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Butensky SD, Billingsley KG, