Echo Decorrelation Imaging of Rabbit Liver and VX2 Tumor during In Vivo Ultrasound Ablation

In open surgical procedures, image-ablate ultrasound arrays performed thermal ablation and imaging on rabbit liver lobes with implanted VX2 tumor. Treatments included unfocused (bulk ultrasound ablation, N = 10) and focused (high-intensity focused ultrasound ablation, N = 13) exposure conditions. Echo decorrelation and integrated backscatter images were formed from pulse-echo data recorded during rest periods after each therapy pulse. Echo decorrelation images were corrected for artifacts using decorrelation measured prior to ablation. Ablation prediction performance was assessed using receiver operating characteristic curves. Results revealed significantly increased echo decorrelation and integrated backscatter in both ablated liver and ablated tumor relative to unablated tissue, with larger differences observed in liver than in tumor. For receiver operating characteristic curves computed from all ablation exposures, both echo decorrelation and integrated backscatter predicted liver and tumor ablation with statistically significant success, and echo decorrelation was significantly better as a predictor of liver ablation. These results indicate echo decorrelation imaging is a successful predictor of local thermal ablation in both normal liver and tumor tissue, with potential for real-time therapy monitoring.

How Much Should We Pay to Minimize Pancreatic Leak? The Cost-effectiveness of Pasireotide in Pancreatic Resection: RETRACTED

INTRODUCTION

Pasireotide was recently shown to decrease leak rates after pancreatic resection, though the significant cost of the drug may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile by improving outcomes.

METHODS

A cost-effectiveness model was constructed to compare pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a recent randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify the most influential clinical components of the model.

RESULTS

Without considering pasireotide cost, prophylactic use of the drug saved an average of $8,109 per patient. However, when the cost of pasireotide was included, per patient costs increased from $42,159 to $77,202. This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A) (21.9% to 9.2%). The resultant cost per PF/PL/A avoided was $301,628. Threshold analysis demonstrated that for this intervention to be cost neutral, either the purchase price of pasireotide ($43,172) must be reduced by 92.3% (to $3324) or drug reimbursement must be $39,848. Sensitivity analyses exploring variable perioperative mortality, rate of PF/PL/A, and readmission rates did not significantly alter model outcomes.

CONCLUSIONS

Our analyses demonstrate that when prophylactic pasireotide is administered, the cost per PF/PL/A avoided is approximately $300,000. Aggressive pricing negotiation, payer reimbursement for the drug, high-volume use, and consensus among the public, payers, and surgical community regarding the value of reducing morbidity will ultimately determine the utility of widespread pasireotide application in pancreatic resection.

Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible

BACKGROUND

We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes.

METHODS

The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients.

RESULTS

Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization.

CONCLUSION

Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.

Preoperative Modified FOLFIRINOX Treatment Followed by Capecitabine-Based Chemoradiation for Borderline Resectable Pancreatic Cancer: Alliance for Clinical Trials in Oncology Trial A021101

IMPORTANCE

Although consensus statements support the preoperative treatment of borderline resectable pancreatic cancer, no prospective, quality-controlled, multicenter studies of this strategy have been conducted. Existing studies are retrospective and confounded by heterogeneity in patients studied, therapeutic algorithms used, and outcomes reported.

OBJECTIVE

To determine the feasibility of conducting studies of multimodality therapy for borderline resectable pancreatic cancer in the cooperative group setting.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, multicenter, single-arm trial of a multimodality treatment regimen administered within a study framework using centralized quality control with the cooperation of 14 member institutions of the National Clinical Trials Network. Twenty-nine patients with biopsy-confirmed pancreatic cancer preregistered, and 23 patients with tumors who met centrally reviewed radiographic criteria registered. Twenty-two patients initiated therapy (median age, 64 years [range, 50-76 years]; 55% female). Patients registered between May 29, 2013, and February 7, 2014.

INTERVENTIONS

Patients received modified FOLFIRINOX treatment (85 mg/m2 of oxaliplatin, 180 mg/m2 of irinotecan hydrochloride, 400 mg/m2 of leucovorin calcium, and then 2400 mg/m2 of 5-fluorouracil for 4 cycles) followed by 5.5 weeks of external-beam radiation (50.4 Gy delivered in 28 daily fractions) with capecitabine (825 mg/m2 orally twice daily) prior to pancreatectomy.

