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Singh G, Morant L, Bedra M, Emel J, Harris K, Markan Y, de Borja C, Tong M, Downs P, Boutros C. Value of a multidisciplinary geriatric oncology committee on patient care in a community-based, academic cancer center. J Geriatr Oncol 2024; 15:101771. [PMID: 38615579 DOI: 10.1016/j.jgo.2024.101771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/14/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION The heterogeneity in health and functional ability among older patients makes the management of cancer a unique challenge. The Geriatric Oncology Program at the University of Maryland Baltimore Washington Medical Center (BWMC) was created to optimize cancer management for older patients. This study aimed to assess the benefits of the implementation of such a program at a community-based academic cancer center. MATERIALS AND METHODS We analyzed patients aged ≥80 years presenting to the Geriatric Oncology Program between 2017 and 2022. A multidisciplinary team of specialists collectively reviewed each patient using geriatric-specific domains and stratified each patient into one of three management groups- Group 1: those deemed fit to receive standard oncologic care (SOC); Group 2: those recommended to receive optimization services prior to reassessment for SOC; and Group 3: those deemed to be best suited for supportive care and/or hospice care. RESULTS The study cohort consisted of 233 patients, of which 76 (32.6%) received SOC, 43 (18.5%) were optimized, and 114 (49.0%) received supportive care or hospice referral. Among the optimized patients, 69.8% were deemed fit for SOC upon re-evaluation following their respective optimization services. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) score was implemented in 2019 (n = 90). Patients receiving supportive/hospice care only had an average score of 5.8, while the averages for those in the optimization and SOC groups were 4.6 and 4.1, respectively (p ≤0.001). Patients receiving SOC had the longest average survival of 2.71 years compared to the optimization (2.30 years) and supportive care groups (0.93 years) (p ≤0.001). For all patients that underwent surgical interventions post-operatively, 23 patients (85%) were discharged home and four (15%) were discharged to a rehabilitation facility. DISCUSSION The present study demonstrates the profound impact that the complexities in health status and frailty among older individuals can have during cancer management. The Geriatric Oncology Program at BWMC maximized treatment outcomes for older adults through the provision of SOC therapies and optimization services, while also minimizing unnecessary interventions on an individual patient-centric level.
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Affiliation(s)
- Gurbani Singh
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States; University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201, United States
| | - Lena Morant
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - McKenzie Bedra
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Jennifer Emel
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Kelly Harris
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Yudhishtra Markan
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Christopher de Borja
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Monica Tong
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Patrice Downs
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States
| | - Cherif Boutros
- University of Maryland Baltimore Washington Medical Center, 301 Hospital Dr, Glen Burnie, MD 21061, United States; University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201, United States.
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Boalt-Watson B, Boutros C. Enhancing recovery: Joining the Improving Surgical Care and Recovery programme to decrease colorectal surgical site infections. J Perioper Pract 2021; 31:419-426. [PMID: 33844594 DOI: 10.1177/1750458920962029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Surgical site infections after colorectal surgery are a clinical and financial challenge in healthcare. The purpose of this project was to decrease the rate of surgical site infections in colorectal surgical patients in a community hospital with an academic cancer centre in the United States of America. METHOD The Quality Improvement Department obtained data to measure the hospital's performance with colorectal surgical patients. The data examined the surgical site infection rate and the length of stay. A multidisciplinary team was established to implement protocols to improve compliance. RESULTS More than 200 patients received a colorectal surgical resection at the hospital. The implemented protocols decreased both the surgical site infection rate and the length of stay (9.1-0% and median 6-4 days respectively). DISCUSSION Challenges with implementation of the Improving Surgical Care and Recovery programme, in a community setting, are discussed. The challenges were worked through collaboratively to achieve the best outcomes for the patients. CONCLUSION The interdisciplinary committee used evidence-based practices to enhance the care of the colorectal patients. Some of the protocols that emerged were: patient education, pain medication, mechanical bowel preparation and antibiotics, as well as early alimentation. The protocols are discussed in Tables 1 to 4.
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Affiliation(s)
| | - Cherif Boutros
- 21666Baltimore Washington Medical Center, Glen Burnie, MD, USA
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Sun R, Sundahl N, Hecht M, Putz F, Lancia A, Milic M, Carré A, Lerousseau M, Theo E, Battistella E, Andres EA, Louvel G, Durand-Labrunie J, Bockel S, Bahleda R, Robert C, Boutros C, Vakalopoulou M, Paragios N, Frey B, Massard C, Fietkau R, Ost P, Gaipl U, Deutsch E. PD-0425: Radiomics for selection of patients treated with immuno-radiotherapy: pooled analysis from 6 studies. Radiother Oncol 2020. [DOI: 10.1016/s0167-8140(21)00447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Leone MJ, Sun H, Boutros C, Sullivan L, Thomas RJ, Robbins G, Mukerji S, Westover M. 1008 Brain Age Based on Sleep Encephalography is Elevated in HIV+ Adults on ART. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Sleep EEG is a promising tool to measure brain aging in vulnerable populations such as people with HIV, who are high risk of brain aging due to co-morbidities, increased inflammation, and antiretroviral neurotoxicity. Our lab previously developed a machine learning model that estimates age from sleep EEG (brain age, BA), which reliably predicts chronological age (CA) in healthy adults. The difference between BA and CA, the brain age index (BAI), independently predicts mortality, and is increased by cardiovascular co-morbidities. Here, we assessed BAI in HIV+ compared to matched HIV- adults.
