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The management of the primary tumor in metastatic colorectal, gastric and pancreatic cancer patients may be challenging. Indeed, primary tumor progression could be associated with severe symptoms, compromising the quality of life and the feasibility of effective systemic therapy, and might result in life-threatening complications. While retrospective series have suggested that surgery on the primary tumor may confer a survival advantage even in asymptomatic patients, randomized trials seem not to definitively support this hypothesis. We discuss the evidence for and against primary tumor resection for patients with metastatic gastrointestinal (colorectal, gastric and pancreatic) cancers treated with systemic therapies and put in context the pros and cons of the onco-surgical approach in the time of precision oncology. We also evaluate current ongoing trials on this topic, anticipating how these will influence both research and everyday practice.

Background The main aim of this study was to compare short-term results and long-term outcomes of patients who underwent intraoperative colonic lavage (IOCL) with primary anastomosis with those who had stent placement prior to scheduled surgery for obstructive left-sided colonic cancer (OLCC). Methods We conducted a prospective, controlled, randomized study of patients diagnosed with OLCC. Patients were divided into two groups: stent and deferred surgery (group 1) and emergency IOCL (group 2). Demographic variables, risk prediction models, postoperative morbidity and mortality, staging, complications due to stent placement, surgical time, clinical follow-up, health costs, and follow-up of survival were recorded. Results Twenty-eight patients (15 group 1 and 13 group 1) were enrolled. The study was suspended upon detecting excess morbidity in group 2. The two groups were homogeneous in clinical and demographic terms. Overall morbidity in group 1 was 2/15 (13.3%) compared with 7/13 (53.8%) in group 2 ( p  = 0.042). None of the 15 patients in group 1 presented anastomotic dehiscence compared with 4/13 (30.7%) in group 2 ( p  = 0.035). Surgical site infection was detected in 2 (13.3%) patients in group 1 and in 6 (46.1%) in group 2 ( p  = 0.096). Postoperative stay was 8 days (IQR 3, group 1) and 10 days (IQR 10, group 2) ( p  = 0.05). The mean follow-up period was 37.6 months (SD = 16.08) with no differences in survival between the groups. Conclusion In our setting, the use of a stent and scheduled surgery is safer than IOCL and is associated with lower morbidity, shorter hospital stay, and equally good long-term survival.

ObjectiveThe aim of this study was to investigate the prognostic role of plasma platelet count (PLT), mean platelet volume (MPV), and the combined COP-MPV score in patients with resectable adenocarcinomas of the gastroesophageal junction.BackgroundPlatelet activation, quantified by PLT and elevated MPV, plays an essential part in the biological process of carcinogenesis and metastasis. An increased preoperative COP-MPV is associated with poor survival in various tumor entities.MethodsData of 265 patients undergoing surgical resection for adenocarcinoma of the gastroesophageal junction were abstracted. COP-MPV score was defined for each patient. Utilizing univariate and multivariate Cox proportional hazard analyses, survival was determined.ResultsIn univariate analysis, elevated PLT (HR 3.58, 95% CI 2.61–4.80, p<0.001) and increased COP-MPV (HR 0.27, 95% CI 0.17–0.42, p<0.001 and HR 0.42, 95% CI 0.29–0.60, p<0.001) significantly correlated with shorter patients’ overall and disease-free survival, for all 256 patients, as well as in the subgroups of neoadjuvantly treated (p<0.001) and primarily resected patients (p<0.001). COP-MPV remained a significant prognostic factor in multivariate analysis for OS. However, PLT alone showed significant diminished OS and DFS in all subgroups (p<0.001) in univariate and multivariate analysis.ConclusionPLT is a potent independent prognostic biomarker for survival in a large prospective cohort of patients with resectable adenocarcinoma of the gastroesophageal junction. Additionally, we confirm that the COP-MPV score is significantly associated with worse outcome in these patients, but has no benefit in comparison to PLT.

