[POSTGRADUATE MEDICAL EDUCATION DURING COVID-19 PANDEMIC IN ISRAEL]

The Covid-19 pandemic has posed significant challenges to many aspects of life, including work processes to which we have become accustomed. Health systems world-wide have been affected in numerous ways and face epic and unprecedented challenges. Medical education, both in Israel and around the world, has been deeply impacted. It is no surprise that the institutions responsible for medical education, as well as many other institutions, have had to deal with uncertainty and unrest. In this article, we review the processes adopted by the Scientific Council of the Israel Medical Association, the body responsible for postgraduate medical training in the various medical specialties. The article reviews the actions taken by the Council during the first few months of the pandemic, March-July 2020, in order to maintain the quality of training.

[RESIDENCY EXAMINATIONS IN THE COURSE OF THE COVID-19 CRISIS: THE EFFORTS OF THE ISRAELI SCIENTIFIC COUNCIL TO EXECUTE THE FINAL BOARD ORAL EXAMINATIONS DURING A LOCAL AND A WORLDWIDE PANDEMIC]

INTRODUCTION

The Israeli Scientific Council is responsible for the physician's training process and the residency exams. These are performed in two phases: Stage A (written examination) and Stage B (the final Board oral examination). The COVID-19 pandemic started in Israel a few weeks before the scheduled spring 2020 Stage B exams and had a major impact, not only on the health and economic systems in Israel, but also on the residency exams.

AIMS

To describe the efforts of the Israeli Scientific Council to execute the spring 2020 Stage B exams during the COVID-19 pandemic in comparison to the worldwide data, and to deduce the appropriate management during potential future crises.

METHODS

We present a description of the activity of the Israeli Scientific Council since the start of the COVID-19 pandemic according to documents and other sources, An internet search was conducted on the destiny of residency examinations throughout the world, and a comparison between them.

RESULTS

Due to rapid worsening in the restrictions enforced in Israel, the spring 2020 oral board exams were cancelled. However, a decision was made to execute them in the summer. This new schedule dictated a delay in the schedule of other residency examinations and forced condensation of 5 periods into 10 months instead of 14. The examination team prepared the new summer exams period under the assumption that heavy restrictions will still be implemented. Indeed, COVID-19 was still around and the restrictions were still enforced. Despite that, all oral Board examinations were perfectly executed. This contrasts with the rest of the world, in which most residency exams were cancelled, even without a solution or an alternative date.

CONCLUSIONS

Recruitment of all involved and preparation for the worst-case scenario enabled the perfect execution of the previously cancelled exams, and will enable the execution of future residency exams under conditions of potential health or war crises.

DISCUSSION

To the best of our knowledge, the Israeli Scientific Council is the only communal body in the world which organized an alternative period for the cancelled oral exams, only 4 months after the cancelled dates. Due to an enormous effort and rigorous preparations, Israel is also the only place in which oral exams were successfully executed, physically, under an active disease and very heavy restrictions.

Some Nursing Screening Tools Can Be Used to Assess High-Risk Older Adults Who Undergo Colorectal Surgery for Cancer

Aim

Life expectancy and incidence of cancer among older adults are increasing. The aim of this study was to assess whether routinely used nursing screening tools can predict surgical outcomes in older adults with colorectal cancer.

Methods

Data of patients who underwent elective colorectal cancer surgery at Rabin Medical Center during the years 2014-2016 were collected retrospectively. Patients were divided into study group (age 80-89 y), and control group (age 60-69 y) for comparing surgical outcomes and six-month mortality. In the study group, screening tool scores were evaluated as potential predictors of surgical outcomes. These included Malnutrition Universal Screening Tool (MUST), Admission Norton Scale Scores (ANSS), Morse Fall Scale (MFS), and Charlson Co-morbidity Index (CCI).

Results

The study group consisted of 77 patients, and the control group consisted of 129 patients. Postoperative mortality and morbidity were similar in both groups. Nursing screening tools did not predict immediate postoperative outcomes in the study group. MUST and CCI were predictors for six-month mortality. CCI score was 9.43±2.44 in those who died within six months from surgery compared to 7.07 ±1.61 in those who were alive after six months (p<0.05). Post-operative complications were not associated with increased 30-day mortality. Advanced grade complications were associated with an increased six-month mortality (RR=1.37, 95% CI 0.95-1.98, p=0.013).

