Minimally invasive distal pancreatectomy and the cost of conversion

BACKGROUND

Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open.

METHODS

A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy.

RESULTS

There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay.

CONCLUSIONS

Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.

Should We Be Doing Cytoreductive Surgery with HIPEC for Signet Ring Cell Appendiceal Adenocarcinoma? A Study from the US HIPEC Collaborative

BACKGROUND

Appendiceal adenocarcinoma with signet ring cells (SCA) is associated with worse overall survival (OS), and it is unclear whether cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) should be pursued in this patient population. We assessed the prognostic implications of signet ring cells in patients with appendiceal adenocarcinoma and peritoneal carcinomatosis undergoing CRS-HIPEC.

METHODS

The US HIPEC Collaborative, a 12-center, multi-institutional database of patients undergoing CRS-HIPEC, was reviewed for patients with SCA. Univariate and multivariate analyses were performed.

RESULTS

Of 514 patients undergoing CRS-HIPEC for appendiceal adenocarcinoma, 125 (24%) had SCA. The SCA and non-SCA groups had similar baseline characteristics. SCA had worse OS compared with non-SCA (32.0 vs 91.4 months, p < 0.001). In univariate analysis for only SCA cases, there was worse OS in patients with poorly differentiated tumors, positive lymph nodes, LVI, PCI > 20, or incomplete cytoreduction (CC-2/3). However, multivariate analysis showed only positive lymph nodes (HR 1.14 [95% CI 1.00-1.31], p = 0.04), poor differentiation (5.60 [1.29-24.39], p = 0.02), and incomplete cytoreduction (4.90 [1.11-12.70], p = 0.03) were independently associated with decreased OS for SCA.

CONCLUSION

While signet cells are a negative prognostic feature, they should not be a contraindication to CRS-HIPEC in patients with well-moderately differentiated tumors with negative lymph nodes, where complete cytoreduction can be achieved.

The Association of Tumor Laterality and Survival After Cytoreduction for Colorectal Carcinomatosis

BACKGROUND

Primary tumor location has emerged as an important surrogate for tumor biology in metastatic colorectal cancer treated with systemic chemotherapy. It is unclear if primary tumor location is associated with survival after cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy (HIPEC) for colorectal carcinomatosis.

METHODS

Study of a contemporary cohort merged data from the California Cancer Registry, 2004-2012, and the Office of Statewide Health Planning and Development inpatient database. For patients undergoing CRS/HIPEC, clinicopathologic variables, treatment characteristics, and survival were compared by right versus left colon primary site. Survival was analyzed by Cox proportional hazards.

RESULTS

Of 272 patients identified, 128 (47.1%) had right-sided tumors. Left- and right-sided cohorts had similar patient, tumor, and treatment factors. Patients with left-sided primary tumors had significantly prolonged overall survival (mean 34 versus 15.5 mo, P = 0.0010). Factors independently associated with decreased overall survival included age >80 (HR 7.0, P < 0.0001), advanced T4 stage (HR 3.6, P = 0.0031), and positive lymph nodes (HR 2.2, P = 0.0004). Metachronous peritoneal involvement (HR 0.38, P < 0.0001) and left-sided primary tumors (HR 0.72, P = 0.041) were independently associated with improved overall survival.

CONCLUSIONS

This study identifies location of primary tumor as an important determinant of long-term survival after CRS/HIPEC. Patients with left-sided tumors have a more favorable prognosis.

What is the Optimal Preoperative Imaging Modality for Assessing Peritoneal Cancer Index? An Analysis From the United States HIPEC Collaborative

BACKGROUND

Radiographic prediction of peritoneal carcinomatosis index (PCI) can improve patient selection for cytoreductive surgery. We aimed to determine the correlation of computed tomography (CT)-predicted PCI (CT-PCI) and magnetic resonance imaging (MRI)-predicted PCI (MRI-PCI) with intraoperative-PCI, and if a preoperative-PCI cutoff is associated with incomplete cytoreduction.

