary solitary HCC measuring ≤ 5 cm in diameter, which was resectable either by AR or limited resection (non-AR), long-term outcomes were compared with propensity score adjustment. Advantages of AR in local tumor control and postprogression survival were then evaluated by a multivariate analysis and a Markov model.ResultsThe AR group showed better recurrence-free survival [hazard ratio (HR), 0.51; 95% CI, 0.28–0.91; P = 0.023), time-to-interventional failure (TIF) (HR, 0.08; 95% CI, 0.01–0.60; P = 0.014), and overall survival (HR, 0.11; 95% CI, 0.01–0.79, P = 0.029) than the non-AR group. Competing-risks regression revealed that AR significantly decreases local recurrence (HR, 0.13; 95% CI, 0.02–0.97; P = 0.047) and is correlated with smaller number and size of recurrent lesions, both of which were predictors for better TIF and postprogression survival. A Markov model demonstrated that annual transition rate from the early recurrence stage (i.e., curative-intent treatment indicated) to the intermediate stage (i.e., only palliative-intent treatment indicated) was significantly lower (9.0% versus 35.6%, P = 0.027) when AR was completed at the initial hepatectomy.ConclusionsAR is oncologically advantageous for patients with primary solitary HCC. Initial choice of surgical procedure may have significant influence on the pattern of recurrence and postprogression clinical course that may affect overall survival of patients with HCC.

Purpose This study sought to investigate the clinical impact of repeated interventions for recurrent hepatocellular carcinoma (HCC) and to establish a new surrogate measure for survival: the time-to-interventional failure (TIF). Methods Based on a retrospective review of 1158 patients who underwent curative resection for HCC, the abilities of recurrence-free survival (RFS) and TIF, which was defined as the elapsed time from resection to unresectable/unablatable recurrence, to predict overall survival (OS) were compared. Results Within a median follow-up period of 84.9 months, 676 (59.0%) recurrence events occurred, 78.1% of which were resectable/ablatable recurrences. Of these, 99.1% of the patients underwent repeated treatments. TIF had a stronger correlation than RFS ( r  = 0.921 vs. r  = 0.631) in prediction of OS. Patients who underwent curative-intent treatment (i.e., resection or ablation) for recurrence showed significantly better survival outcomes compared with those who underwent non-curative treatment (e.g., TACE, chemotherapy) (median OS, 89.1 months vs. 55.0 months; P  < 0.0001). This tendency was constant across the AJCC stages and multivariate analysis confirmed that curative-intent treatment is associated with improved survival after initial recurrence (hazard ratio, 0.55; 95% CI, 0.37–0.81; P  = 0.003). Conclusions OS after HCC resection is more strongly dependent on TIF than on RFS. Aggressive curative-intent interventions for recurrent HCC may prolong survival regardless of the cancer stage.

Background Adhesion barriers are increasingly used in hepatobiliary surgery. However, there has been no solid evidence yet in support of their safety. Methods Incidences of global postoperative morbidities and major abdominal morbidities were compared between 101 consecutive patients who received a sheet-type adhesion barrier (Interceed ® ) and 134 patients who did not receive any adhesion barriers during hepatectomy. Propensity score (PS) adjustment was used to account for potential bias to receive Interceed. Results In the PS-adjusted population, the incidences of both global postoperative morbidities and major abdominal morbidities showed no significant difference between the Interceed group and the control group (17.9% vs. 17.6%; P  = 0.948 and 7.8% vs. 9.1%; P  = 0.813, respectively). Multivariate analysis showed that age + 10 years (odds ratio [OR], 1.70; 95% CI, 1.15–2.50; P  = 0.007), estimated blood loss + 100 mL (OR, 1.05; 95% CI, 1.01–1.09, P  = 0.009), and laparoscopic approach (OR, 0.10; 95% CI, 0.01–0.75; P  = 0.026) were independent predictors for global postoperative morbidities and operation time + 1 h (OR, 1.56; 95% CI, 1.23–1.96; P  < 0.001) was a risk factor for major abdominal morbidity, while no specific association between the use of Interceed and the risk of postoperative morbidity was observed. Conclusions Use of Interceed does not increase the risk of postoperative morbidities after hepatectomy.