Conclusion

Different screening tools for high-risk older adults who are candidates for surgery have been developed, with the caveat of necessitating skilled physicians and resources such as time. Routinely used nursing screening tools may be helpful in better patient selection and informed decision making. These tools, specifically MUST and CCI who were found to predict six-month survival, can be used to additionally identify high-risk patients by the nursing staff and promote further evaluation. This can be a valuable tool in multidisciplinary and patient-centered care.

[EVALUATION OF THE ELDERLY PATIENT WITH CANCER]

In recent years, there has been a significant increase in the number of adult patients with malignant diseases. These patients are a major therapeutic challenge due to a high incidence of comorbidities, lower functional status and often a diagnosis of the disease at a relatively advanced stage. The preferred approach to the treatment of cancer is a multidisciplinary approach. In the last decade, we have witnessed the integration of geriatricians as part of the multidisciplinary team in order to better assess patients' ability to withstand oncological or surgical treatment and, if necessary, to prepare them better for these treatments. In this article we review the use of various geriatric tools, such as generalized geriatric assessment, fragility and sarcopenia, and their effect on the decision-making process of the treating physicians and on the outcomes of the various treatments, including the outcomes of the operations. We show that comprehensive geriatric assessment is the basis for the evaluation of the adult oncology patients, and proper preparation for treatment in order to improve the outcomes of the treatment and reduce its complications. The rapid growth rate of the elderly population in Israel, together with the continuous development of oncology and cancer treatments, indicate the need to allocate resources and efforts to treat this unique population. We recommend an integration of geriatricians in the multidisciplinary team that treats this population.

Abdominal Surgery in Patients with a Ventricular Assist Device: A Single Center Experience in Israel

BACKGROUND

Left ventricular assist devices (LVADs) are used more commonly in patients with advanced-stage heart failure. Some of these patients may require elective or urgent abdominal surgical procedures.

OBJECTIVES

To determine the outcomes of the management of LVAD-supported patients who underwent elective and urgent abdominal surgical procedures in our institution.

METHODS

A retrospective review was conducted on 93 patients who underwent LVAD implantation between August 2008 and January 2017. All abdominal surgeries in these patients were studied, and their impact on postoperative morbidity and mortality Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patientswas evaluated.

RESULTS

Ten patients underwent abdominal surgical procedures. Of these procedures, five were emergent and five were elective. The elective cases included one bariatric surgery for morbid obesity, one hiatal hernia repair, two cholecystectomies, and one small bowel resection for a carcinoid tumor. The emergency cases included suspected ischemic colitis, right colectomy for bleeding adenocarcinoma, laparotomy due to intraabdominal bleeding, open cholecystectomy for gangrenous cholecystitis, and laparotomy for sternal and abdominal wall infection. All patients undergoing elective procedures survived. Of the five patients who underwent emergency surgery, three died (60%, P = 0.16) and one presented with major morbidity. One of the two survivors required reintervention. In total, 12 interventions were performed on this group of patients.

CONCLUSIONS

It is safe to perform elective abdominal procedures for LVAD-supported patients. The prognosis of these patients undergoing emergency surgery is poor and has high mortality and morbidity rates.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis

AIM

Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome.

PATIENTS AND METHODS

A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome.

RESULTS

One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4).

CONCLUSION

Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Young-onset gastric cancer and Epstein-Barr Virus (EBV) - a major player in the pathogenesis?

Objective

Gastric cancer (GC) is a leading cause of cancer death, occurs predominantly in older age, with increasing incidence in young patients. The Cancer Genome Atlas indicates four subtypes for GC among which Epstein-Barr virus (EBV) subtype is estimated at 8.7%. We aim to determine the prevalence of EBV subtype in young GC patients (≤45 years) compared with an average-onset cohort (≥55 years) and characterize the clinicopathologic pattern of young-onset GC.

Methods

Gastric cancer samples of patients of both cohorts were screened for EBV by qPCR. Additional staining was done for Human epidermal growth factor receptor 2 (HER2), microsatellite instability (MSI) status and Programmed death-ligand 1 (PD-L1). Demographics and clinical data were retrieved from the medical records.