PATIENTS AND METHODS

Patients from the US HIPEC Collaborative (2000-2017) with appendiceal, colorectal, or peritoneal mesothelioma (PM) histology who underwent cytoreductive surgery were included. Pearson correlation coefficients were used to determine correlation between preoperative and intraoperative-PCI values. Fisher r-to-z transformation was used to compare correlations.

RESULTS

A total of 488 patients were included. Of these, 34% had noninvasive appendiceal, 30% invasive appendiceal, 28% colorectal, and 8% PM histology. CT-PCI was correlated with intraoperative-PCI for patients with noninvasive and invasive appendiceal and colorectal histologies (r = 0.689, 0.554, and 0.571; all P < .001), but not PM (r = 0.188; P = .295). MRI-PCI was correlated with intraoperative-PCI for all histologies (non-invasive appendiceal: r = 0.591; P = .002; invasive appendiceal: r = 0.848; P < .001; colorectal: r = 0.729; P < .001; PM: r = 0.890; P = .007). Comparing CT and MRI, correlations were similar in noninvasive appendiceal and colorectal histologies; MRI was better for invasive appendiceal and PM (P = .005 and P = .021, respectively). Twenty-eight (6%) patients underwent an incomplete cytoreduction (cytoreduction score, 2-3). PCI greater than 15 was associated with cytoreduction score of 2 to 3 for both CT and MRI (CT-PCI: odds ratio, 3.0; P = .033; MRI-PCI: odds ratio, 7.6; P = .071).

CONCLUSIONS

In this multi-institutional cohort, CT and MRI-PCI correlate well with intraoperative-PCI. MRI appears to be superior for invasive appendiceal and peritoneal mesothelioma. External validation in a larger population is needed.

Predicting Long-Term Health-Related Quality of Life after Bariatric Surgery Using a Conventional Neural Network: A Study Based on the Scandinavian Obesity Surgery Registry

Severe obesity has been associated with numerous comorbidities and reduced health-related quality of life (HRQoL). Although many studies have reported changes in HRQoL after bariatric surgery, few were long-term prospective studies. We examined the performance of the convolution neural network (CNN) for predicting 5-year HRQoL after bariatric surgery based on the available preoperative information from the Scandinavian Obesity Surgery Registry (SOReg). CNN was used to predict the 5-year HRQoL after bariatric surgery in a training dataset and evaluated in a test dataset. In general, performance of the CNN model (measured as mean squared error, MSE) increased with more convolution layer filters, computation units, and epochs, and decreased with a larger batch size. The CNN model showed an overwhelming advantage in predicting all the HRQoL measures. The MSEs of the CNN model for training data were 8% to 80% smaller than those of the linear regression model. When the models were evaluated using the test data, the CNN model performed better than the linear regression model. However, the issue of overfitting was apparent in the CNN model. We concluded that the performance of the CNN is better than the traditional multivariate linear regression model in predicting long-term HRQoL after bariatric surgery; however, the overfitting issue needs to be mitigated using more features or more patients to train the model.

Is hepatectomy safe following Yttrium-90 therapy? A multi-institutional international experience

BACKGROUND

Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe.

METHODS

Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints.

RESULTS

Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009).

CONCLUSIONS

These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

Comparison of Rates and Outcomes of Readmission to Index vs Nonindex Hospitals After Major Cancer Surgery

Importance

Increasing regionalization of cancer surgery has the inadvertent potential to lead to fragmentation of care if readmissions occur at a facility other than the index hospital. The magnitude and adverse effects of readmission to a facility other than the one where the surgery was performed are unclear.

Objectives

To assess rates of readmission to nonindex hospitals after major cancer surgery and to compare outcomes between index and nonindex hospital readmissions.

Design, Setting, and Participants

In this multicenter, population-based, nationally representative study of adult patients undergoing a major cancer operation (defined as esophagectomies or gastrectomies, hepaticobiliary resections, pancreatectomies, colorectal resections, or cystectomies), retrospective analyses were performed using the Nationwide Readmissions Database (admissions from January 1 through September 30, 2013). Descriptive analyses were performed to determine 90-day readmission characteristics, including timing, cost, and outcomes. Adjusting for clustering by facility, the study used multivariate logistic regression to identify factors associated with nonindex vs index readmissions. The study also used regression models to identify differences in mortality, major complications, and subsequent readmissions between the 2 groups. Data analysis was performed from January 1 through December 31, 2013.