Background Preoperative nutritional status is reportedly associated with the clinical outcomes in patients with colorectal cancer (CRC), although it remains inconclusive whether the preoperative nutritional status that may improve after surgery is truly predictive of the survival outcomes of patients with CRC. Methods Clinical records of patients with stage III CRC ( n  = 821) in whom curative resection had been achieved were retrospectively reviewed and the prognostic impact of nutritional status, determined by the controlling nutritional status (CONUT) score, was analyzed. Results The CONUT undernutrition grade was significantly associated with the overall survival rate (OS) in the original population ( P  < 0.0001). By adopting a cut-off value of CONUT score of ≥ 2 and adjustment for clinical variables using the inverse probability treatment weighting methods, the group with a preoperative CONUT score of ≥ 2 showed a worse OS as compared to the groups with a preoperative CONUT score of < 2 ( P  = 0.037). However, sub-analysis based on the dynamic changes in the CONUT score revealed that sustained malnutrition in the postoperative period was more frequent among patients with preoperative CONUT score of ≥ 2, and that the OS and recurrence-free survival rate (RFS) were significantly correlated with the “postoperative” nutritional status, irrespective of the preoperative nutritional status. Patients who showed improvements of the nutritional status after surgery showed a significantly longer OS and RFS. Conclusions Sustained undernutrition or worsening of the nutritional status after colectomy may be associated with a worse OS and RFS after curative resection in patients with stage III CRC.

BackgroundBody composition data are reportedly correlated with patient prognosis for various cancers. However, little is known about the prognostic impact of adipose tissue distribution among patients with hepatocellular carcinoma (HCC).MethodsData for 181 consecutive cirrhotic patients who underwent hepatectomy for HCC were retrospectively reviewed. The clinical significance of the visceral-to-subcutaneous adipose tissue ratio (VSR) was investigated through analysis of short- and long-term surgical outcomes.ResultsOf the 181 patients, 60 (33%) were classified as the high-VSR group and 121 (67%) as the low-VSR group. Although VSR was not correlated with a risk of postoperative morbidity, multivariate analysis confirmed that a higher VSR was significantly correlated with a shorter time to interventional failure (hazard ratio [HR] 2.24; P = 0.008) and overall survival (HR 2.65; P = 0.001) independently of American Joint Committed on Cancer stage or preoperative nutritional status. Analysis of the recurrence patterns showed that the proportion of unresectable recurrence at the initial recurrence event was significantly higher in the high-VSR group (39% vs. 18%; P = 0.025). The yearly transition probabilities, defined by a Markov model from postoperative R0 status to advanced disease or death (7.6% vs. 1.5%, P < 0.001) and early recurrence stage to advanced disease or death (15.4% vs. 2.8%, P = 0.004), were higher in the high-VSR group, suggesting that patients with a higher VSR are vulnerable to disease progression.ConclusionA high VSR was found to be an independent predictor of disease progression and poor prognosis for HCC patients with underlying liver cirrhosis having resection for HCC.

Background Patients with esophageal cancer often feel depression or fear of death influenced by multiple clinical factors. This study sought to investigate the clinical factors associated with psychological distress, focusing on the influence of health-related quality of life (HRQOL) for better psychological management of patients with esophageal cancer. Methods In total, 102 of 152 consecutive patients surgically treated at Toranomon Hospital met the eligibility criteria for analysis. Questionnaires designed to identify psychological distress and QOL (EORTC QLQ C-30/OES18) were administered at five time points during the treatment course. Degree of psychological distress was assessed by Hospital Anxiety and Depression Scale (HADS). Results Patients with HADS score ≥ 11 at each visit showed significantly higher level of symptoms or problems measured by the score of EORTC QLQ C-30/OES18 compared with those with HADS score ≤ 10. Emotional status was a significant factor associated with psychological distress at all times. Although functional scales including global health status or QOL status and symptom scales associated with esophageal cancer were strongly associated with psychological distress before treatment, scales associated with changes in habitus after esophagectomy showed significant correlation with psychological distress after surgery. No significant correlation was observed between psychological distress and individual baseline characteristics, apart from history of surgery and pathological staging. Conclusions Psychological distress during treatment course of esophageal cancer is significantly associated with HRQOL influenced by esophagectomy. The current results may warrant prospective intervention through enhanced recovery after surgery to better manage patients undergoing highly invasive procedures for esophageal cancer.