Results

Thirty-nine young-onset and 35 average-onset GC patients were reviewed. There was no apparent difference in tumor location, family history, histology and HER2 status between the cohorts. More young-onset patients were diagnosed with metastatic disease (27% vs 9%, p = 0.0498). EBV was significantly more prevalent in the young-onset cohort (33% vs 11%, p = 0.025). 15/17 EBV positive patients were under the median age of diagnosis for GC in the US (68 years). MSI-H was found only in the average-onset cohort [0% vs 27%, p = 0.001). PD-L1 positivity was higher in the young-onset cohort (31% vs 3%, p = 0.002).

Conclusion

Our study indicates that EBV subtype is more prevalent in young-onset GC and may play a key role in the pathogenesis. Higher rate of PD-L1 positivity in young-onset GC could change treatment strategies. We are currently evaluating these findings in a prospective trial.

Isolated Traumatic Brain Injury in the Very Old

BACKGROUND

Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients.

OBJECTIVES

To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79).

METHODS

Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center.

RESULTS

The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines.

CONCLUSIONS

There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

[POSTGRADUATE MEDICAL EDUCATION ACCREDITATION IN ISRAEL]

Accreditation of Post-Graduate Medical Education permits medical institutions to train residents, allowing them to achieve specialist certification. An accreditation system usually employs several tools such as site-visits, information gathering and occasionally self-evaluation, to determine adherence to pre-defined standards. The Scientific Council of the Israeli Medical Association is entrusted by law on this accreditation system in Israel. In our article, we briefly review the Post-Graduate Medical Education accreditation system in Israel and a number of pivotal challenges faced by the Scientific Council in this field in the 21st century. These challenges include the adaptation to different medical settings such as community based clinics and medical arrays, the adaptation of tools used for accreditation, new methods for up to date information gathering and updated structure of site-visit teams. A significant future challenge will be adapting the accreditation system to the new Competency Based Medical Education model of residency promoted in Israel by the Scientific Council.

Proteomic analysis to identify markers for response to treatment in esophageal cancer

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Background: Neoadjuvant chemoradiotherapy (NCRT) followed by surgery represents a key therapeutic strategy for locally advanced esophageal cancer (LAEC). Former studies addressed the clinicopathological patterns of patients who demonstrated good response to NCRT compared with inferior response. Nevertheless, there is paucity of data regarding potentially involved cellular pathways that account for tumor response to NCRT. We performed a comprehensive proteomic analysis to identify the key differences in protein function and pathway activation between patients with a poor response and those with a favourable response to treatment. Methods: Patients diagnosed with LAEC who were treated with NCRT and operated at our institution were included in the study. Patients were defined as good responders (GR) upon the tumor regression grade (TRG) in the pathological specimen: GR defined as TRG 0/1 and no evidence of recurrence at 1-year post surgery. Bad responders (BR) were defined as TRG 2/3 and recurrence < 1year. Tumor was isolated from the surgical specimen and proteins were extracted and processed for mass spectrometry-based analysis. Clinical data of demographics, response to treatment, and survival was retrieved from electronic medical records. Difference in protein expression between GR and BR were analysed using validated gene expression pathways tools and correlated to clinical data. Results: Forty-four patients were included in the cohort. Mean age was 66.7 years, male predominance (33/44). Thirty-five patients had adenocarcinoma – 17 GR and 18 BR. Nine patients had squamous cell carcinoma – 6 GR and 3 BR. Protein expression patterns significantly differed between GR and BR regardless of histology, mainly in cellular pathways account for nucleic acid metabolism (p < 10-9), whereas BR had overexpression of these genes. Conclusions: Our study indicate that lack of response to NCRT may derive from overexpression of unique cellular pathways. Former studies imply these cellular pathways may play a role in resistance to cisplatin. Larger transcriptomic studies are warranted for future analysis to extend these observations.