Exposures

Readmission to index vs nonindex hospitals (defined as any hospital other than the hospital where the major cancer operation was performed).

Main Outcomes and Measures

Proportion of 90-day readmissions and nonindex readmissions after major cancer surgery, factors associated with nonindex readmissions, and difference between in-hospital mortality, hospital costs, and subsequent readmissions for patients admitted to index vs nonindex hospitals.

Results

A total of 60 970 patients were included in the study (mean [SD] age, 67 [13] years; 7619 [55.6%] male and 6075 [44.4%] female). The 90-day readmission rate was 23.0%. Of the 13 695 first readmissions, 20.1% were to a nonindex hospital. Independent factors associated with readmission to a nonindex hospital included type of procedure, comorbidities (OR, 1.40; 95% CI, 1.15-1.70), elective admission (OR, 1.21; 95% CI, 1.06-1.37), discharge to a nursing facility (OR, 1.20; 95% CI, 1.07-1.36), and surgery at a teaching hospital (OR, 1.16; 95% CI, 1.00-1.34) (all P < .05). After risk adjustment, patients readmitted to nonindex hospitals had 31.2% higher odds of mortality (odds ratio, 1.31; 95% CI, 1.05-1.64) and 27.3% higher odds of having a major complication (odds ratio, 1.27; 95% CI, 1.14-1.42). Subsequent readmissions and hospital costs were not different between the 2 groups.

Conclusions and Relevance

Approximately one-fifth of readmissions were to a nonindex hospital and were associated with higher mortality and morbidity than readmission to index hospitals. Factors that influence nonindex readmissions have been identified to target interventions.

Adjuvant chemotherapy versus chemoradiation in high-risk pancreatic adenocarcinoma: A propensity score-matched analysis

PURPOSE

The American Society of Clinical Oncology guidelines recommend adjuvant chemoradiation (ACR) for margin-positive (R1) and/or node-positive (N+) pancreatic cancers. Our goal was to investigate if there is evidence of superiority of adjuvant chemoradiation (ACR) over adjuvant chemotherapy (AC).

METHODS

We utilized data from the National Cancer Database (NCDB) for N+ and/or R1 pancreatic adenocarcinoma patients diagnosed from 2004 to 2012 who underwent ACR or AC. Patients who received neoadjuvant radiation, no adjuvant treatment, or adjuvant radiation alone were excluded. Propensity score nearest-neighbor 1:1 matching (PSM) was performed between ACR and AC groups based on age, sex, race, insurance, year of diagnosis, comorbidities, tumor site and size, T-stage, nodal status, margin status, grade, and treatment facility. Primary outcome was overall survival (OS).

RESULTS

A total of 8297 patients were eligible. After PSM, two well-balanced groups of 3244 patients each were analyzed. ACR resulted in superior OS compared with AC alone (Hazard ratio [HR] 0.83, 95% CI 0.79-0.87; median OS 22 vs 19 months, P < .0001). Subset analyses demonstrated OS benefit of ACR compared with AC in N+, R0 patients (HR: 0.82, 95% CI 0.77-0.88; Median OS 24 vs 20 months, P < .001) as well as N+, R1 patients (HR: 0.77, 95% CI 0.68-0.87; Median OS 17 vs 15 months, P < .001); but not in node-negative, R1 patients (HR: 1.12, 95% CI 0.84-1.48; Median OS 18 vs 22 months, P = .63).

CONCLUSION

The addition of radiation to AC was associated with a clinically small but meaningful increase in survival of patients undergoing curative-intent pancreatic resections. This association was not evident in patients with microscopically positive margins but node-negative disease and larger studies will be needed.

A prognostic nomogram for patients with resected fibrolamellar hepatocellular carcinoma

Background

Fibrolamellar hepatocellular carcinoma (FLHC) is a unique entity compared to conventional hepatocellular carcinoma. The aim of this study was to examine post-resection outcomes and prognostic indicators for survival in this group of FLHC patients.