Methods
Sleep EEGs from 43 treated HIV+ adults were gathered and matched to controls (HIV-, n=284) by age, gender, race, alcoholism, smoking and substance use history. We compared BAI between groups and used additional causal interference methods to ensure robustness. Individual EEG features that underlie BA prediction were also compared. We performed a sub-analysis of BAI between HIV+ with or without a history of AIDS.
Results
After matching, mean CA of HIV+ vs HIV- adults were 49 and 48 years, respectively (n.s.). The mean HIV+ BAI was 3.04 years higher than HIV- (4.4 vs 1.4 yr; p=0.048). We found consistent and significant results with alternative causal inference methods. Several EEG features predictive of BA were different in the HIV+ and HIV- cohorts. Most notably, non-REM stage 2 sleep (N2) delta power (1-4Hz) was decreased in HIV+ vs. HIV- adults, while theta (4-8Hz) and alpha (8-12Hz) power were increased. Those with AIDS (n=19, BAI=4.40) did not have significantly different BAI than HIV+ without AIDS (n=23, BAI=5.22). HIV+ subjects had higher rates of insomnia (56% vs 29%, p<0.001), obstructive apnea (47% vs 30%, p=0.03), depression (49% vs 23%, p<0.001), and bipolar disorder (19% vs 4%, p<0.001).
Conclusion
HIV+ individuals on ART have excess sleep-EEG based brain age compared to matched controls. This excess brain age is partially due to reduction in delta power during N2, suggesting decreased sleep depth. These results suggest sleep EEG could be a valuable brain aging biomarker for the HIV population.
Support
This research is supported by the Harvard Center for AIDS Research HU CFAR NIH/NIAID 5P30AI060354-16.
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Affiliation(s)
- M J Leone
- Massachusetts General Hospital, Boston, MA
| | - H Sun
- Massachusetts General Hospital, Boston, MA
| | - C Boutros
- Massachusetts General Hospital, Boston, MA
| | - L Sullivan
- Massachusetts General Hospital, Boston, MA
| | - R J Thomas
- Massachusetts General Hospital, Boston, MA
| | - G Robbins
- Massachusetts General Hospital, Boston, MA
| | - S Mukerji
- Massachusetts General Hospital, Boston, MA
| | - M Westover
- Massachusetts General Hospital, Boston, MA
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Boutros C, Chaput N, Lanoy E, Larive A, Mateus C, Routier E, Roy S, Sun R, Lancia A, Tao Y, Ibrahim N, Khoury-Abboud R, Massard C, Bahleda R, Schwob D, Caramella C, Cassard L, Soria JC, Robert C, Deutsch E. Ancillary evaluation of systemic immune antitumour response (SIAR) and tumour growth rate (TGR) of patients (pts) with metastatic melanoma (MM) treated with radiotherapy (RT) combined with ipilimumab (ipi) in the phase I study Mel-Ipi-Rx. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz255.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sun R, Lancia A, Sundahl N, Milic M, Carre A, Lerousseau M, Estienne T, Battistella E, Klausner G, Bahleda R, Alvarez-Andres E, Robert C, Boutros C, Vakalopoulou M, Paragios N, Ost P, Massard C, Deutsch E. Evaluation of a radiomic signature of CD8 cells in patients treated with immunotherapy-radiotherapy in three clinical trials. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz239.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Seaton M, Hanna A, Boutros C, Hanna N. Adjuvant therapy for pancreatic body or tail adenocarcinoma: a study of the National Cancer Database. Ther Adv Med Oncol 2019; 11:1758835919842438. [PMID: 31105777 PMCID: PMC6501493 DOI: 10.1177/1758835919842438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 01/23/2019] [Indexed: 01/19/2023] Open
Abstract
Background: The optimal multimodality therapy for pancreatic ductal adenocarcinoma in the body or tail of the pancreas (PDAC-BT) is unclear. The purpose of this study was to compare overall 5-year survival between patients treated with adjuvant chemotherapy, adjuvant chemoradiation, and surgery alone. Methods: Patients from the National Cancer Database (1998–2012) with resected stage I or II PDAC-BT were included. Overall survival between the three treatment groups was compared using Cox proportional-hazards regression, propensity-score matching, and the Kaplan–Meier method. Results: Of the 700 patients included in the analysis, 189 (27%) were treated with chemotherapy, 226 (32%) were treated with chemoradiation, and 285 (41%) were treated with surgery alone. Chemoradiation was associated with higher survival than surgery alone [adjusted hazard ratio (HRadj): 0.67; 95% confidence interval (CI): 0.54, 0.84; p = 0.001], but there was no difference between chemotherapy and chemoradiation (HRadj: 0.82; 95% CI: 0.65, 1.05; p = 0.115). In propensity-score matched cohorts, median survival was 24.1 months (95% CI: 20.4, 28.4) with chemotherapy and 25.4 months (95% CI: 22.1, 31.7) with chemoradiation (log-rank p = 0.122). Among patients with positive resection margins, chemoradiation was associated with higher survival compared with chemotherapy (HRadj: 0.54; 95% CI: 0.32, 0.92; p = 0.022). In this subgroup of the propensity-score matched cohorts, median survival was 9.5 months (95% CI: 8.4, 16.0) with chemotherapy and 18.3 months (95% CI: 11.6, 26.3) with chemoradiation (log-rank p = 0.011). Conclusion: In patients with resected pancreatic body or tail adenocarcinoma, adjuvant chemoradiation was associated with higher survival compared with surgery alone. Among patients with positive resection margins, adjuvant chemoradiation was associated with higher survival compared with adjuvant chemotherapy.
