Perioperative Outcomes from a Phase II Study of Robotic Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Patients with Gastric Cancer and Limited Peritoneal Metastasis: ROBO-CHIP Trial - Annals of Surgical Oncology Introduction Traditional open cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal limited metastatic gastric cancer (GC) is associated with significant morbidity and prolonged recovery. We hypothesized that a robotic approach may significantly reduce postoperative recovery. Patients and Methods Prospective phase II, single-arm trial conducted in patients with synchronous, low volume (PCI ≤ 7) peritoneal limited metastatic GC who had completed ≥ 4 months of systemic chemotherapy were enrolled. Patients were treated with laparoscopic HIPEC followed by robotic cytoreduction, gastrectomy, and HIPEC with 175 mg/m2 paclitaxel and 100 m2/mg cisplatin. The primary end point was hospital length of stay (LOS). The secondary outcomes were 90-day postoperative complications, readmission, reoperations, and mortality. Results Between January 2023 and March 2025, 20 patients met eligibility criteria and were enrolled. Two patients subsequently progressed and were deemed ineligible for complete cytoreduction and were thus excluded leaving 18 evaluable patients. A total of 2 patients had positive peritoneal cytology only, and 16 had peritoneal carcinomatosis. Patients completed a median of 9 (IQR 8–10) cycles of neoadjuvant chemotherapy, most (72.2.%) commonly FOLFOX +/− nivolumab. The median peritoneal carcinomatosis index (PCI) at CRS/Gastrectomy and HIPEC was 6 (IQR 3–7). A complete cytoreduction was achieved in 100%. The median blood loss was 300 ml (IQR 200–450 ml) and the red blood cell (RBC) transfusion rate was 22.2%. The median operative time was 688 min (642–722 min) and the primary end point of hospital LOS was 5 days (4–6). The 90-day major morbidity, and readmission rate was 38.9% and 27.8%. There was a single (5.6%) 90-day reoperation and death. There were negligible risks attributed to HIPEC with only two (11.1%) grade IV cytopenia and one (5.9%) acute kidney injury. Conclusions Robotic cytoreduction, gastrectomy, and HIPEC for low volume peritoneal limited metastatic gastric cancer, in this highly selected patient population, is associated with favorable outcomes such as decreased hospital LOS and less blood loss/blood transfusions compared with the open approach in the literature. We continue to enroll and follow patients to assess long-term oncologic outcomes.

Robotic Surgery for Limited Peritoneal Metastatic Gastric Cancer Yields Positive Outcomes

by Buckarma E, Steadman J (...) Grotz TE et 3 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Diverticulitis Admissions Show Seasonal Patterns Worldwide

by Cheng E, Yeh D (...) Sarofim M et 3 al. in JAMA Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Preoperative Biliary Drainage with Metal Stent Versus Early Surgery in Patients with Pancreatic Cancer: A Randomized Clinical Trial - Annals of Surgical Oncology Background Among patients with pancreatic cancer and biliary obstruction planned for pancreaticoduodenectomy, preoperative biliary drainage (PBD) may be considered during surgical delays. Higher complication rates have been reported for PBD using plastic stents versus early surgery. PBD with a self-expanding metal stent (SEMS) has not been compared with early surgery in a randomized controlled trial (RCT). Patients and Methods We conducted a noninferiority RCT comparing PBD using a SEMS versus early surgery at 11 centers in 9 countries. We enrolled patients with resectable pancreatic or periampullary cancer and serum total bilirubin level ≥ 5.8 mg/dL, scheduled for primary resection. Primary endpoint was the proportion of patients reporting ≥ 1 serious adverse event (SAE) 120 days post-randomization. Secondary endpoints included rate of SEMS insertion, rate of curative-intent resection, and all-cause mortality. Results Among 284 patients, 144 were randomized to PBD and 140 to early surgery. In the modified intention-to-treat primary endpoint analysis, ≥ 1 SAE(s) occurred in 29.0% (40/138) in the PBD group and 26.5% (36/136) in the early surgery group (between-group difference, 2.5%; one-sided upper 95% confidence limit, 11.7%; P = 0.011 for noninferiority). Among 144 PBD patients, 140 (97.2%) received a SEMS; 119 (82.6%) underwent surgery with curative intent. Among 140 early surgery patients, 14 (10.0%) underwent ERCP and drainage; 130 (92.9%) underwent surgery with curative intent in 115 (88.5%). During follow-up, 7.9% (11/138) in the PBD group and 8.0% (11/136) in the early surgery group died. Conclusion Safety following PBD using SEMS was noninferior to early surgery for pancreatic or periampullary cancer. ClinicalTrials.gov, no. NCT01774019.