Methods

A retrospective analysis of the National Cancer Database (NCDB) for patients with FLHC who underwent resection from 2004 to 2014 was performed. Univariate and multivariate Cox proportional hazard models were used to identify factors associated with overall survival, and a prognostic nomogram was generated.

Results

There were 197 patients identified, 171 (86.8%) of whom had long-term follow-up data. Univariate and multivariate analyses were performed using patient and tumor demographics with the outcome variable of overall survival. On multivariate analysis, age [hazard ratio (HR) 1.03, P=0.003], vascular invasion (HR 1.75, P=0.05), tumor size >7 cm (HR 2.18, P=0.044), multifocal disease (HR 3.34, P=0.002), and node positive (pN+) disease (HR 2.75, P=0.003) were all negative predictors of overall survival. A prognostic nomogram was generated using these factors with a c-statistic superior to that of American Joint Committee on Cancer (AJCC) staging (0.710 vs. 0.654).

Conclusions

Independent predictors of decreased overall survival in patients with FLHC include age, vascular invasion, tumor size >7 cm, multifocal disease, and pN+ disease. This is the first study to develop a nomogram exclusively for FLHC that may predict survival in future studies.

Multivisceral robotic liver surgery: feasible and safe

The application of robotic technology allows for the performance of multi-organ liver resections by multidisciplinary teams in a minimally invasive manner. Their technique and outcomes are not established. Herein we describe our technique with robotic liver surgery combined with colon, pancreas and urologic resections. Our patients are an 84-year-old (yo) female (Body Mass Index, BMI: 25) with a recently diagnosed right colon adenocarcinoma and two synchronous liver metastases at segments 5 and 6, a 75-year-old female (BMI: 50.4) with a history of right renal cell cancer status post (s/p) right robotic radical nephrectomy now with tumor recurrence with multiple intra-abdominal masses including a segment 7 liver lesion and a 71-year-old female (BMI: 24) with history of pancreatic ductal adenocarcinoma of the tail and a segment 3 liver lesion s/p neoadjuvant chemotherapy. The Xi robotic system (Intuitive Surgical, Sunnyvale, CA, USA) was utilized in all cases. Port placement in all cases was decided within the multidisciplinary teams to accommodate both the hepatic and the extra-hepatic portion of the operation. Parenchymal transections were performed with the use of the Vessel Sealer and the robotic stapler as appropriate. Indocyanine green (ICG) was used to assess the anastomotic perfusion in the first patient. Blood loss was 50 ml for the first two cases and 300 ml for the third. Surgical margins were negative in all cases. Patients were discharged at POD 8, 3 and 5 with one patient experiencing postoperative ileus. Robotic multivisceral liver resections are feasible and safe within multidisciplinary surgical teams with expertise in robotic surgery. The robotic platform can offer a minimally invasive approach in liver surgery synchronous with colonic, pancreatic and urologic surgery.

Lymphovascular Invasion Is Associated with Lymph Node Involvement in Small Appendiceal Neuroendocrine Tumors

BACKGROUND

Appendiceal neuroendocrine tumors (NETs) are incidentally found in up to 1% of appendectomy specimens. The association of lymphovascular invasion (LVI) with risk of regional lymph node involvement is unclear.

METHODS

From the National Cancer Database, 2004-2015, this study identified patients who had tumors 2 cm or smaller with one or more lymph nodes (LNs) pathologically evaluated. The histology was defined as typical, goblet cell, or composite NETs. Patient demographics, tumor characteristics, and treatment variables were analyzed.

RESULTS

The histologies for the 1767 identified patients were typical (n = 921, 52.1%), goblet cell (n = 556, 31.5%), and composite (n = 290, 16.4%). The tumor grades were low (70.4%), moderate (18.6%), and high (11%). The overall LN positivity was 17%. Of 1052 tumors evaluated, 215 (20.4%) had LVI. Overall survival decreased with node involvement (mean 84 vs. 124 months; p < 0.0001, log-rank). In the multivariate logistic regression analysis, LVI was independently associated with node involvement [odds ratio (OR) 5.0; p < 0.0001] after adjustment for patient age and tumor histologic subtype, size, and grade. In the subset analysis of typical NETs, tumor size of 1-2 cm (ref. < 1 cm; OR 5.5; p < 0.001) and presence of LVI (ref. absence of LVI; OR 4.8; p < 0.0001) were the only factors independently associated with LN involvement.