Background In non-small cell lung cancer (NSCLC), patients with extrathoracic metastases typically have a poor prognosis, with systemic chemotherapy being the standard care. The full potential of primary resection therapy (PRT) in these patients, especially during the immunotherapy era, is not fully established. Additionally, the effectiveness of systemic preoperative therapy in this context is unclear. Methods This retrospective study identified NSCLC patients with extrathoracic metastases from the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019. We compared the survival rates of those treated with just chemotherapy vs those receiving both chemotherapy and PRT. Results In a study of 41 909 patients with extrathoracic metastatic NSCLC receiving chemotherapy, we found that adding PRT significantly increased overall survival (median OS post-PSM: 18 months vs 11 months, P < 0.001). However, in the immunotherapy era, its effectiveness was less pronounced (HR: 0.56 vs 0.7, P for interaction = 0.011). For patients who have metastases to multiple distant organs, combined distant organ and distant lymph node metastases, or lung metastases, no additional survival benefit from PRT was observed (all P > 0.05). Patients receiving systemic preoperative therapy before PRT had significantly better outcomes than those who did not (HR = 0.69, P < 0.001). A predictive nomogram was developed and validated, showing AUCs of 0.751 and 0.766 in the training and test sets. Conclusion In both pre- and post-immunotherapy eras, patients with extrathoracic metastatic NSCLC benefit more from adding primary tumor resection to chemotherapy, especially those with preoperative systemic therapy. We created a precise nomogram to identify the best candidates for PRT among patients with extrathoracic NSCLC metastases.

Background Sigmoid volvulus is the commonest cause of large bowel obstruction in many regions of the world. Its prevalence varies greatly geographically. In Ethiopia, the disease is the commonest cause of emergency admissions due to intestinal obstruction. However, few studies have been conducted discussing the management outcome in Ethiopia and Africa. This research was conducted to assess the pattern & management outcome of acute sigmoid volvulus at a district hospital in South-west Ethiopia. Methods A facility based retrospective cross-sectional review of surgical records was done to identify patients who had acute sigmoid volvulus. Data was collected using structured questionnaire by three pre trained data collectors. The collected data was checked for its completeness, and then entered, edited, cleaned and analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0. For all statistical significance tests the cut-off value set was P  < 0.05. Result A total of 131 patients were managed for acute sigmoid volvulus. 108 (82.4%) were men with a male to female ratio of 4.7:1. The hospital prevalence of acute sigmoid volvulus was 27.9%. Majority (42%) of the patients were in the 6th decades of life. Abdominal pain, abdominal distention & inability to pass feces & flatus were the predominant presenting compliant while abdominal distention was the dominant physical finding in all of the patients. Ninety-seven patients (74%) had viable bowel obstruction of which 29 patients had successful rectal tube deflation. The remaining 68 patients were managed operatively by either primary resection & anastomosis (62 patients) or derotation alone (6 patients). Thirty-four patients had gangrenous bowel obstruction and were managed by either primary resection and anastomosis (16 patients) or Hartman’s colostomy (18 patients). Six patients died of which 5 had primary resection and anastomosis (2 for viable and 3 for gangrenous bowel obstruction).The predominant postoperative complication was wound infection in 11(10.7%) patients. Factors associated with unfavorable outcome were female sex, primary resection & end to end anastomosis and presentation of illness more than 24 h. Conclusion The most common management was primary resection and anastomosis. The overall mortality rate was 4.5% and the mortality rate related to primary resection and end to end anastomosis was 6.4%. Mortality rate was higher in those patients who had resection and anastomosis for gangrenous bowel compared to those who had viable bowel (19% vs 3%). Generally factors associated with poor outcome were duration of illness, primary resection and anastomosis and being female.

Background/Aims: The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. Methods: Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. Results: In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients >70 years, but mortality rates up to 32.2% were observed in high-risk elderly patients. Conclusion: Acute resection as first choice treatment seems justified for patients >70 years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.

Background:Surgery and imatinib are the mainstays of the management of gastrointestinal stromal tumours (GIST). This study aimed to analyse the outcomes in the management of GIST utilising surgery and imatinib.Methods:Progression-free survival (PFS) and overall survival (OS) were analysed in relation to imatinib therapy, location of tumour, resection margins, type and extent of surgery. Imatinib was administered in the neoadjuvant (maximum 12 months) and adjuvant setting (minimum 36 months) and until disease progression or drug intolerance. Disease response was assessed with the Choi criteria. Survival analysis included calculation of PFS, OS and Kaplan–Meier curves.Results:Sixty-two patients were reviewed and 56 had surgical resection. The median age (range) was 58.5 (8–95) years. The median PFS and OS (IQR) was 24.0 (0–52.0) and 41.0 (15.0–74.0) months, respectively. Thirty-nine (70%) patients were treated with imatinib, with 21 of these in a neoadjuvant setting. In the patients undergoing surgery, surgical margins were R0, R1 and R2 in 41 (75%), eight (15%) and six (11%) respectively. There was an insignificant difference in the overall survival in these three groups. For those having liver metastasectomy and multivisceral resection, the PFS and OS were 32.5 (17.5–60.3) and 28.5 (5.75–49.8) (p = 0.008), and 96.0 (58.5–116) and 80 (50.5–92.3) months (p = 0.033), respectively.Conclusion:Whilst the numbers were small, certain trends were observed. Surgery in combination with imatinib offers survival benefit in patients undergoing R0, R1, R2, liver metastases and multivisceral resections.