Baseline 18F-FDG PET/CT as predictor of the pathological response to neoadjuvant therapy in esophageal cancer: A retrospective study

The type of pathological response to neoadjuvant chemoradiation in patients with locally advanced esophageal cancer predicts overall survival (OS).We aimed to assess early 18F-FDG positron emission tomography/computed tomography parameters in predicting the pathological response to neoadjuvant treatment.The cohort included consecutive patients with locally advanced esophageal cancer who underwent baseline 18F-FDG positron emission tomography/computed tomography between September 2006 and February 2015. Positron emission tomography variables of maximum and average standardized uptake values (SUVmax, SUVaverage), metabolic tumor volume (MTV), and total lesion glycolysis were recorded in addition to computed tomography volume. MTV was calculated using cut-off values of 42%, 50% and 60% (MTV 0.42, 0.5, and 0.6) of the tumoral SUVmax. Receiver operating characteristic (ROC) analysis was used to determine sensitivity and specificity.Sixty-one patients (44 male, 17 female) fulfilled the inclusion criteria. Only MTV values of 13.6 mL (MTV 0.42) and 7.4 mL (MTV 0.5) remained significant on ROC analysis, with an area under the curve of 0.690 (confidence interval 0.557-0.823, p = .02] and 0.664 (confidence interval 0.527-0.802, P = .048), respectively in differentiating patients with a complete (n = 44) or incomplete (n = 17) pathological response.MTV at presentation is associated with the pathological response to neoadjuvant chemoradiation in patients with locally advanced esophageal cancer.

Early PET-CT in patients with pathological stage III colon cancer may improve their outcome: Results from a large retrospective study

Background

Current staging of pathological stage III colon cancer (CC) is suboptimal; many patients recur despite unremarkable preoperative staging. We previously reported that early postoperative PET‐CT can alter the stage and management of up to 15% of patients with high‐risk stage III CC. This study aimed to determine the role of the test in the general stage III CC population.

Methods

A retrospective study of all consecutive patients with stage III CC who underwent early postoperative PET‐CT between 2005 and 2017.

Results

A total of 342 patients, 166 (48.5%) males, median age 66 years (range, 29‐90), were included. Pathological stage was IIIA, IIIB, and IIIC in 18 (5.3%), 257 (75.1%), and 67 (19.6%) patients, respectively. Median number of positive lymph nodes was 2 (range, 0‐32). PET‐CT results modified the management of 46 patients (13.4%): 37 (10.8%) with overt metastatic disease and 9 (2.6%) with a second primary. The 5‐year disease‐free survival for true stage III patients was 81%. The median overall survival for the entire cohort and for true stage III patients was not reached and was 57.2 months for true stage IV. Of the 37 patients found to be metastatic, 14 (37.8%) underwent curative treatments and 9/14 (64.3%) remain disease‐free, with a median follow‐up of 83.8 months. Predictive factors for upstaging following PET‐CT were identified.

Conclusion

Early postoperative PET‐CT changed the staging and treatment of 13.4% of stage III CC patients and has the potential for early detection of curable metastatic disease. Outcome results are encouraging. Prospective validation is ongoing.

Urgent Laparotomy in Patients with Metastatic Colorectal Cancer Presenting as an Acute Abdomen: A Retrospective Analysis

BACKGROUND

Unlike the elective treatment of metastatic colorectal cancer (MCRC), sufficient data and consensual guidelines on acute care are lacking.

OBJECTIVES

To analyze a cohort of MCRC patients who required urgent surgery due to acute abdomen and to identify risk factors contributing to the patient's perioperative mortality and morbidity.

METHODS

A retrospective analysis was conducted of patients diagnosed with stage IV colorectal cancer who required urgent laparotomy at the Rabin Medical Center. Comparative analysis was performed using Pearson's chi-square and Student`s t-test.

RESULTS

Between 2010 and 2015, 113 patients underwent urgent laparotomy due to colorectal cancer complications, of which 62 patients were found to have a metastatic, stage IV, disease. Large bowel obstruction was the most common indication for urgent laparotomy. In-hospital mortality was 30% (n=19), and overall 30 day mortality was 43%. Fifteen patients (24%) required more than one surgery. The average length of hospital stay was 21 days. Age and lactate levels at presentation were the only prognostic factor found for mortality (P < 0.05).

CONCLUSIONS

MCRC laparotomy patients incur a significant burden of care and have a relatively high incidence of early mortality. Our data suggest high, verging on unacceptable, mortality and complication rates in this subgroup of patients. This finding is further accentuated in the subgroup of older patients presenting with lactatemia. These data should be considered by surgeons when discussing treatment options with patients and families.

Laparoscopic hand-assisted liver resection for tumours in the left lateral section

Context:

The role of the laparoscopic left lateral sectionectomy (LLLS) is debatable, and Level-1 data are lacking.