Preoperative Biliary Drainage with Metal Stents Safe in Pancreatic Cancer

by Costamagna G, Reddy DN (...) Lau J et 13 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Robotic Distal Splenopancreatectomy and Left Nephrectomy: Double Docking for En Bloc Resection of Pancreatic Cancer - Annals of Surgical Oncology Background Robotic approach has been demonstrated as a safe option for selected patients undergoing left pancreatectomy.1 Nevertheless, robotic approach is still uncommon in case of multivisceral resections involving the pancreas.2,3 We describe a reproducible distal splenopancreatectomy with en bloc left kidney resection for the treatment of pancreatic cancer. Patient and Methods An 81-year-old male patient was diagnosed with adenocarcinoma in the tail of the pancreas with renal infiltration. After completing neoadjuvant therapy with Gem-Abraxane, with a good response, a decision was made to perform resective surgery using a robotic approach. The teams of urology and pancreatic surgery collaborated to perform the procedure. The approach prioritized an en bloc resection with negative margin. Early identification of the renal hilum and kidney mobilization from the inferior and lateral margin facilitated further en bloc mobilization. Results Following partial kidney mobilization, the patient’s position and trocar placement were modified. The splenic artery was sectioned, and the pancreatic body was mobilised. It was then sectioned to the left of the pancreatic neck, together with the splenic vein, using an endostapler. Finally, the pancreatic tail, upper renal pole, and spleen were mobilized en bloc without detaching the three organs. The patient was discharged on postoperative day 6. Pathology results showed a T4 pancreatic adenocarcinoma with kidney invasion and two out of 26 lymph nodes involved. Conclusions The involvement of a multidisciplinary team and the option of re-docking in complex robotic procedures reduces the conversion risk and offers patients benefits by ensuring oncological radicality.

Robotic en bloc resection for pancreatic cancer is safe.

by González-Abós C, Mercader C, Musquera M and Ausania F in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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High Satisfaction in Mentor-Mentee Surgical Programs

by Kehagias D, Popoiu T (...) Portelli M et 3 al. in Am J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Surgical availability impacts patient care decisions in urgent cases.

by Abid M, Holmes GM and Charles A in J Surg Res #Surgery #SurgSky #GeneralSurgery #MedSky

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The Clip-Pulley Maneuver: Atraumatic and Adjustable Retraction in Robotic Liver Resection - Annals of Surgical Oncology Background Precise liver retraction is essential in robotic hepatectomy. Conventional retraction methods using barbed sutures1,2 or hook-needle systems3 are penetrative and traumatic, risking diaphragmatic injury or tension pneumothorax. We developed a nonpenetrating Clip-Pulley Maneuver (CPM) to achieve safe and adjustable retraction. Materials and Methods From February to November 2025, 26 robotic hepatectomies were performed using CPM. A 3-0 polydioxanone monofilament (PDS; Ethicon, Inc., Bridgewater, NJ, USA) was placed on the liver surface at the resection margin. After suture placement, a triangular clip from the Internal Organ Retractor system (Aesculap, Inc., Center Valley, PA, USA) was introduced and the suture passed through its loop. The clip was then positioned on the diaphragm using a dedicated applicator. The suture was exteriorized through the abdominal wall using an Endo Close device (MC Medical Inc., Tokyo, Japan), forming a pulley-like system. The surgeon adjusted the traction force externally, and the assistant could reposition the clips to modify retraction direction. The direction of traction is determined by the spatial relationship between the suture placement on the liver surface and the clip position, rather than by the direction of external pulling. This setup allowed real-time, atraumatic retraction without additional punctures to the diaphragm or peritoneum. In most cases, two clips were sufficient; additional clips may be used for larger anatomical resections. Results There were no CPM-related complications or Clavien–Dindo grade III or higher events. The diaphragm remained intact in all cases. Conclusions CPM offers a safe, effective, and reusable liver retraction method for robotic hepatectomy.