CONCLUSIONS

Node involvement is associated with worse overall survival in appendiceal NETs. The presence of LVI was strongly associated with lymph node involvement. An appendectomy specimen showing LVI should prompt strong consideration of colectomy with regional lymphadenectomy even for small, typical appendiceal NETs.

Intraoperative bile spillage is associated with worse survival in gallbladder adenocarcinoma

BACKGROUND

Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor.

METHODS

A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS).

RESULTS

Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006).

CONCLUSIONS

Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.

Readmissions After Complex Cancer Surgery: Analysis of the Nationwide Readmissions Database

PURPOSE

Hospital readmissions after surgery are a focus of quality improvement efforts. Although some reflect appropriate care, others are potentially preventable readmissions (PPRs). We aim to describe the burden, timing, and factors associated with readmissions after complex cancer surgery.

METHODS

The Nationwide Readmissions Database (2013) was used to select patients undergoing a complex oncologic resection, which was defined as esophagectomy/gastrectomy, hepatectomy, pancreatectomy, colorectal resection, lung resection, or cystectomy. Readmissions within 30 days from discharge were analyzed. International Classification of Diseases (9th revision) primary diagnosis codes were reviewed to identify PPRs. Multivariable logistic regression analyses identified demographic, clinical, and hospital factors associated with readmissions.

RESULTS

Of the 59,493 eligible patients, 14% experienced a 30-day readmission, and 82% of these were deemed PPRs. Half of the readmissions occurred within the first 8 days of discharge. Infections (26%), GI complications (17%), and respiratory conditions (10%) accounted for most readmissions. Factors independently associated with an increased likelihood of readmission included Medicaid versus private insurance (odds ratio [OR], 1.32; 95% CI, 1.17 to 1.48), higher comorbidity score (OR, 1.5; 95% CI, 1.33 to 1.63), discharge to a facility (OR, 1.39; 95% CI, 1.29 to 1.51), prolonged length of stay (OR, 1.42; 95% CI, 1.32 to 1.52), and occurrence of a major in-hospital complication (OR, 1.24; 95% CI, 1.16 to 1.34).

CONCLUSION

One in seven patients undergoing complex cancer surgery suffered a readmission within 30 days. We identified common causes of these and identified patients at high risk for such an event. These data can be used by physicians, administrators, and policymakers to develop strategies to decrease readmissions.

The role of sequential radiation following adjuvant chemotherapy in resected pancreatic cancer

Background

Optimal adjuvant therapy for resectable pancreatic cancer remains controversial. The Radiation Therapy Oncology Group (RTOG) 0848 is evaluating adjuvant chemotherapy (CT) with or without sequential chemoradiation in the absence of disease progression. In the absence of completed RTOG 0848 data, we addressed the question through a retrospective analysis.

Methods

The National Cancer Database was queried for non-metastatic, histologically-confirmed pancreatic carcinoma status post resection and adjuvant CT. Patients receiving neoadjuvant therapy were excluded. Multivariable logistic regression was performed to identify factors associated with receipt of sequential radiation therapy (RT) starting at least 4 months after CT, with generation of propensity scores. Log-rank analysis assessed univariate overall survival (OS), while multivariable Cox proportional hazards modeling examined multivariate OS. Six-month landmark analysis was performed to allow for completion of all planned adjuvant therapy.

Results

Of 15,661 patients, 14,167 (90.5%) underwent CT alone, and 1,494 (9.5%) received RT. Patients receiving RT had nodal disease and R+ resection more often (P<0.05). Median follow-up was 53.6 months. Sequential RT after adjuvant CT improved outcomes compared to adjuvant CT alone (3-year OS 44.6% vs. 35.3%; P<0.001). On multivariate analysis, sequential RT continued to improve OS (HR =0.68; 95% CI, 0.63-0.73; P<0.001). After propensity score adjustment, the benefit of sequential RT was maintained (HR =0.68, P<0.001).