Aims:

The aim of the study is to evaluate the feasibility and safety of this approach.

Settings and Design:

This was a retrospective study.

Subjects and Methods:

From 2007 to 2014, patients undergoing LLLS were identified from two institutions.

Statistical Analysis Used:

Continuous variables were compared between groups with Student's t-test or Mann–Whitney test, as appropriate by type of distribution. Categorical variables were compared with Chi-square or Fisher's exact test, depending on the number of observations.

Results:

Thirty-eight patients were included in the study. The mean age was 63.5 + 13 years (range, 31–89), and the mean number of tumours was 1.7 + 1.5. Eleven (29%) patients underwent LLS combined with an additional liver resection (combined resections group). The mean duration of the operation and the mean estimated blood loss were significantly decreased in the LLS group compared to the combined resection group (101 + 71 min vs. 208 + 98 min and 216 + 217 ml vs. 450 + 223 ml; P < 0.05 for both, respectively). The major complications rate was 8% and no mortality occurred.

Conclusions:

In a subset of carefully selected cases, LLLS may provide the benefits of laparoscopy. This does not appear to compromise perioperative morbidity rates. We believe that this approach may serve as a training platform for surgical trainees.

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study

BACKGROUND

Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes.

RESULTS

260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups.

CONCLUSION

In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.

Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study

PURPOSE

Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making.

METHODS

Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers.

RESULTS

Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure.

CONCLUSION

Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.

Esophageal Cancer in Israel has Unique Clinico-Pathological Features: A Retrospective Study

Introduction: Data regarding esophageal cancer (EC) in Israel are limited. The aim of this study was hence to characterize this entity in the Israeli population and to compare it to the literature.

Patients/Methods: This is a retrospective study of all consecutive EC patients treated at our institution between 1997-2013. Data were retrieved from patients' medical files.

Results: Two hundred patients were included. The median age at diagnosis was 70.5 years; 63.5% were males; 63% were Ashkenazi Jews, 29% were Sephardic Jews, and 0.5% were Arabs. Squamous cell carcinoma (SCC) was predominant: 52% versus 45.5% with adenocarcinoma (ADC). SCC was common even in the distal esophagus (45%). The overall 5-year survival rate was 25.5%. A temporal trend (2006-2013 vs 1997-2005) shows a decline in the proportion of SCC (47% vs 63%, p=0.061) and a rise in ADC (50% vs 33%, p=0.041), with a parallel decrease in patients' age (median: 68.5 vs 73 years, p=0.014). In the later period, patients received more treatment for localized and metastatic disease, with a trend for improved median survival (20.1 vs 14.9 months, p=0.658). Ashkenazi Jews were diagnosed at an older age than Sephardic Jews (median: 73 vs. 65 years, p=0.001), had a higher rate of family history of GI cancer (34% vs. 17%, p=0.026) and a higher rate of cardiovascular co-morbidity (41% vs. 24%, p=0.041).

Conclusion: EC in Israel represents an intermediate entity between the Western and the endemic subtypes, showing some unique features. These included delayed reversal of the SCC/ADC ratio, commonness of SCC in the distal esophagus, prevalence of other malignancies and predominance of Ashkenazi ethnicity. The reason for these findings is unclear and its further evaluation is warranted.

Association of the addition of cetuximab to preoperative chemoradiotherapy (CRT) for locally advanced esophageal squamous cell carcinoma (SqCC) with rate of long term survival: Mature results of a prospective phase Ib/II trial