MAIN OUTCOMES AND MEASURES

Feasibility, defined by the accrual rate, the safety of the preoperative regimen, and the pancreatectomy rate.

RESULTS

The accrual rate of 2.6 patients per month was superior to the anticipated rate. Although 14 of the 22 patients (64% [95% CI, 41%-83%]) had grade 3 or higher adverse events, 15 of the 22 patients (68% [95% CI, 49%-88%]) underwent pancreatectomy. Of these 15 patients, 12 (80%) required vascular resection, 14 (93%) had microscopically negative margins, 5 (33%) had specimens that had less than 5% residual cancer cells, and 2 (13%) had specimens that had pathologic complete responses. The median overall survival of all patients was 21.7 months (95% CI, 15.7 to not reached) from registration.

CONCLUSIONS AND RELEVANCE

The successful completion of this collaborative study demonstrates the feasibility of conducting quality-controlled trials for this disease stage in the multi-institutional setting. The data generated by this study and the logistical elements that facilitated the trial's completion are currently being used to develop cooperative group trials with the goal of improving outcomes for this subset of patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01821612.

Two studies pave the way for preoperative therapy in pancreatic cancer patients

The delivery of chemotherapy and/or radiation in the preoperative setting (before surgical resection, instead of after it) has been hypothesized to improve both rates of margin-negative resection and survival.

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

BACKGROUND

Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT).

METHODS

We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points.

RESULTS

The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01).

CONCLUSIONS

Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

The natural history of chronic pancreatitis after operative intervention: The need for revisional operation

BACKGROUND

For patients with chronic pancreatitis, duodenum-sparing head resections and pancreaticoduodenectomy are effective operations to relieve abdominal pain. For patients who develop recurrent symptoms after their index operation, the long-term management remains controversial.

METHODS

Between 2002 and 2014, patients undergoing operative intervention for chronic pancreatitis were identified retrospectively. Patients requiring reoperation after their index operation were reviewed.

RESULTS

A total of 121 patients with chronic pancreatitis underwent an index operation. At a median time of 33 months, 85 patients underwent no further operative intervention, while 36 patients underwent reoperation. A reoperative procedure was completed with acceptable perioperative morbidity and blood loss. After a revision operation, 25% of patients became narcotic independent. Narcotic requirements decreased from 143 morphine equivalent milligrams per day (MEQ/d) to 80 MEQ/d, and 58% of patients required less than 50 MEQ/d. Insulin requirements were not increased from preoperative levels. Multivariate analysis demonstrated only narcotic requirement and exocrine insufficiency after the index operation to be predictive for the need for a revision operation.

CONCLUSION

Our data demonstrate the following: (1) A significant number of patients undergoing duodenum-sparing head resections (26%) or pancreaticoduodenectomy (29%) required reoperation for recurrent abdominal pain; and (2) a revisional operation can be effective in relieving recurrent abdominal symptoms. Patients with recurrent symptoms should be considered for additional operative intervention.

Gastric duplication cyst: a rare entity

Gastric duplication cysts are an uncommon finding, especially in the adult population. Presenting symptoms can be non-specific, but can include abdominal pain, nausea and emesis. In this report, we present a 28-year-old female diagnosed with a communicating gastric cyst with both gastric and duodenal mucosa, along with pancreatic tissue and no evidence of dysplasia or malignancy. The clinical picture, diagnosis and treatment are described and compared to findings in the literature.

Perception Is Reality: quality metrics in pancreas surgery - a Central Pancreas Consortium (CPC) analysis of 1399 patients

INTRODUCTION

Several groups have defined pancreatic surgery quality metrics that identify centers delivering quality care. Although these metrics are perceived to be associated with good outcomes, their relationship with actual outcomes has not been established.

METHODS

A national cadre of pancreatic surgeons was surveyed regarding perceived quality metrics, which were evaluated against the Central Pancreas Consortium (CPC) database to determine actual performance and relationships with long-term outcomes.