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Affiliation(s)
- Max Seaton
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Andrew Hanna
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Cherif Boutros
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA Department of Surgery, Tate Cancer Center, Baltimore Washington Medical Center, Glen Burnie, MD, USA
| | - Nader Hanna
- Professor of Surgery, University of Maryland Medical Center, 29 South Greene Street, Suite 600, Baltimore, MD 21201-1595, USA
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Pradère P, Boutros C, Scoazec J, Dorfmüller P, Leroy-Ladurie F, Boulate D, Le Pavec J, Robert C. Pulmonary nodules and immunotherapy: disease progression or toxicity of anti-PD1/anti-PDL1 checkpoint inhibitors? Eur J Cancer 2018; 93:144-146. [DOI: 10.1016/j.ejca.2017.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/24/2022]
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Bedra M, Vyskocil T, Emel J, Edwards C, Boutros C. Synergetic role of integrating the departments of cancer registry and clinical research at an academic comprehensive cancer center. World J Methodol 2017; 7:33-36. [PMID: 28706857 PMCID: PMC5489421 DOI: 10.5662/wjm.v7.i2.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/10/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
Integration of the cancer registry and clinical research departments can have a significant impact on the accreditation process of a Commission on Cancer (CoC) Program. Here in we demonstrate that the integration of both departments will benefit as there is increased knowledge, manpower and crossover in job responsibilities in our CoC-accredited Academic Comprehensive Cancer Center. In our model this integration has led to a more successful cooperative interaction among departments, which has in turn created an enhanced combined effect on overall output and productivity. More manpower for the cancer registry has led to increased caseloads, decreased time from date of first contact to abstraction, quality of data submissions, and timely follow-up of all patients from our reference date for accurate survival analysis along with completeness of data. In 2016, our Annual Facility report showed an additional 163 cases over prediction by the state of Maryland Cancer Registry and a 39% increase in case completeness. As proof of the synergetic effectiveness of our model within one year of its implementation, the cancer center was able to apply for, and was awarded membership from Alliance for Clinical Trials in Oncology, Central IRB, and in turn led to increased clinical trial accrual from 2.8% in 2014 compared to 13.2% currently. Our cancer registry in year one submitted over 150 more cases than predicted, improved quality outcome measures displayed by our Cancer Program Practice Profile reports and had more timely and complete data submissions to national and state registries. This synergetic integration has led to a better understanding, utilization and analysis of data by an integrated team with Clinical Research expertise.
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Reigneau M, Mateus C, Routier E, Boutros C, Fahmy J, Gohufi L, Libenciuc C, Robert C. Réponse rapide et spectaculaire de deux mélanomes desmoplastiques localement avancés au pembrolizumab. Ann Dermatol Venereol 2016. [DOI: 10.1016/j.annder.2016.09.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Boutros C, Mateus C, Routier E, Chouaib S, Libenciuc C, Reigneau M, Girault I, Caramella C, Hibat S, Vagner S, Tao Y, Chaput N, Adam J, Soria JC, Eggermont A, Deutsch E, Robert C. A dose escalation phase 1 study of radiotherapy (RT) in combination with anti-cytotoxic-T-lymphocyte-associated antigen 4 (CTLA-4) monoclonal antibody ipilimumab (Ipi) in patients (pts) with metastatic melanoma. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw379.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Boutros C, Routier E, Hua C, Texier M, Mateus C, Libenciuc C, Reigneau M, Benannoune N, Roy S, Lanoy E, Le Pavec J, Ladurie F, Carbonnel F, Lambotte O, Izzedine H, Berdelou A, Champiat S, Soria JC, Eggermont A, Robert C. Detailed safety profile of the anti-PD-1 monoclonal antibody pembrolizumab in 78 consecutive patients (pts) with advanced melanoma. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw379.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bluthgen M, Boutros C, Fayard F, Remon J, Planchard D, Besse B. Activity and safety of oral etoposide in pretreated patients with metastatic or recurrent thymic epithelial tumors (TET): A single-institution experience. Lung Cancer 2016; 99:111-6. [DOI: 10.1016/j.lungcan.2016.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/20/2016] [Accepted: 06/26/2016] [Indexed: 11/17/2022]
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Cunetta M, Point G, Liu Z, Guha P, Darpolor J, Lima M, Espat NJ, Hanna N, Boutros C, Junghans RP, Katz S. Abstract 2301: Intraperitoneal CAR-T infusion results in durable protection against peritoneal metastases and control of systemic tumor growth. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-2301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Colorectal carcinomatosis due to peritoneal metastases (PM) is a significant cause of morbidity and mortality. Present treatments fail to cure the majority of patients with PM. We are developing a chimeric antigen receptor T cell (CAR-T) regional infusion immunotherapy platform for PM. We treated mice with established CEA+ MC38 PMs with anti-CEA CAR-Ts either via regional intraperitoneal (IP) or systemic tail vein (TV) infusion. When compared to TV infusion, IP delivery resulted in significantly improved responses (37-fold reduction in tumor growth, p<0.01). To measure the durability of protection from IP tumor growth, we re-challenged mice with IP tumor following successful treatment with IP CAR-Ts. Mice who had received initial IP CAR-T treatment were protected from tumor growth following re-challenge for 20 days compared to control animals (1390-fold reduction in tumor growth, p = 0.016). Assessment of IP tumor 10 and 28 days following tumor re-challenge revealed a high proportion of intratumoral CAR-Ts (Day 10- 70.0%, Day 28- 46.6%; p = 0.10) and the proportion of CAR-Ts with an effector memory phenotype (CD44+CD62L-CCR7-, Day 10- 19.3%, Day 28- 60.0%; p<0.01). In separate experiments, we studied the effect of IP CAR-T infusions on tumor growth at distant sites. We established both IP and subcutaneous (SQ) flank tumors in mice prior to CAR-T infusions. Following treatment, IP CAR-T infusion resulted in a significant decrease in SQ tumor growth on day 8 compared to control (5.7-fold, p = 0.03), and a trend toward improvement compared to TV (4.9-fold, p = 0.224). While CAR-Ts were not detected in whole blood, SQ tumor, or draining lymph nodes following IP CAR-T infusion, serum IFNγ levels were significantly elevated on day 4 compared to control mice (p = 0.04), and returned to baseline by day 7. Our findings demonstrate that regional IP CAR-T delivery provides durable protection against IP tumor growth in association with CAR-T effector memory programming, in addition to a systemic anti-tumor effect.
