AIMTo investigate the neoadjuvant chemotherapy (NAC) effect on the survival of patients with proper stomach cancer submitted to D2 gastrectomy.METHODSWe proceeded to a review of the literature with PubMed, Embase, ASCO and ESMO meeting abstracts as well as computerized use of the Cochrane Library for randomized controlled trials (RCTs) comparing NAC followed by surgery (NAC + S) with surgery alone (SA) for gastric cancer (GC). The primary outcome was the overall survival rate. Secondary outcomes were the site of the primary tumor, extension of node dissection according to Japanese Gastric Cancer Association (JGCA) performed in both arms, disease-specific (DSS) and disease-free survival (DFS) rates, clinical and pathological response rates and resectability rates after perioperative treatment.RESULTSWe identified a total of 16 randomized controlled trials comparing NAC + S (n = 1089) with SA (n = 973) published in the period from January 1993 - March 2017. Only 6 of these studies were well-designed, structured trials in which the type of lymph node (LN) dissection performed or at least suggested in the trial protocol was reported. Two out of three of the RCTs with D2 lymphadenectomy performed in almost all cases failed to show survival benefit in the NAC arm. In the third RCT, the survival rate was not even reported, and the primary end points were the clinical outcomes of surgery with and without NAC. In the remaining three RCTs, D2 lymph node dissection was performed in less than 50% of cases or only recommended in the “Study Treatment” protocol without any description in the results of the procedure really perfomed. In one of the two studies, the benefit of NAC was evident only for esophagogastric junction (EGJ) cancers. In the second study, there was no overall survival benefit of NAC. In the last trial, which documented a survival benefit for the NAC arm, the chemotherapy effect was mostly evident for EGJ cancer, and more than one-fourth of patients did not have a proper stomach cancer. Additionally, several patients did not receive resectional surgery. Furthermore, the survival rates of international reference centers that provide adequate surgery for homogeneous stomach cancer patients’ populations are even higher than the survival rates reported after NAC followed by incomplete surgery.CONCLUSIONNAC for GC has been rapidly introduced in international western guidelines without an evidence-based medicine-related demonstration of its efficacy for a homogeneous population of patients with only stomach tumors submitted to adequate surgery following JGCA guidelines with extended (D2) LN dissection. Additional larger sample-size multicentre RCTs comparing the newer NAC regimens including molecular therapies followed by adequate extended surgery with surgery alone are needed.
Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.
Aggressive treatment of intrahepatic recurrence of hepatocellular carcinoma (HCC) increases patients' survival, but most frequently, these patients are not suitable for hepatic resection (HR). The aim of this study was to analyze the indications for and results of laparoscopic radiofrequency ablation (RFA) in the treatment of recurrent HCC after HR or after RFA. A retrospective analysis was conducted of 88 consecutive patients with recurrent HCC (group REC) who underwent to laparoscopic RFA after prior either RFA (66 pts.) or partial HR (22 pts.) as initial local treatment. Another 170 patients with primary HCC (group PRIM) treated by laparoscopic RFA were regarded as a control group. All patients were in stage A according BCLC classification. The incidences of postoperative morbidity (18% vs 21, respectively) and mortality (0% both) were similar for patients with prior RFA and patients with prior HR (p = NS). This group had a longer hospital stay than group with prior RFA (median time of 5 days vs. 3 days, respectively; p = 0.0016). Both overall survival and DFS rates were not significantly different between patients with prior RFA (cumulative 3-year survival rate of 59%; cumulative 3-year DFS of 21%) and patients with prior HR (cumulative 3-year survival rate of 78%; cumulative 3-year DFS of 8%; p = NS). Comparing group REC vs. group PRIM, the incidences of morbidity (21% vs 20%) and mortality (0%) were similar (p = NS). Cumulative 3-year survival rate were 63% in REC group and 59% in PRIM rec (p = 0.5739), while cumulative 3-year DFS were 17% in REC group and 22% in PRIM group (p = 0.5266). Similar HCC recurrences occurred following similar follow-up durations in all groups: only multiple HCC recurrences occurred more frequently in the group after HR (p = 0.039) than after RFA. Laparoscopic RFA can be performed safely and may be efficacious, in terms of overall survival and DFS, for selected patients with intrahepatic HCC recurrence after prior both RFA and HR. Furthermore, laparoscopic RFA for recurrent HCC obtains similar survival and DFS rates comparing to laparoscopic RFA for primary HCC without increasing morbidity. Laparoscopic RFA could be proposed as first-line treatment for intrahepatic HCC recurrence in selected patients.
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