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Background: Current treatment results in locally advanced esophageal cancer (LAEC) are far from being satisfying. This prospective phase IB/II study evaluated the safety and efficacy of the addition of cetuximab to standard preoperative CRT in this disease. Methods: Patients (pts) with potentially resectable LAEC (T2-4N0-1M0, T1-4N1M0 or T1-4N0-1M1A) received an induction cycle of cisplatin 100 mg/m2, day 1, and 5-FU 1000 mg/m2/day as a continuous infusion (CI), days 1–5, followed 4 weeks later by 50.4 Gy radiotherapy given concurrently with 2 cycles of cisplatin 75 mg/m2 and escalating doses of CI 5-FU, days 1–4 and 29-32. Pts received also 10 weekly infusions of cetuximab, 250 mg/m2, with a loading dose of 400 mg/m2, starting from the induction. The phase II part of the study started when the 5-FU dose during CRT was defined. Surgery was planned 6-8 weeks after CRT. Results: 64 pts were enrolled and 60 completed CRT. Median age was 65 years (range: 38-84 years) and 66% were males. The SqCC/adenocarcinoma ratio was 39%/61% (25/39). Pts had very advanced tumors: 95% T3-T4, 67% N1 and 19% M1A. The most common grade > 3 toxicities were leucopenia (45% of pts) and neutropenia (41%). There were two cases (3%) of fatal toxicities (neutropenic sepsis and sudden death). Among the 55 operated pts, R0 resection was achieved in 51 (93%). There were 8 cases (14.5%) of postoperative mortality, due to infection (3 pts), esophageal leak (2), bleeding (2) and pulmonary insufficiency (1). Pathological down-staging was noted in 72% of pts and pathological complete response (pCR) in 33%. 5y-local control, progression-free survival (PFS) and overall survival (OS) rates for all pts were 94%, 40%, 39%, respectively. Pts with SqCC had a significantly higher pCR rate (52% vs 15%, p = 0.007), 5y-PFS (67% vs. 21%, p = 0.008) and 5y-OS (64% vs. 20%, p = 0.019). Conclusions: This study suggests that the addition of cetuximab to standard preoperative CRT is safe. R0, pCR, local control and long term PFS and OS rates in pts with SqCC tumors are encouraging. Further evaluation of this approach in this population seems warranted.

Early postoperative PET-CT in patients with pathological stage III colon cancer may change their outcome: Results from a large single-institution study

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Background: Staging of patients (pts) with pathological stage III colon cancer (CC) is currently suboptimal; many pts still recur despite an unremarkable preoperative staging. We previously reported that early postoperative PET-CT can alter the stage and management of up to 15% of pts with high risk stage III CC and later reported also encouraging preliminary results in a larger cohort of consecutive pts with stage III CC, in which staging and management were altered in 14.5%. The aim of the current study was to expand the previous one to a larger cohort and to evaluate the actual impact of early postoperative PET-CT on pts outcome. Methods: A Retrospective study of all consecutive pts with stage III CC who were treated at our institution and underwent early postoperative PET-CT between 2007-2016. Demographic and clinicopathological data were retrieved. Statistical analyses were done using standard methods. Results: 348 pts, 166 (47.7%) males, with a median age of 66 years (range, 29-92), were included. Pathological stage was IIIA, IIIB and IIIC in 21(6%), 254 (73%) and 73 (21%) pts, respectively. The median number of lymph nodes examined and of positive ones were 14 (range, 3-54) and 2 (range, 0-32), respectively. High FDG-uptake was noted in 95 (27.3%) pts, including 23 (6.6%) with clear postoperative changes and 18 (5.2%) with a false positive uptake, of whom 6 underwent invasive diagnostic procedures. PET-CT results modified the management of 52 pts (14.9%) who were found to have true positive findings: 44 (12.6%) with overt metastatic disease and 8 (2.3%) with a second primary tumor. At a median follow-up of 45.6 months, the estimated 5y disease-free survival for true stage III pts was 81.9% and the 6y overall survival of the entire cohort was 76.4%. Interestingly, of the 44 pts found to be metastatic, 12 (27.3%) underwent curative treatments and 8 (66.7%) of those remain free of disease, with a median follow-up of 64.7 months. Conclusions: In this large cohort, early postoperative PET-CT changed the staging and management of 14.9% of pts with resected stage III CC, with encouraging outcome results. We are conducting a prospective trial to further evaluate this strategy.

The role of early postoperative PET-CT in patients with pathological stage III colon cancer: Results from a large single institution study