Citation Format: Marissa Cunetta, Gary Point, Zhi Liu, Prajna Guha, Josephine Darpolor, Matthew Lima, N J. Espat, Nader Hanna, Cherif Boutros, Richard P. Junghans, Steven Katz. Intraperitoneal CAR-T infusion results in durable protection against peritoneal metastases and control of systemic tumor growth. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2301.
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Affiliation(s)
| | - Gary Point
- 1Roger Williams Medical Center, Providence, RI
| | - Zhi Liu
- 1Roger Williams Medical Center, Providence, RI
| | - Prajna Guha
- 1Roger Williams Medical Center, Providence, RI
| | | | | | - N J. Espat
- 1Roger Williams Medical Center, Providence, RI
| | | | | | | | - Steven Katz
- 1Roger Williams Medical Center, Providence, RI
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Kossai M, Duchemann B, Boutros C, Caramella C, Hollebecque A, Angevin E, Gazzah A, Bahleda R, Ileana E, Massard C, Vielh P, Soria J, Besse B. Antitumor activity in advanced cancer patients with thymic malignancies enrolled in early clinical drug development programs (Phase I trials) at Gustave Roussy. Lung Cancer 2015; 89:306-10. [DOI: 10.1016/j.lungcan.2015.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/08/2015] [Accepted: 06/14/2015] [Indexed: 12/12/2022]
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Point G, Thorn M, Cunetta M, Bais A, Boutros C, Hanna N, Espat N, Junghans R, Katz S. Anti-CEA chimeric antigen receptor T cells in combination with suppressor cell targeting for the treatment of colorectal cancer peritoneal metastases (VAC7P.1043). The Journal of Immunology 2015. [DOI: 10.4049/jimmunol.194.supp.143.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Colorectal peritoneal metastases (PM) is a grave condition in which tumor cells disseminate throughout the abdomen. Chimeric antigen receptor T cell (CAR-T) immunotherapy is a promising therapy for PM. We developed a novel regional delivery approach to maximize CAR-T efficacy against PM while limiting systemic toxicity. Murine tumor cells expressing CEA and luciferase were injected intraperitoneally (IP) in mice to induce PM (day 0). We injected murine anti-CEA CAR-T IP on days 3 and 6, alone or in combination with antibodies against Ly6G/Ly6C, PDL1 or GITR to target myeloid suppressor cells (MSC) or regulatory T cells (Treg), which we have shown to be present in PM. Tumor burden was measured by bioluminescence. In comparison to unmodified T cells, CAR-T alone mediated a 22-fold reduction of tumor burden (p=0.028). The combination of CAR-T with anti-PDL1, anti-GITR or anti-Ly6G/Ly6C treated groups showed 25-fold, 104-fold and 153-fold reductions, respectively. The CAR-T + anti-GITR and CAR-T + anti-Ly6G/Ly6C groups had a significantly better treatment response than CAR-T alone (p=0.005 and p=0.017). On days 8 and 10, CAR-T + anti-Ly6G/Ly6C tumor burdens dropped below detectable levels. Upon gross inspection, CAR-T treated mice did not have detectable tumor. Our findings demonstrate that targeting MSC and Treg in addition to regional IP CAR-T delivery represents a viable immunotherapeutic strategy that resulted in complete responses in mice with established PM.
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Affiliation(s)
- Gary Point
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
| | - Mitchell Thorn
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
| | - Marissa Cunetta
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
| | - Anthony Bais
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
| | | | - Nader Hanna
- 4Dept of Surgery, Univ of Maryland, Baltimore, MD
| | - N Espat
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
- 2Boston University School of Medicine, Boston, MA
| | - Richard Junghans
- 3Department of Medicine, Roger Williams Medical Center, Providence, RI
| | - Steven Katz
- 1Department of Surgery, Roger Williams Medical Center, Providence, RI
- 2Boston University School of Medicine, Boston, MA
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Boutros C, Mazouni C, Lerebours F, Stevens D, Lei X, Gonzalez-Angulo AM, Delaloge S. A preoperative nomogram to predict the risk of synchronous distant metastases at diagnosis of primary breast cancer. Br J Cancer 2015; 112:992-7. [PMID: 25668007 PMCID: PMC4366891 DOI: 10.1038/bjc.2015.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 01/07/2015] [Accepted: 01/12/2015] [Indexed: 01/13/2023] Open
Abstract
Background: The detection of synchronous metastases at primary diagnosis of breast cancer (BC) affects its initial management. A risk calculator that incorporates many factors to evaluate an individual's risk of harbouring synchronous metastases would be useful to adapt cancer management. Patients and Methods: Patients with primary diagnosis of BC were identified from three institutional databases sharing homogeneous work-up recommendations. A risk score for synchronous metastases was estimated and a nomogram was constructed using the first database. Its performance was assessed by receiver characteristic (ROC) analysis. The nomogram was externally validated in the two independent cohorts. Results: A preoperative nomogram based on the clinical tumour size (P<0.001), clinical nodal status (P<0.001), oestrogen (P=0.17) and progesterone receptors (P=0.04) was developed. The nomogram accuracy was 87.3% (95% confidence interval (CI), 84.45–90.2%). Overall, the area under the ROC curve (AUC) was 86.1% for the validation set from the Institut Curie-René Huguenin, and 63.8% for the MD Anderson validation set. The negative predictive value (NPV) was high in the three cohorts (97–99%). Conclusions: We developed and validated a strong metastasis risk calculator that can evaluate with high accuracy an individual's risk of harbouring synchronous metastases at diagnosis of primary BC. Condensed abstract: A nomogram to predict synchronous metastases at diagnosis of breast cancer was developed and externally validated. This tool allows avoiding unnecessary expensive work-up.