(1) Background: Delay in therapy for pancreatic ductal adenocarcinoma (PDAC) may contribute to a worse outcome. The aim of this study was to investigate the prognostic value of time from diagnosis to surgery in patients undergoing upfront surgery for primarily resectable pancreatic carcinoma. (2) Methods: This retrospective single-center study included 214 patients who underwent primary resection of PDAC from January 2000 to December 2018 at University Hospital Erlangen. Using a minimum p-value approach, patients were stratified according to time to surgery (TtS) into two groups: TtS ≤ 23 days and TtS > 23 days. Postoperative outcome and long-term survival were compared. (3) Results: Median TtS was 25 days. The best cut-off for TtS was determined as 23 days. There were no differences regarding postoperative outcome or overall survival (OS) and disease-free survival (DFS) (OS: 23.8 vs. 20.4 months, p = 0.210, respectively, and DFS: 15.8 vs. 13.6 months, p = 0.187). Multivariate analysis revealed age, lymph node metastasis, tumor differentiation and resection status as significant independent prognostic predictors for OS and DFS. (4) Conclusions: A delay of surgery > 23 days after first diagnosis does not affect overall or disease-free survival of patients with primary resectable PDAC. However, the psychological impact of a delay to patients waiting for surgery should not be underestimated.

We aimed to assess the survival benefits of primary tumor resection (PTR) followed by chemotherapy in patients with asymptomatic stage IV colorectal cancer with asymptomatic, synchronous, unresectable metastases compared to those of upfront chemotherapy alone. This was an open-label, prospective, randomized controlled trial (ClnicalTrials.gov Identifier: NCT01978249). From May 2013 to April 2016, 48 patients (PTR, n = 26; upfront chemotherapy, n = 22) diagnosed with asymptomatic colorectal cancer with unresectable metastases in 12 tertiary hospitals were randomized (1:1). The primary endpoint was two-year overall survival. The secondary endpoints were primary tumor-related complications, PTR-related complications, and rate of conversion to resectable status. The two-year cancer-specific survival was significantly higher in the PTR group than in the upfront chemotherapy group (72.3% vs. 47.1%; p = 0.049). However, the two-year overall survival rate was not significantly different between the PTR and upfront chemotherapy groups (69.5% vs. 44.8%, p = 0.058). The primary tumor-related complication rate was 22.7%. The PTR-related complication rate was 19.2%, with a major complication rate of 3.8%. The rates of conversion to resectable status were 15.3% and 18.2% in the PTR and upfront chemotherapy groups. While PTR followed by chemotherapy resulted in better two-year cancer-specific survival than upfront chemotherapy, the improvement in the two-year overall survival was not significant.

Colorectal cancer (CRC) with reduced expression of the homeobox transcription factor CDX2, a master gene essential for the development and maintenance of the intestinal tract, is known as a poor prognosis subtype of CRC. The recurrence rate is high in patients with CDX2 CRC. However, the prognostic significance of CDX2 in advanced CRC is unclear. This study aimed to elucidate the prognostic significance of CDX2 in unresectable metastatic CRC (mCRC). Twenty-nine patients with unresectable mCRC who underwent primary site resection at the Kobe University Hospital during a 6-year period from January 2008 to January 2015 were included. The tissues from those patients were immunohistochemically stained with anti-CDX2 antibody (clone: CDX2-88). The patients were divided into CDX2 CRC group and CDX2 CRC group and their prognoses were analyzed. There were no clear differences in background between the two groups. A low CDX2 expression was associated with reduced overall survival (37.67 months vs. 25.32 months, p=0.03) and tended to associate with reduced progression-free survival (17.4 months vs. 12.9 months, p=0.37). Two patients received chemotherapy after resection of the primary lesion and obtained pathological complete response. CDX2 expression might be a possible prognostic biomarker for unresectable mCRC.