Conclusions

Sequential RT after adjuvant CT for resected pancreatic cancer was associated with improved survival. The final results of RTOG 0848 are eagerly awaited to provide definitive evidence in this clinical scenario.

The effect of central administration of alpha-pinene on capsaicin-induced dental pulp nociception

AIM

To assess the effects of central administration of α-pinene alone and in combination with either bicuculline or naloxone, as GABAA and μ-opioid receptor antagonists, respectively, on capsaicin-induced dental pulp stimulation in rats.

METHODOLOGY

Forty-eight adult male Wistar rats aged 2 months (230-270 g) were cannulated via their lateral ventricles for the central administration of the drugs. α-Pinene was injected at 0.1, 0.2 and 0.4 μmol L-1 . Then, dental pulp stimulation was induced by intradental application of capsaicin solution (100 μg), and nociceptive scores were recorded for up to 40 min. For investigation of the anti-inflammatory effects of α-pinene, expression of COX-2 in the subnucleolus caudalis (Vc) of rats was determined using immunofluorescence staining. Nonparametric repeated measure Friedman and Kruskal-Wallis tests as well as parametric one-way analysis of variance were used for the statistical analysis.

RESULTS

α-Pinene at 0.2 and 0.4 μmol L-1 was able to decrease capsaicin-induced nociception. Moreover, there was a significant increase in the expression of COX-2-positive cells in the Vc of capsaicin-treated rats (P < 0.01). This effect was prohibited by α-pinene (0.4 μmol L-1 ). Co-administration of bicuculline (1 μg per rat) or naloxone (6 μg per rat) with α-pinene (0.4 μmol L-1 ), however, prevented the inhibitory effects of α-pinene on both capsaicin-induced pulp nociception and COX-2 over-expression.

CONCLUSIONS

Pinene exhibited significant curable effects on capsaicin-induced pulpal nociception and inflammation mainly via pharmacological interfacing with GABAA and μ-opioid receptors.

Adjuvant chemotherapy with or without sequential radiation in resected pancreatic adenocarcinoma: Who will win RTOG 0848?

334

Background: The current role of adjuvant radiation in the management of resected pancreatic adenocarcinoma (PC) is controversial. A prospective trial, RTOG 0848, is currently in process to determine optimal adjuvant therapy, comparing adjuvant chemotherapy (CT) with or without radiation (RT). We determined outcomes in this population using the National Cancer Database (NCDB). Methods: Patients with non-metastatic PC diagnosed from 2004 to 2015 were identified from the NCDB. Patients who underwent surgery and adjuvant chemotherapy were included. Patients who received RT were only included if RT began at least 4 months after CT, to emulate RTOG 0848 schema. A 6 month landmark analysis was performed. Overall survival (OS) was compared using log-rank Kaplan-Meier for univariate analysis (UVA), and Cox proportional hazards for multivariate analysis (MVA). Logistic regression was used to determine predictors of RT utilization and generate propensity scores. Results: We identified 16075 patients. Median follow-up was 30 months, 37 months for survivors. Patients received sequential RT in 9.5% of cases. On UVA, sequential RT demonstrated OS benefit compared to adjuvant chemotherapy alone (3-year OS 44.6% vs 35.3%, p < 0.001). RT utilization was more likely with diagnosis after 2010, age ≤ 65 years, private insurance, higher income, ≤ 10 miles to treatment facility, treatment in the northeast, node positive disease, positive margins, and head of pancreas primary. On MVA, benefit to RT on OS was maintained (HR 0.68, 95% CI 0.63-0.73, p < 0.001). Other factors that improved OS included diagnosis after 2010, no comorbidity, non-government insurance, higher income, and treatment at academic facility. Factors that predicted for worse OS included increasing pathologic tumor and nodal staging, positive margins, and CA 19-9 above a cut-off of 90. After propensity-adjustment, OS benefit was maintained for RT (HR 0.68, p < 0.001). Conclusions: In a large national database analysis, sequential RT improves survival in patients who receive at least 4 months of adjuvant chemotherapy following upfront resection for pancreatic adenocarcinoma. The results of RTOG 0848 are awaited to confirm these findings.