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Background: Current staging of patients (pts) with pathological stage III colon cancer is suboptimal; many pts still recur despite unremarkable preoperative staging work-up. We previously reported that early postoperative PET-CT can alter the stage and management of pts with high risk stage III colon cancer in up to 19% of patients. The aim of the current study was to expand the previous one to a larger cohort and to determine the role of early postoperative PET-CT in the general population of stage III colon cancer pts, regardless of their individual risk. Methods: A retrospective chart review of all consecutive pts with stage III colon cancer who underwent early postoperative PET-CT between 2007 and 2016. Demographic and clinicopathological data were collected. Results: 247 pts, 124 (50%) males, with a median age of 66 years (range, 30-92), were included. Pathological stage was IIIA, IIIB and IIIC in 18 (7.3%), 161 (65.1%) and 72 (29.1%) pts, respectively. The median number of lymph nodes retrieved was 15 (range, 6-64) and that of positive lymph nodes was 2 (range, 0-21). High FDG-uptake was observed in 52 (21.0%) pts, including 6 (2.4%) who had clear postoperative changes, 10 (4.0%) who had a false positive abnormal uptake of whom 6 underwent invasive diagnostic procedures. The PET-CT results modified the management of 36 pts (14.5%) who were found to have true positive findings: 30 (12.1%) were proven to have overt metastatic disease and in 6 (2.4%) a second primary was discovered. With the median follow-up of 39.0 months (range 7.2-98.4 months), of the 30 pts found to be metastatic, 10 (33.3%) underwent curative treatments and are currently with no evidence of disease (NED). Updated data, on more patients and a longer follow-up, will be presented at the meeting. Conclusions: Early postoperative PET-CT changed the staging and treatment of 14.5% of resected stage III pts, and has the potential for early detection of curable metastatic disease. We currently evaluate this strategy and its actual impact in a prospective trial.

[LAPAROSCOPIC "SLEEVE" GASTRECTOMY POST HEART TRANSPLANTION]

Morbid obesity affects the function of the transplanted heart either directly, by damaging many elements that affect cardiac function or indirectly, by the initial appearance or worsening of co-morbidities that affect the heart. Bariatric surgery is the most effective treatment for a significant and sustained decrease in weight and it leads to the disappearance of co-morbidities such as diabetes, hypertension and dyslipidemia in high rates. These diseases can damage the blood vessels of the graft and impair its function. We report a case study of a 47-year-old morbidly obese male (BMI 36 kg/m2] who underwent heart transplantation three years previously, developed gradual weight gain and symptoms of aggravating heart failure. Coronary artery disease in the implanted heart was diagnosed. Clinically, he started suffering from shortness of breath and chest pain during minimal effort. In addition, he also suffered from high blood pressure and kidney failure. Laparoscopic sleeve gastrectomy was successfully performed and he was discharged four days later. On follow-up the patient has lost 35 kg. His present weight is 74 kg (BMI 25.7). All symptoms of heart failure improved and oral medications for hypertension and heart failure were withdrawn. Our conclusion is that it is justified to consider bariatric surgery in heart transplant recipients suffering from morbid obesity, as long as the long-term benefit outweighs the surgical risk. The decision to perform bariatric surgery should be made by a multidisciplinary team and the operation should take place at a center with extensive experience in bariatric surgery.

A novel method for screening colorectal cancer by infrared spectroscopy of peripheral blood mononuclear cells and plasma

BACKGROUND

Early detection of colorectal cancer (CRC) can reduce mortality and morbidity. Current screening methods include colonoscopy and stool tests, but a simple low-cost blood test would increase compliance. This preliminary study assessed the utility of analyzing the entire bio-molecular profile of peripheral blood mononuclear cells (PBMCs) and plasma using Fourier transform infrared (FTIR) spectroscopy for early detection of CRC.

METHODS

Blood samples were prospectively collected from 62 candidates for CRC screening/diagnostic colonoscopy or surgery for colonic neoplasia. PBMCs and plasma were separated by Ficoll gradient, dried on zinc selenide slides, and placed under a FTIR microscope. FTIR spectra were analyzed for biomarkers and classified by principal component and discriminant analyses. Findings were compared among diagnostic groups.

RESULTS

Significant changes in multiple bands that can serve as CRC biomarkers were observed in PBMCs (p = ~0.01) and plasma (p = ~0.0001) spectra. There were minor but statistically significant differences in both blood components between healthy individuals and patients with benign polyps. Following multivariate analysis, the healthy individuals could be well distinguished from patients with CRC, and the patients with benign polyps were mostly distributed as a distinct subgroup within the overlap region. Leave-one-out cross-validation for evaluating method performance yielded an area under the receiver operating characteristics curve of 0.77, with sensitivity 81.5% and specificity 71.4%.

CONCLUSIONS

Joint analysis of the biochemical profile of two blood components rather than a single biomarker is a promising strategy for early detection of CRC. Additional studies are required to validate our preliminary clinical results.