RESULTS

The most important metrics were perceived to be participation in clinical trials, appropriate clinical staging, perioperative mortality, and documentation of receipt of adjuvant therapy. Subsequent analysis of 1399 patients in the CPC dataset demonstrated that a R0 retroperitoneal and neck margin was obtained in 79% (n = 1109) and 91.4% (n = 1278) of cases, respectively. 74% of patients (n = 1041) had >10 lymph nodes harvested, and LN positivity was 65% (n = 903). 76% (n = 960) of eligible patients (surgery first approach) received adjuvant therapy within 60 days of surgery. Multivariate analysis demonstrated margin status, identification of >10 lymph nodes, nodal status, tumor grade and delivery of adjuvant therapy within 60 days to be associated with improved overall survival.

CONCLUSIONS

These analyses demonstrate that systematic monitoring of surgeons' perceived quality metrics provides critical prognostic information, which is associated with patient survival.

Adjuvant Therapy in Pancreas Cancer: Does It Influence Patterns of Recurrence?

BACKGROUND

Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC.

STUDY DESIGN

Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated.

RESULTS

There were 1,130 patients who were divided into those having surgery alone (n = 392), ACT (n = 291), or ACRT (n = 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT.

CONCLUSIONS

This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC.

A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Resectable pancreatic ductal adenocarcinoma continues to carry a poor prognosis. Of the controllable clinical variables known to affect outcome, margin status is paramount. Though the importance of a R0 resection is generally accepted, not all margins are easily managed. The superior mesenteric artery [SMA] in particular is the most challenging to clear. The aim of this study was to systematically review the literature with specific focus on the role of a SMA periadventitial dissection during PD and it's effect on margin status in pancreatic adenocarcinoma.

STUDY DESIGN

The MEDLINE, EMBASE and Cochrane databases were searched for abstracts that addressed the effect of margin status on survival and recurrence following pancreaticoduodenectomy [PD]. Quantitative analysis was performed.

RESULTS

The overall incidence of a R1 resection ranged from 16% to 79%. The margin that was most often positive following PD was the SMA margin, which was positive in 15-45% of resected specimens. Most studies suggested that a positive margin was associated with decreased survival. No consistent definition of R0 resection was observed.

CONCLUSIONS

Margin positivity in resectable pancreatic adenocarcinoma is associated with poor survival. Inability to clear the SMA margin is the most common cause of incomplete resection. More complete and consistently reported data are needed to evaluate the potential effect of periadventitial SMA dissection on margin status, local recurrence, or survival.

A multi-center study of 349 pancreatic mucinous cystic neoplasms: Preoperative risk factors for adenocarcinoma

231

Background: Pancreatic mucinous cystic neoplasms (MCN) are defined by presence of ovarian stroma per WHO 2000 classification. Given their malignant potential, current guidelines recommend resection. However, there are limited data on preoperative risk factors for adenocarcinoma (AC) and high grade dysplasia (HGD) occurring in an MCN. Methods: MCN resections from 2000-2014 at the 8 institutions of the Central Pancreas Consortium were included. Patients with and without AC/HGD were compared. Primary aims were to determine preoperative risk factors for AC/HGD in an MCN and to assess outcomes of MCN-associated AC. Results: Of 1667 resections for pancreatic cystic lesions, 349 pts (21%) had an MCN with 52 (15%) having MCN-associated AC/HGD. Male gender (29 vs 8%; p<0.001), head/neck location (39 vs 13%; p<0.001), increased MCN size (7.2 vs 4.6 cm; p=0.004), radiographic presence of a solid component/mural nodule (54 vs 20%; p<0.001), and duct dilation (43 vs 12%; p<0.001) were associated with AC/HGD compared to benign MCN. All persisted as independent predictors of MCN-associated AC/HGD (Table). AC/HGD was not associated with presence of radiographic septations or preoperative cyst fluid analysis (CEA, amylase, or mucin). Median CA19-9 for patients with AC/HGD was 210 vs 15 U/ml for those without (p=0.001). In the 44 pts with AC, 41 (93%) had lymph nodes harvested with nodal metastases in only 14 (34%). Median FU for pts with AC was 27 mos. AC recurred in 12 pts (27%) with a 3-yr RFS of 59%. OS for pts with MCN-associated AC was 64% at 3 yrs. Conclusions: Adenocarcinoma or high grade dysplasia is present in 15% of resected pancreatic mucinous cystic neoplasms. Pre-operative factors associated with AC/HGD in an MCN include male gender, head/neck location, larger MCN, solid component/mural nodule, and duct dilation on imaging. MCN-associated AC appears to have decreased LN involvement and increased RFS and OS compared to typical pancreatic ductal adenocarcinoma. [Table: see text]

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care

OBJECTIVE(S)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

METHODS

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

RESULTS

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p < 0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48-3.07], p < 0.001), discharge to rehab (OR 1.84, [1.28-2.64], p < 0.001), home with home health care (OR 1.38, [1.08-1.76], p = 0.01), and surgery at a low-volume hospital (OR 1.49, [1.18-1.88], p < 0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53-0.85], p < 0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

CONCLUSIONS

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

Adjuvant Therapy for Gallbladder Cancer: an Analysis of the National Cancer Data Base

BACKGROUND

The role of adjuvant therapy in patients with resected gallbladder cancer (GBC) is unclear.

METHODS

The American College of Surgeons National Cancer Data Base was used to identify patients with resected GBC (pathologic stage 1-3) from 1998 to 2006 (n = 6690). We compared three groups: surgery only (S, 78.6 %), surgery plus adjuvant chemotherapy (AC, 6.2 %), and surgery plus adjuvant chemotherapy and radiation therapy (ACR, 15.1 %). Univariate and Cox regression analyses were used to determine factors influencing overall survival and the use of adjuvant therapy.

RESULTS

ACR was associated with improved survival for all patients (HR 0.77, 95 % CI 0.66-0.90), especially node-positive patients (HR 0.64, 95 % CI 0.53-0.78); AC was not associated with changes in survival. Patients were less likely to have their lymph nodes examined if they had any comorbidities, lower income, or were treated at community cancer centers (all p < 0.05). Among patients with unknown lymph node status, those with T2 or T3 disease saw improved survival with ACR (T2: HR 0.79, 95 % CI 0.63-0.99; T3: HR 0.43, 95 % CI 0.30-0.62), while AC did not affect survival.

CONCLUSION

ACR is associated with improved survival for patients with node-positive GBC, as well as those with T2 or T3 GBC with unknown lymph node status.

Disability adjusted life years among arsenicosis patients in an arsenic-affected area of southern Bangladesh

Disability adjusted life years (DALY) is the sum of the present value of future years of lifetime lost through premature mortality, and the present value of years of future life-time adjusted for the average severity of any mental or physical disability caused by a disease or injury. As a method for estimating the global burden of disease, DALY was first introduced in the World Development Report in 1993 by the World Bank. The aim of this study was to estimate DALY among arsenicosis patients. DALY was calculated for 104 arsenicosis patients from an arsenic-affected rural area of southern Bangladesh using the estimated years they lived with disability (YLD). The mean (SD) of cumulative arsenic exposure level was 5.0 (3.2) mg/l-years. Among the patients, 64% reported reduction in working ability. The portion of the patients with disability for more than 50 years was as high as 58.7%. The mean (SD) of YLD and DALY was 54.0 (9.8) and 9.2 (1.5), respectively. A total of 5621 YLD equivalent to 961.7 DALY was lost due to arsenicosis (when life expectancy at birth according to Bangladesh Bureau of Statistics was applied, the YLD and DALY were 3899.2 and 868.9, respectively). There was significant relationship of YLD with education of the patients (p < 0.05). There was significant relationship between DALY and education of the patients (p < 0.05). There was also significant relationship between DALY and reduction in working ability of the patients (p < 0.05). The findings of the study justify for the policy makers to adopt adequate measures such as prevention, treatment and rehabilitation to alleviate the sufferings of the arsenicosis patients.Mediscope Vol. 2, No. 1: 2015, Pages 4-12