Using a Lymph Node Count Metric to Identify Underperforming Hospitals After Rectal Cancer Surgery

BACKGROUND

Investigating methods to assess the quality of cancer surgery and then benchmarking hospitals on these quality indicators can lead to improvements in cancer care in the United States. We sought to determine the utility of lymph node count as a quality metric.

METHODS

We performed a retrospective analysis of the California Cancer Registry database (2004-2011) merged with Office of Statewide Health Planning and Development inpatient database. Patients with locally advanced rectal adenocarcinoma who underwent neoadjuvant therapy and resection were included. Hospital quality score was defined as the proportion of patients at a particular hospital that had adequate examination with at least nine lymph nodes. High-quality score hospitals were those that retrieved nine or more nodes among ≥25% of operations. A multivariate Cox proportional hazards (standard and shared frailty) model was used to determine differences in overall survival adjusting for age, hospital volume, race, sex, insurance, comorbidity, T-stage, response to neoadjuvant therapy, adjuvant chemotherapy, and teaching hospital status as covariates.

RESULTS

A total of 2704 patients were treated at 228 hospitals (low-scoring hospital = 85 and high-scoring hospital = 143). Patient- and disease-specific characteristics were similar between the groups. Socioeconomic status and hospital characteristics were strongly associated with score status. High-scoring hospitals had higher sphincter preservation (P = 0.004), lower complications (P = 0.021), and a trend toward lower mortality (P = 0.079). Care at high-scoring hospitals independently predicted overall survival (hazard ratio: 0.74; 95% confidence interval: 0.61-0.90; P = 0.003).

CONCLUSIONS

This study demonstrates that hospital quality score based on lymph node count can be used to identify underperforming hospitals.

Prognostic significance of Chromogranin A in small pancreatic neuroendocrine tumors

BACKGROUND

The incidence of nonfunctional pancreatic neuroendocrine tumors ≤2cm is rising. The biologic behavior of these tumors is variable; thus, their management remains controversial. Chromogranin A upregulation is a useful diagnostic biomarker of neuroendocrine tumors; however, the prognostic significance of Chromogranin A is unclear. The objective of this study was to determine whether Chromogranin A levels have prognostic value in pancreatic neuroendocrine tumor patients and may help guide management.

METHODS

We evaluated the National Cancer Database over a 10-year period (2004-2013). Patients with pancreatic neuroendocrine tumors measuring ≤2cm, without distant metastases, were identified and categorized as Chromogranin A high (>420ng/mL) or Chromogranin A low (≤420ng/mL), and those lacking data on Chromogranin A levels were excluded from the study. Univariate and multivariate analyses were performed using Cox proportional hazards model. Cut-point determination was performed using the Contal and O'Quigley method.

RESULTS

Of the 445 eligible patients, 352 (79%) were Chromogranin A low and 93 (21%) were Chromogranin A high. Median Chromogranin A level was 71ng/mL (interquartile range, 24-294ng/mL). Chromogranin levels were associated with clinical nodal status and grade. Furthermore, on multivariate analysis, Chromogranin A levels (Chromogranin A high versus Chromogranin A low) independently predicted overall survival after controlling for tumor size, grade, clinical nodal status, and academic status of the facility (hazard ratio: 7.90, 95%CI: 2.34-26.69, P = .001). The greatest benefit of surgical resection was noted in patients in the Chromogranin A high subgroup (log-rank P <.001).

CONCLUSION

Serum Chromogranin A levels can be incorporated in surgical decision-making for patients with small pancreatic neuroendocrine tumors. Patients in the Chromogranin A low group can be considered for observation, whereas patients in the Chromogranin A high group should be strongly considered for resection.

Activation of orexin-1 receptors in the ventrolateral periaqueductal grey matter (vlPAG) modulates pulpal nociception and the induction of substance P in vlPAG and trigeminal nucleus caudalis

AIM

To characterize the role of orexin-1 receptors (OX1Rs) in ventrolateral periaqueductal grey matter (vlPAG) on modulation of capsaicin-induced pulpal nociception in rats.