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Affiliation(s)
- C Boutros
- Department of Breast and Medical Oncology, Institut Gustave Roussy, Villejuif 94805, France
| | - C Mazouni
- Department of Surgery, Division of Breast and Plastic Surgery, Institut Gustave Roussy, Villejuif 94805, France
| | - F Lerebours
- Department of Breast and Medical Oncology, Institut Curie, Hôpital René Huguenin, Saint-Cloud, France
| | - D Stevens
- Department of Breast and Medical Oncology, Institut Curie, Hôpital René Huguenin, Saint-Cloud, France
| | - X Lei
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA
| | - A M Gonzalez-Angulo
- Department of Breast Medical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - S Delaloge
- Department of Breast and Medical Oncology, Institut Gustave Roussy, Villejuif 94805, France
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Boutros C, Mateus C, Texier M, Routier E, Violet-Khayat R, Boussemart L, Thomas M, Cazenave H, Benannoune N, Celebic A, Robert C. Tolérance et effets indésirables de l’anticorps monoclonal MK-3475 chez les patients atteints de mélanome avancé. Ann Dermatol Venereol 2014. [DOI: 10.1016/j.annder.2014.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Zhu Y, Hanna N, Boutros C, Alexander HR. Assessment of clinical benefit and quality of life in patients undergoing cytoreduction and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for management of peritoneal metastases. J Gastrointest Oncol 2013; 4:62-71. [PMID: 23450068 DOI: 10.3978/j.issn.2078-6891.2012.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 09/28/2012] [Indexed: 12/21/2022] Open
Abstract
Peritoneal metastasis is a significant clinical challenge; life expectancy following diagnosis is usually very short. Surgical cytoreduction with HIPEC is being used with increasing frequency in selected patients; most outcome data have shown that prolonged median survivals can be observed in selected patients. This review summarizes the published data related to outcome and quality of life after cytoreduction and HIPEC to provide insights into its use in patients with peritoneal carcinomatosis.
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Affiliation(s)
- Yue Zhu
- Division of Surgical Oncology, Department of Surgery and the Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ambe C, Zhu Y, Boutros C, Hanna N. Survival Analysis of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Advanced Gastric Cancer. J Surg Res 2013. [DOI: 10.1016/j.jss.2012.10.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Boutros C, Gary M, Baldwin K, Somasundar P. Gallbladder cancer: past, present and an uncertain future. Surg Oncol 2012; 21:e183-91. [PMID: 23025910 DOI: 10.1016/j.suronc.2012.08.002] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 08/27/2012] [Accepted: 08/28/2012] [Indexed: 02/06/2023]
Abstract
Although gallbladder cancer (GBC) is the most common malignancy of the biliary tract, its relatively low incidence and confounding symptomatology result in advanced disease at the time presentation, contributing to the poor prognosis and decreased survival associated with this disease. It is therefore increasingly important to understand its pathogenesis and risk factors to allow for the earliest possible diagnosis. To date, gallbladder cancer is poorly understood compared to other malignancies, and is still most commonly discovered incidentally after cholecystectomy. Moreover, while much is known about biliary neoplasms as a whole, understanding the clinical and molecular nuances of GBC as a separate disease process will prove a cornerstone in the development of early intervention, potential screening and overall more effective treatment strategies. The present work reviews the most current understanding of the pathogenesis, diagnosis, staging and natural history of GBC, with additional focus on surgical treatment. Further, review of current adjuvant therapies for unresectable and advanced disease as well as prognostic factors provide fertile ground for the development of future studies which will hopefully improve treatment outcomes and affect overall survival for this highly morbid, poorly understood malignancy.
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Affiliation(s)
- C Boutros
- University of Maryland School of Medicine, Division of Surgical Oncology, Baltimore, MD, USA
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Abstract
Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS ( P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.
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Affiliation(s)
- Cherif Boutros
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristin Ryan
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - Steven Katz
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - N. Joseph Espat
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
| | - Ponnandai Somasundar
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, Rhode Island
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Boutros C, Ryan K, Katz S, Espat NJ, Somasundar P. Total laparoscopic distal pancreatectomy: beyond selected patients. Am Surg 2011; 77:1526-1530. [PMID: 22196669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP. Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS (P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14 patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP. Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.
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Affiliation(s)
- Cherif Boutros
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Boutros C, Mazouni C, Saghatchian M, Domont J, Balleyguier C, Bourgier C, Mathieu MC, Spielmann M, Delaloge S. Prevalence of synchronous metastases of breast cancer depends both on tumor subtypes and tumor burden. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.1096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Boutros C, Espat NJ. What, how, and when to offer nonresectional therapy for colorectal cancer liver metastases. J Gastrointest Surg 2011; 15:420-2. [PMID: 21264686 DOI: 10.1007/s11605-011-1428-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 01/11/2011] [Indexed: 01/31/2023]
Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, 825 Chalkstone Ave., Prior 4, Providence, RI 02908, USA
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Boutros C, Somasundar P, Espat NJ. Early results on the use of biomaterials as adjuvant to abdominal wall closure following cytoreduction and hyperthermic intraperitoneal chemotherapy. World J Surg Oncol 2010; 8:72. [PMID: 20727181 PMCID: PMC2931502 DOI: 10.1186/1477-7819-8-72] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 08/20/2010] [Indexed: 02/04/2023] Open
Abstract
Background Hyperthermic chemotherapy applies thermal energy to both abdominal wall as well as the intra-abdominal viscera. The combination of the hyperthemia, chemotherapy and cytoreductive surgery (CRS) is associated with a defined risk of abdominal wall and intestinal morbidity reported to be as high as 15%, respectively to date, no studies have evaluated the use of biomaterial mesh as adjuvant to abdominal wall closure in this group of patients. In the present report, we hypothesized that post HIPEC closure with a biomaterial can reduce abdominal wall morbidity after CRS and hyperthermic intraperitoneal chemotherapy. Materials and methods All patients treated with HIPEC in a tertiary care center over 12 months (2008-2009) period were included. Eight patients received cytoreductive surgery followed by HIPEC for 90 minutes using Mitomycin C (15 mg q 45 minutes × 2). Abdominal wall closure was performed using Surgisis (Cook Biotech.) mesh in an underlay position with 3 cm fascial overlap-closure. Operative time, hospital length of stay (LOS) as well as postoperative outcome with special attention to abdominal wall and bowel morbidity were assessed. Results Eight patients, mean age 59.7 ys (36-80) were treated according to the above protocol. The primary pathology was appendiceal mucinous adenocarcinoma (n = 3) colorectal cancer (n = 3), and ovarian cancer (n = 2). Four patients (50%) presented initially with abdominal wall morbidity including incisional ventral hernia (n = 3) and excessive abdominal wall metastatic implants (n = 1). The mean peritoneal cancer index (PCI) was 8.75. Twenty eight CRS were performed (3.5 CRS/patient). The mean operating time was 6 hours. Seven patients had no abdominal wall or bowel morbidity, the mean LOS for these patients was 8 days. During the follow up period (mean 6.3 months), one patient required exploratory laparotomy 2 weeks after surgery and subsequently developed an incisional hernia and enterocutaneous fistula. Conclusion The use of biomaterial mesh in concert with HIPEC enables the repair of concomitant abdominal wall hernia and facilitates abdominal wall closure following the liberal resection of abdominal wall tumors. Biomaterial mesh prevents evisceration on repeat laparotomy and resists infection in immunocompromised patients even when associated with bowel resection.
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Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, Providence, RI, USA
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Boutros C, Somasundar P, Espat NJ. Open cystogastrostomy, retroperitoneal drainage, and G-J enteral tube for complex pancreatitis-associated pseudocyst: 19 patients with no recurrence. J Gastrointest Surg 2010; 14:1298-303. [PMID: 20535579 DOI: 10.1007/s11605-010-1242-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 05/25/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Various techniques have been described to achieve definitive resolution of complex acute pancreatitis associated pseudocysts (PACs). Many of these strategies, inclusive of open, minimally invasive, and radiological procedures, are hampered by high recurrence or failed resolution, particularly for PAC near the pancreatic head. The present series describes a multimodal strategy combining a minilaparotomy for anterior gastrostomy for the creation of a stapled posterior cystogastrostomy, placement of an 8F secured silastic tube for intentional formation of a cystogastric fistula tract in combination with gastric drainage, and postduodenal enteral alimentation. MATERIALS AND METHODS Using a prospectively maintained hepatobiliary database, patients with complex PAC undergoing the above procedures were identified. PAC location, postoperative length of stay (LOS), and time to start enteral feeding were identified. PAC were assessed by computed tomography (CT) scan prior to operation, 1 month after drainage, and patients with PAC resolution were started on oral diet, with the fistula silastic tube kept in place for an additional month. RESULTS Over the interval 2003 to 2008, 19 patients were managed with the stated strategy. PACs were located at the pancreatic body/tail in 12 patients, and 7 patients had PAC at the level of the pancreatic head/neck area. In this cohort, prior to surgical drainage, 17/19 patients had undergone failed endoscopic retrograde cholangiopancreatography (ERCP) with decompressive stent placement and 13/19 had a failed percutaneous PAC drainage. There was no perioperative mortality after open surgical drainage. All patients started on jejunal tube feeding 24 h after surgical procedure. Median postoperative LOS was 7 days (4-13). At 1 month, 16/19 (84%) of patients showed complete resolution of the PAC on CT scan and were started on oral diet; 3/19 required additional month for complete resolution. After a mean follow-up of 31 months, there was no PAC recurrences in any of these patients demonstrated on follow-up. CONCLUSION The described strategy is safe, efficient, and allows early restoration of enteral feeding with early hospital discharge. High resolution rates and absence of PAC recurrences in this series supports this approach for complex PAC.
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Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Oncologic Surgery, Roger Williams Medical Center, Providence, RI, USA
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Abstract
The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.
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Affiliation(s)
- Cherif Boutros
- Department of Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, 825 Chalkstone Avenue, Prior 4, Providence, RI 02908, USA
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Boutros C, Espat NJ. Further Uses of Gastrografin in Adhesive Small Bowel Obstruction: Are We Close to a Definitive Answer. J Surg Res 2010; 160:60-2. [DOI: 10.1016/j.jss.2009.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 04/29/2009] [Accepted: 05/14/2009] [Indexed: 11/16/2022]
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Boutros C, Espat NJ, Somasundar P. Completely laparoscopic subtotal pancreatectomy with splenic artery preservation. J Gastrointest Surg 2010; 14:171-4. [PMID: 19727972 DOI: 10.1007/s11605-009-0995-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 08/10/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic distal pancreatectomy has emerged as an attractive minimally invasive alternative for selected patients. Although technically challenging, distal pancreatectomy with splenic artery preservation has consistently been correlated with reduced blood loss and perioperative morbidity in multiple studies. Herein presented is our technique for completely laparoscopic (non-hand-assisted) subtotal pancreatectomy with splenic artery preservation (LSP-SAP). METHODS An 87-year-old woman with an incidentally identified 3-cm cystic lesion in the pancreatic body-tail interface underwent EUS, which supported side-branch intraductal papillary mucinous neoplasm. The patient subsequently underwent laparoscopic resection. A completely laparoscopic procedure was performed using a four-trochar technique. The tail and body of the pancreas were dissected off of the retroperitoneum along the embryologic plane and separated from the colonic splenic flexure. Next, the splenic artery was dissected, isolated, and preserved, while the splenic vein was dissected off the ventral pancreas up to the level of the splenic-portal vein confluence. The technique employed a bipolar cutter-sealing device for dissection and hemostasis. Pancreatic parenchymal transection was performed with a standard vascular load endomechanical stapling device. RESULTS Total procedure time was 210 min, and the estimated blood loss was 200 mL. Postoperatively, the patient was admitted, advanced to regular diet the next day, and discharged home on postoperative day 3. The pathological review of the specimen revealed high-grade dysplasia with a non-invasive malignant component, classified as intraductal carcinoma. Foci of PanIN 1-3 were identified with no high grade dysplasia at the surgical margin. Five lymph nodes were included in the specimen and were negative for malignancy. CONCLUSION Completely LSP-SAP can be safely performed in selected patients. This procedure may be an optimal alternative to open surgery.
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Affiliation(s)
- Cherif Boutros
- Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, Providence, RI 02908, USA
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Boutros C, Somasundar P, Espat NJ. Low common bile duct bifurcation incidentally discovered during pancreaticoduodenectomy. J Gastrointest Surg 2009; 13:2092-3. [PMID: 19184611 DOI: 10.1007/s11605-009-0811-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 01/12/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Bile duct injury due to failure to recognize anatomical variations can have considerable consequences. DISCUSSION We report an incidental discovery of a low common bile duct bifurcation below the level of the cystic duct, incidentally discovered during pancreaticoduodenectomy.
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Affiliation(s)
- C Boutros
- Division Surgical Oncology, Roger Williams Medical Center, 825 Chalkstone Ave., Providence, RI 02908, USA
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Boutros C, Somasundar P, Garrean S, Saied A, Espat NJ. Microwave coagulation therapy for hepatic tumors: review of the literature and critical analysis. Surg Oncol 2009; 19:e22-32. [PMID: 19268571 DOI: 10.1016/j.suronc.2009.02.001] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 01/12/2009] [Accepted: 02/04/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical resection of malignant hepatic tumors has been demonstrated to increase overall survival; however, the majority of patients are not candidates for resection. For patients with unresectable tumors, various chemical and thermal ablation modalities have been developed. microwave coagulation therapy (MCT) is one such thermal ablation modality and the purpose of this review is to evaluate the presently available data for MCT and assess the level of evidence to support its clinical use. METHODS This review is limited to published studies in the English literature including at least 30 patients per study with MCT for hepatocellular cancer (HCC) or colorectal hepatic metastasis (CRHM). Patterns of local recurrence, complications and survival outcome of MCT ablation are presented and discussed including assessment of Asian experience using the 2.4GHZ device and American experience using the 914MHZ device. CONCLUSIONS Although randomized controlled trials comparing RFA and MCT for hepatic ablation are lacking, our review (based on level 2 data) supports that MCT may be optimal when larger necrosis zones and/or ablation of multiple lesions are the objectives. The data support that the potential procedural advantage(s) noted for ablation of CRHM and HCC >3cm, is not supported for HCC <3cm; moreover MCT shares with all other ablation modalities a high rate of locoregional recurrence in HCC; likely due to the multicentricity of this disease process.
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Affiliation(s)
- C Boutros
- Hepatobiliary and Surgical Oncology, Roger Williams Medical Center, 825 Chalkstone Ave., Providence, RI 02908, USA
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Somasundar P, Boutros C, Helton WS, Espat NJ. Evaluation of a bipolar radiofrequency device for laparoscopic hepatic resection: technique and clinical experience in 18 patients. HPB (Oxford) 2009; 11:145-9. [PMID: 19590639 PMCID: PMC2697884 DOI: 10.1111/j.1477-2574.2009.00026.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 11/30/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND The increased frequency of laparoscopic hepatic resection as a principal or adjunct component of patient care has driven the need for and development of efficient and safe hepatic parenchymal transection technologies. At present, various devices are available for pre-coagulation transection (PCT) of hepatic parenchyma with the intent of minimizing procedure-associated postoperative haemorrhage and bile leak. This report presents the evaluation of a novel bipolar radiofrequency (RF) energy device for PCT used for laparoscopic hepatic resection. METHODS Patients undergoing laparoscopic hepatic resection using the Enseal device (SurgRx Inc.) were identified from the prospectively maintained hepatobiliary database. Information on patient demographics, procedures and postoperative complications was collected and analysed; complications were grouped into early (at <30 days) and late (at > or = 30 days) events. RESULTS A total of 18 patients, of whom 13 had malignant tumours (12 colorectal metastases and one hepatocellular carcinoma) and five had benign tumours (two hepatic adenomas and three haemangiomas) underwent 18 hepatic procedures, including two formal hemi-hepatectomies, four left lateral sections, three posterior sections and nine atypical non-anatomic resections. Estimated blood loss did not differ from institutional historical control data; no postoperative haemorrhage, bile leaks or hepatic abscess or necrosis were identified (n = 18). CONCLUSIONS This initial experience using the laparoscopic bipolar RF device demonstrates an acceptable safety profile in terms of the outcomes analysed.