Improved Liver Retraction in Robotic Hepatectomy

by Ashida R, Sugiura T (...) Uesaka K et 4 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Total Neoadjuvant Therapy Hurts Survival in Rectal Cancer

by Ito K, Jain AJ (...) Chun YS et 5 al. in BMC Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Efficacy and Safety of Tranexamic Acid in Solid Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials with GRADE Assessment - Annals of Surgical Oncology Background There is a significant risk of blood loss and transfusion requirements during surgeries for different cancers, raising perioperative morbidity and mortality. The antifibrinolytic drug tranexamic acid (TXA) has been studied to address this issue, but the results remain conflicting. This systematic review and meta-analysis pools all available evidence regarding the use of this medication in cancer surgeries. Patients and Methods The PubMed, Scopus, Web of Science, and Cochrane CENTRAL databases were used for data retrieval until 29 April 2025. Any randomized controlled trial involving surgical patients with cancer who received TXA as the intervention was included. The main addressed outcomes were perioperative blood loss, transfusion requirements, and complications. Study quality and evidence certainty were appraised with the Cochrane RoB 2.0 tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Results A total of 16 RCTs with 1830 patients were analyzed. TXA markedly reduced total, intraoperative, and postoperative blood loss compared with control. Hemoglobin changes were also smaller in the TXA group. Intraoperative blood component and perioperative red blood cell transfusions were lower with TXA. TXA was also linked to a modest reduction in operative time. No significant differences were observed between the groups for perioperative complications, reoperation rate, in-hospital or 30-day mortality, and length of hospital stay. GRADE assessments for the outcomes were mainly moderate or low, except for two that had very low certainty. Conclusions TXA appears to statistically improve perioperative outcomes in cancer surgeries while maintaining a favorable safety profile.

Tranexamic Acid Cuts Blood Loss in Cancer Surgeries

by Soliman A, Azim AAA (...) Qutob IA et 6 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Validation of Textbook Outcome in Gastric Surgery (TOGS) for Primary Gastric Cancer in an Eastern High-Volume Center - Annals of Surgical Oncology Background Textbook Outcome defines the ideal perioperative course after surgery. A specific Textbook Outcome in Gastric Surgery (TOGS) was developed in Western centers; however, its validation among Eastern patients has rarely been investigated. We assessed its achievement in a Korean cohort and identified its predictors. Methods We included adults who underwent curative distal or total gastrectomy for gastric cancer (GC) between 2013 and 2023. TOGS consisted of three surgical criteria (no intraoperative complications, R0 resection, and adequate lymphadenectomy: > 20 nodes in subtotal and > 25 in total gastrectomy) and four postoperative criteria (no re-intervention, no unplanned intensive care unit stay, no unplanned 90-day readmission or mortality). Results Of the 5806 patients with GC enrolled, 4338 (74.7%) achieved the TOGS, with rates of 77.9% for stage I tumors and 68.8% for stages II–III. The TOGS rate declined with age, from 82.3% in patients aged < 40 years to 67.5% in those aged >80 years, with hospital readmission being the strongest negative predictor of its achievement in the elderly. Several factors were independently associated with a higher likelihood of TOGS: early lesions (P = 0.003), female sex (P < 0.001), recent surgery (P = 0.024), distal gastrectomy (P < 0.001), and minimally invasive approach (P < 0.001). Patients with TOGS had shorter hospital stays (P = 0.014) and improved 5-year overall survival (87.6%, vs. 75.6%, P < 0.001), independent of the pathological stage (stage I, P < 0.001; stages II–III, P < 0.001). Conclusions The new definition of TOGS provides valuable insights into the quality of surgical care for patients with GC and has a strong impact on oncological outcomes, including in Eastern patients.

Validation of Textbook Outcome in Gastric Cancer Surgery

by Carbone L, Cho YS (...) Lee HJ et 13 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Navigating Role Ambiguity in Surgical Education

by Cha JS, Tucker EL, Lauer KV and Smith B in J Am Coll Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Prehospital Whole Blood Transfusion Not Superior in Trauma

by Smith JE, Cardigan R (...) Green L et 22 al. in N Engl J Med #Surgery #SurgSky #GeneralSurgery #MedSky

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Preoperative Low-Energy Diets May Reduce Surgical Risks

by McKechnie T, Kuszaj O (...) Bhandari M et 15 al. in Br J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Pre-hospital deaths dominate trauma fatalities in urban systems

by Nijhawan A, Ter Avest E (...) Perkins ZB et 6 al. in Br J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Obesity Linked to Higher Cancer Rates: Significant Implications for Surgery

by Shen S, Brown KA, Green AK and Iyengar NM in JAMA #Surgery #SurgSky #GeneralSurgery #MedSky

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Gravity Modeling to Predict Patient Choice of Hospital for Pancreaticoduodenectomy - Annals of Surgical Oncology Background Prior studies simulating how regionalization of complex surgeries such as pancreatoduodenectomy (PD) would affect access to care assumed that patients travel to their closest hospital. The validity of this assumption had not been evaluated. Our objectives were to assess the accuracy of a distance-only model in predicting where a patient received PD and determine whether incorporating hospital characteristics improved accuracy. Methods Data on patients undergoing PD from 2016 to 2017 in New York or Florida were obtained from the Statewide Inpatient Databases. We assessed three models: distance alone (model 1), distance and hospital volume (model 2), and distance, hospital volume, rurality, cancer accreditation, medical school affiliation, and centralization taxonomy of the health system (model 3). Model accuracy was determined by comparing the predicted hospital and the actual hospital where the patient received care. Results Among the 2949 included patients, model 1 was accurate for only 16.3%; model 2 was accurate for 32.9%, and model 3 was accurate for 24.3%. Patients who were accurately classified with models 2 or 3 but not 1 were more likely to live in major metropolitan areas (74.7% vs. 61.0%, p < 0.001), more likely to be non-Hispanic white (71.3% vs. 68.3%, p = 0.04), more likely to have private insurance (35.0% vs. 27.8%, p < 0.001), and had lower in-hospital mortality (1.3% vs. 3.3%, p = 0.03). Conclusions Distance-only models were largely inaccurate for predicting where patients received PD. Simulations of patient redistribution should incorporate volume, distance, and additional patient- and provider-level factors.

New Models for Predicting Hospital Choice in Pancreatic Surgery

by Ross-Driscoll K, Huber S (...) Ellis RJ et 5 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Retroperitoneal-First Laparoscopic Approach (Retlap) for Bile Duct Resection in Pancreaticobiliary Maljunction (PBM): A Novel and Reasonable Approach to Intrapancreatic Bile Duct - Annals of Surgical Oncology Background Pancreaticobiliary maljunction (PBM) is a congenital anomaly in which the pancreatic and bile ducts join outside the duodenal wall.1,2 Reflux of pancreatic juice induces chronic inflammation and epithelial regeneration, promoting carcinogenesis. Biliary dilation increases the risk of cholangiocarcinoma, and prophylactic resection of the extrahepatic bile duct and gallbladder is recommended even for asymptomatic patients.3,4 To prevent postoperative carcinogenesis, the intrapancreatic bile duct should be transected just above the pancreatobiliary junction. The authors describe a novel dorsal approach to the pancreatic head using the retroperitoneal-first laparoscopic approach (Retlap).5–7 Methods A 73-year-old woman under follow-up evaluation for choledocholithiasis-associated cholangitis was found to have a gallbladder tumor. Evaluation showed PBM with biliary dilation. Computed tomography exhibited wall-thickening of the gallbladder fundus. Magnetic resonance cholangiopancreatography demonstrated a common bile duct diameter of 13 mm and a common channel length of 12 mm, whereas endoscopic retrograde cholangiopancreatography measured both as 15 mm. Biliary amylase was elevated. The preoperative diagnosis was gallbladder carcinoma with PBM and biliary dilation. After an explanation of the procedure and her informed consent, the woman underwent extrahepatic bile duct and gallbladder resection with lymphadenectomy using Retlap. Results The operative time was 480 min, including 210 min for Retlap, with 40 mL blood loss. The postoperative course was uneventful, and she was discharged on postoperative day 14. Pathology confirmed gallbladder carcinoma with single-node metastasis. At this writing, after adjuvant chemotherapy, the woman has remained recurrence-free 3 years. Conclusion Although additional trocars and steps are required, Retlap for PBM may enable safe bile duct transection just above the pancreatobiliary junction and facilitate lymphadenectomy, providing excellent visualization and stable maneuverability.

Novel Laparoscopic Method for Bile Duct Resection in PBM

by Karasuyama T, Kiguchi G (...) Takeyama O et 2 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Fluorescence Lymphography Using Indocyanine Green During Esophagectomy for Cancer to Prevent Chyle Leakage: A Propensity Score Matched Analysis - Annals of Surgical Oncology Background This study evaluated the efficacy of intraoperative fluorescent lymphography with indocyanine green (ICG) to reduce the incidence of chyle leakage post-esophagectomy. Methods This prospective observational cohort study was conducted among patients who underwent fluorescence lymphography during esophagectomy for cancer between May 2022 and August 2023 at a single tertiary referral center. After 1:3 propensity score matching, the results were compared between 59 patients who underwent fluorescence lymphography (ICG group) and a historical cohort who did not (non-ICG group). The primary outcome was the incidence of postoperative chyle leakage. Results The study included 59 patients in the ICG group and 177 non-ICG controls. ICG was ultrasound guided bilaterally injected into inguinal lymph nodes in 26 patients (44%), the small bowel mesentery in 30 patients (51%), and both sites in three patients (5%). Thoracic duct visualization was successful in 85%. Fluorescence lymphography influenced intraoperative management in 21 patients (36%), with placement of additional clips. The incidence of chyle leakage was 17% (10/59) in the ICG group and 10% (18/177) in the non-ICG group (p = 0.163). All patients with chyle leakage in the ICG group were treated conservatively versus two re-interventions in the non-ICG group (p=0.271). Conclusions Real-time ICG fluorescence lymphography is a promising tool for the intraoperative detection and management of chyle leakage during esophagectomy, although no reduction in chyle leakage was demonstrated. Further studies are required to elucidate the efficacy of fluorescence lymphography with ICG in reducing the incidence of postoperative chyle leakage.

Fluorescence Lymphography in Esophagectomy Shows No Chyle Leakage Benefit

by Henckens SPG, van der Aa DC (...) Gisbertz SS et 4 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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AI-Driven Marker Improves Outcomes for Pancreatic Cancer Nonproducers

by Thalji SZ, Aldakkak M (...) Kothari AN et 18 al. in JAMA Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Occult Nodal Disease in Gallbladder Cancer: An International Multi-institutional Analysis and Preoperative Risk Stratification - Annals of Surgical Oncology Introduction Accurate preoperative nodal staging remains challenging in gallbladder cancer (GBC), and a substantial proportion of patients presumed to be clinically node-negative have nodal metastasis at surgery. This study aimed to quantify the burden of occult nodal disease (OND)—defined as pathologic node-positive disease among clinically node-negative patients—and to identify preoperative factors associated with OND. Methods Patients who underwent upfront curative-intent resection with regional lymphadenectomy for GBC were identified from an international multi-institutional database. Among patients staged as clinically node-negative (cN0) on preoperative imaging, multivariable logistic regression was used to identify preoperative predictors of OND. CA19-9 and the systemic immune-inflammation index (SII) were log-transformed for modeling purposes. Results Among 187 patients, 142 (75.9%) were classified as cN0 preoperatively, among whom 47 (33.1%) had OND on final pathology. On multivariable analysis, higher ln(SII) (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.05–2.86), higher ln(CA19-9) (OR 1.30, 95% CI 1.12–1.53), and preoperative jaundice (OR 3.68, 95% CI 1.21–11.76) were independently associated with OND. The observed OND rate increased stepwise with the number of elevated preoperative markers (SII > 890.2, CA19-9 > 37 U/mL, and jaundice): 17.1% with 0 markers, 44.8% with 1 marker, and 73.6% with 2–3 markers. Conclusions OND was present in approximately one-third of clinically node-negative GBC patients undergoing lymphadenectomy. Preoperative jaundice, elevated CA19-9, and elevated SII independently predicted OND and provided simple risk stratification. Incorporating these readily available markers into preoperative assessment may improve risk enrichment for OND and help guide additional staging and treatment sequencing.

Occult Nodal Disease in Gallbladder Cancer: Critical Insights

by Kawashima J, Yuza K (...) Pawlik TM et 9 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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High Variation in Expert Assessment of Peritoneal Malignancy

by Bhatt A, Sharma V (...) Glehen O et 42 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Improved Technique for Chronic Anal Fissures

by Liu R, Li J (...) Zhong S et 3 al. in Dis Colon Rectum #Surgery #SurgSky #GeneralSurgery #MedSky

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Surveillance strategies for colorectal cancer need improvement

by Samur S, Gursel E (...) Neugut AI et 8 al. in BMJ Open #Surgery #SurgSky #GeneralSurgery #MedSky

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Tumor Debulking in Multiorgan Metastatic Colorectal Cancer Fails to Improve Survival

by Gootjes EC, Bakkerus L (...) Verheul HMW et 17 al. in JAMA #Surgery #SurgSky #GeneralSurgery #MedSky

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Gastric Cancer Peritoneal Metastasis Management Consensus Established

by Boshier PR, Ann Chia DK (...) So JB et 40 al. in Br J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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New Checklist for Surgical Prehabilitation Reporting

by Gillis C, McIsaac DI (...) Fiore JF et 30 al. in Br J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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Prognostic Significance of Radiological Adjacent Organ Invasion in Resectable Left-Sided Pancreatic Cancer - Annals of Surgical Oncology Background The resectability of pancreatic cancer depends on the extent of vascular involvement. Left-sided pancreatic cancer (LPC) rarely invades major vessels but frequently involves adjacent organs. This study aimed to assess the prognostic significance of radiological adjacent organ invasion (RAOI) in resectable LPC. Methods This study included 162 patients who underwent distal pancreatectomy for resectable LPC between 2002 and 2020. Radiological adjacent organ invasion was defined as contact of the primary tumor or a continuous soft tissue density to the adjacent organs (stomach, adrenal gland, colon, or liver) on computed tomography. Clinicopathological factors and survival outcomes were compared between the RAOI (+) (n = 17) and RAOI (−) (n = 145) groups. Results The RAOI (+) group had significantly higher CA19-9 levels (279 vs. 33 U/mL, p = 0.005), larger radiological tumor sizes (37 vs. 21 mm, p < 0.001), and more frequently positive peritoneal cytology results (41% vs. 8%, p = 0.002). Overall survival (OS) in the RAOI (+) group was significantly worse than that in the RAOI (−) group (median survival time [MST], 25.9 vs. 67.2 months, p < 0.001). Among patients with negative cytology results (n = 141), OS was still significantly worse in the RAOI (+) group (MST, 33.5 vs. 71.9 months, p = 0.001). Multivariate analysis revealed CA19-9 levels ≥37 U/mL and RAOI as independent risk factors for poor OS. Conclusions Radiological adjacent organ invasion is an independent negative prognostic factor in resectable LPC and is associated with early systemic dissemination and worse survival outcomes. Radiological adjacent organ invasion (+) LPC may be considered a borderline resectable disease that requires intensive multimodal treatment strategies.

Radiological Organ Invasion Signals Poor Outcomes in Pancreatic Cancer

by Kitahama T, Ohgi K (...) Sugiura T et 6 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Integrated Liquid Biopsy and Tumor Tissue Genomic Profiling of Appendiceal Cancer: cfDNA Burden, Mutation Landscapes, and Clinical Outcomes - Annals of Surgical Oncology Background Appendiceal cancer (AC) is a rare malignancy that often presents at advanced stages with significant histological variability influencing clinical outcomes. Precise genomic profiling is essential for accurate diagnosis and personalized patient management. This study interrogated DNA from appendiceal tumor tissue, buffy coat cells, and the cell-free DNA component of plasma using a 523-gene panel for comprehensive genomic profiling (CGP) to identify cancer-related genetic mutations in tumor and blood, evaluate tumor mutation burden, and determine genetic markers associated with histologic grade. Patients and Methods A total of 73 patients provided blood samples comprising cell-free DNA (cfDNA) and germline buffy coat cells (bcDNA) for analysis compared with tumor tissues available from 56 of these patients. Concordance of mutations between matched tumor tissue and plasma samples (n = 51) was assessed and tumor-specific and germline variants were classified using OncoKB™ clinical criteria to delineate oncogenic and therapeutically actionable variants [level 1 mutations with U.S. Food and Drug Administration (FDA)-approved therapy]. Additionally, cfDNA concentrations were tested for association with clinical and pathologic features and oncologic outcome including disease-specific (DSS) and progression-free (PFS) survival. Results Circulating tumor DNA (ctDNA) from plasma cell-free DNA demonstrated high concordance with tumor genomic profiling, reaching 98.4% concordance [median, interquartile range (IQR) 13.5, 21.5] overall and 85.7% (IQR 64.6, 100) for therapeutically actionable level 1 mutations. Prevalent appendiceal tumor-specific mutations included KRAS proto-oncogene, GTPase (KRAS) (41%), GNAS complex locus (GNAS) (30%), tumor protein p53 (TP53) (30%), and SMAD family member 4 (SMAD4) (29%). Tumor-specific TP53, SMAD4, and spectrin alpha, erythrocytic 1 (SPTA1) mutations strongly correlated with intermediate and high-grade histology, whereas GNAS mutations predominated in low-grade tumors. Germline analysis identified coding mutations shared among this patient cohort in notch receptor 4 (NOTCH4) (55%) and BRCA1 associated RING domain 1 (BARD1) (48%) genes, with zinc finger homeobox 3 (ZFHX3) (29%) and adhesion G protein-coupled receptor A2 (ADGRA2), DNA polymerase epsilon (POLE), and transcription factor 3 (TCF3) mutations (all = 23%) specifically enriched in intermediate and high-grade AC. Both histological grade and cfDNA stratified by concentration tertiles independently predicted progression-free and disease-specific survival. Plasma samples exhibited consistently lower variant allele frequencies than solid tumors, limiting sensitivity for discovery of novel mutations exclusively from plasma. Conclusions This study supports integrating comprehensive ctDNA assays into standard diagnostic and treatment pathways for AC using large gene panels. TP53, SMAD4, SPTA1, and GNAS mutations serve as prospective tumor-specific molecular classifiers for histological grade, while germline variants in NOTCH4 and BARD1 may further influence disease biology, with ZFHX3, ADGRA2, POLE, and TCF3 affecting grade stratification. Overall cfDNA concentration may serve as a potential prognostic biomarker in AC.

High Concordance of cfDNA and Tumor Profiling in Appendiceal Cancer

by Patel S, Petrosko P (...) LaFramboise WA et 16 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Disparities in Surgical Care of Patients with Colorectal Cancer Liver Metastases - Annals of Surgical Oncology Background Up to 25% of patients with colorectal cancer present with liver metastases (CRLM), and 50% develop metastases over time. Surgical and ablative management of CRLM can be curative, but certain demographic and socioeconomic factors disproportionately hinder vulnerable patient populations from receiving advanced local therapies. Methods We queried the 2011–2021 National Cancer Database for cases of CRLM. We explored patient and facility characteristics associated with receipt of local intervention versus no intervention for metastatic liver lesions. Results Of 72,273 cases, 18.0% underwent hepatectomy or ablation. Controlling for patient- and center-level factors, non-Hispanic Black and Hispanic/Latino patients were less likely to undergo liver intervention than were non-Hispanic white patients (odds ratio [OR] 0.83 [95% confidence interval (CI) 0.78–0.88] vs. OR 0.92 [95% CI 0.85–0.99]). Patients treated at academic programs had significantly higher odds of liver intervention than did those in community cancer programs (OR 2.24 [95% CI 2.06–2.43]). Patients with private, Medicaid, Medicare, or other government insurance had higher odds of liver intervention than did uninsured patients (OR 2.07 [95% CI 1.86–2.30], OR 1.40 [95% CI 1.24–1.58], OR 1.81 [95% CI 1.61–2.03], OR 2.20 [95% CI 1.81–2.66], respectively). Patients in the highest income quartile were more likely to have liver intervention than those in the lowest quartile (OR 1.18 [95% CI 1.10–1.27]). Patients receiving liver intervention traveled farther than those receiving non-surgical care (p<0.001). Conclusion Surgical or local ablative management of CRLM is necessary to achieve cure for appropriately selected patients. However, this advanced liver interventional care is not equally distributed among patient populations. Significant socioeconomic and demographic disparities exist in the receipt of local liver interventional management among patients with CRLM and require further exploration to improve resource allocation.

Colorectal Cancer Liver Metastases Reveal Care Disparities

by Martinez AE, Webber A (...) DiBrito S et 3 al. in Ann Surg Oncol #Surgery #SurgSky #GeneralSurgery #MedSky

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Minimally Invasive Surgery Reduces Risks in Hepatectomy

by Shindoh J, Kobayashi Y (...) Matsumura M et 7 al. in World J Surg #Surgery #SurgSky #GeneralSurgery #MedSky

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