METHODOLOGY

Sixty-six adult male Wistar rats (2 months old) weighing between 230 and 260 g were used. The animals were cannulated for microinjection of drugs into the vlPAG matter. Pulpalgia was induced by intradental application of capsaicin solution (100 μg) into the incisor teeth of the rats. Ten min prior to capsaicin application, orexin-A (50, 100 and 150 pmol L^-1 per rat) was administered. Orexin-A (150 pmol L^-1 ) was also co-administrated with SB-334867 (40 nmol L^-1 per rat), an OX1Rs antagonist; or bicuculline (1 μg per rat), a GABAA receptors antagonist. Moreover, treatment effects on the release of pro-nociceptive modulator substance P (SP) in vlPAG and trigeminal nucleus caudalis (Vc) of rats were explored using an immunofluorescence technique. One-way analysis of variance was used for the statistical analysis.

RESULTS

Orexin-A dose-dependently decreased capsaicin-induced nociceptive behaviour. However, SB-334867 (40 nmol L^-1 per rat) pretreatment (P < 0.05), but not bicuculline (1 μg per rat), attenuated the analgesic effect of orexin-A (150 pmol L^-1 ). The level of SP was significantly increased in Vc and decreased in vlPAG of capsaicin-treated rats (P < 0.05). Capsaicin-induced changes in SP levels, however, were prohibited by orexin-A treatment (150 pmol L^-1 ) (P < 0.05).

CONCLUSIONS

Orexin-A administration into the vlPAG was associated with an inhibitory effect on capsaicin-induced pulpal nociception and bidirectional effects on the induction of SP in vlPAG and Vc of rats. Central activation of OX1Rs is a potential therapeutic tool for pulpalgia.

Robotic Versus Open Minor Liver Resections of the Posterosuperior Segments: A Multinational, Propensity Score-Matched Study

BACKGROUND

Minor liver resections of posterosuperior segments (1, 4A, 7, 8) are challenging to perform laparoscopically and are mainly performed using an open approach. We determined the feasibility of robotic resections of posterosuperior segments and compared short-term outcomes with the open approach.

METHODS

Data on open and robotic minor (≤ 3 segments) liver resections including the posterosuperior segments, performed between 2009 and 2016, were collected retrospectively from four hospitals. Robotic and open liver resections were compared, before and after propensity score matching.

RESULTS

In total, 51 robotic and 145 open resections were included. After matching, 31 robotic resections were compared with 31 open resections. Median hospital stay was 4 days (interquartile range [IQR] 3-7) for the robotic group, versus 8 days (IQR 6-10) for the open group (p < 0.001). Median operative time was 222 min (IQR 164-505) for robotic cases versus 231 min (IQR 190-301) for open cases (p = 0.668). Median estimated blood loss was 200 mL (IQR 100-400) versus 300 mL (IQR 125-750), respectively (p = 0.212). In the robotic group, one patient (3%) had a major complication, versus three patients (10%) in the open group (p = 0.612). Readmissions were similar-10% in the robotic group versus 6% in the open group (p > 0.99). There was no mortality in either group.

CONCLUSION

Minor robotic liver resections of the posterosuperior segments are safe and feasible and display a shorter length of stay than open resections in selected patients at expert centers.

Academic productivity in surgical oncology: Where is the bar set for those training the next generation?

BACKGROUND AND OBJECTIVES

Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation.

METHODS

Faculty were identified from accredited surgical oncology fellowships in the United States. Scopus was used to obtain the number of publications/citations and h-index values. The National Institutes of Health (NIH) RePORT website was used to identify funding history.

RESULTS

Of the 319 surgeons identified, complete rank information was obtained for 308. The majority of faculty were men (70%) and only 11% of full professors were women. The median h-index values were 7, 17, and 39 for assistant, associate, and full professors, respectively. While 50% of full professors had a history of NIH funding, only 26% had RO1s and 20% had current NIH funding. Using multivariate analysis, years in practice, h-index, and a history of NIH funding were associated with academic rank (P < .05).

CONCLUSION

Objective benchmarks, such as the median h-index and NIH funding, provide additional insights for both junior faculty and leadership into the productivity needed to attain promotion to the next academic rank for surgical oncologists.