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Affiliation(s)
- Ponnandai Somasundar
- Hepatobiliary and Oncologic Surgery, Roger William Medical Center, Providence, RI 02908, USA
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Farhat FS, Boutros C, Kattan JG, Chahine G, Younes F, Ghosn M. Sequential therapy with gemcitabine and carboplatin followed by paclitaxel in first line treatment of advanced urothelial cancer. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.16051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Willekes L, Boutros C, Goldfarb MA. VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection. J Cardiothorac Surg 2008; 3:13. [PMID: 18348733 PMCID: PMC2278144 DOI: 10.1186/1749-8090-3-13] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Accepted: 03/19/2008] [Indexed: 11/16/2022] Open
Abstract
Introduction Video-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness. Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound. As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule. Case description This paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection. Methods In two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule. The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion. Results Three lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity. Conclusion VATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.
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Boutros C, Cheng-Robles D, Goldenkranz R. Intestinal neuroendocrine tumor in a patient with pituitary adenoma. A case report and review of the current screening recommendations. J Med Case Rep 2007; 1:140. [PMID: 18021452 PMCID: PMC2204028 DOI: 10.1186/1752-1947-1-140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 11/19/2007] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Multiple endocrine neoplasia type 1 (MEN-1) patients are prone to develop carcinoid tumors. Few cases report the development of gastrointestinal carcinoid tumors in patients with MEN-1 syndrome related tumors. This is the first paper to report the occurrence of an intestinal carcinoid tumour in association with a pituitary adenoma. CASE PRESENTATION A sixty eight year old female presented with intestinal obstruction four years after transphenoidal pituitary resection for pituitary adenoma. During surgical exploration and lysis of adhesions, we accidentally discovered an intestinal carcinoid tumour. Resection of the involved small bowel segment and the draining lymph nodes was undertaken. Postoperative follow up showed no biochemical or radiological evidence of residual tumor.Neuroendocrine tumors (NETs) may occur as part of familial endocrine cancer syndromes including MEN-1. It is recommended that clinicians search thoroughly for MEN-1 in patients presented with NETs, however, there is no current consensus for screening patients suspected to have MEN-1 to rule out NET. CONCLUSION We recommend screening patients suspected to have any familial type of endocrine tumors for the presence of NET.
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Affiliation(s)
- Cherif Boutros
- Department of Surgery, Monmouth Medical Center 300 Second Avenue, Long Branch, NJ 07740, USA
- Department of Surgery, Newark Beth Israel Medical Center201 Lyons Avenue, Newark, NJ 07112, USA
| | - Diana Cheng-Robles
- Department of Surgery, Monmouth Medical Center 300 Second Avenue, Long Branch, NJ 07740, USA
- Department of Surgery, Newark Beth Israel Medical Center201 Lyons Avenue, Newark, NJ 07112, USA
| | - Robert Goldenkranz
- Department of Surgery, Newark Beth Israel Medical Center201 Lyons Avenue, Newark, NJ 07112, USA
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Boutros C, Zegdi R, Lila N, Cambillau M, Fornes P, Carpentier A, Fabini JN. Carbon monoxide can prevent acute lung injury observed after ischemia reperfusion of the lower extremities. J Surg Res 2007; 143:437-42. [PMID: 17825843 DOI: 10.1016/j.jss.2007.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2006] [Revised: 01/31/2007] [Accepted: 02/03/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary expression of heme oxygenase has been observed in multiple studies. This expression has been found beneficial in decreasing the severity of acute lung injury (ALI) post ischemia-reperfusion (I/R). The aim of this study was to assess the role of exogenous administration of the end-products of heme oxygenase reaction, carbon monoxide, and bilirubin, in the severity of ALI. STUDY DESIGN We compared five groups of rats (n = 7/group) including a sham group and four I/R of the lower extremities by clamping the abdominal aorta for 2 h followed by reperfusion for 2 h. The four I/R groups included a control group, one pretreated with bilirubin (50 micromol/kg IV), another with inhaled carbon monoxide (CO) (250 ppm), and the last pretreated with both. The severity of ALI has been evaluated by a histological assay grading neutrophilic infiltration, as well as a study of the microvascular permeability using the Evans blue. RESULTS The administration of CO prevented pulmonary microvascular permeability alteration noted after I/R of the lower limbs (pulmonary content of Evans blue: 141 +/- 23 microg/g of tissue in the isolated I/R group versus 68 +/- 34 microg/g of tissue in CO group; P < 0.001). Histologically CO administration inhibited neutrophilic sequestration observed after I/R. On the other hand, treatment by bilirubin alone (50 micromol/kg IV) did not modify the extent of pulmonary injury. CONCLUSION Exogenous administration of carbon monoxide by inhalation at low doses prevented ALI post-I/R in this model.
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Affiliation(s)
- Cherif Boutros
- Laboratory of the Study of Cardiac Grafts and Protheses, Broussias Hospital, Paris, France.
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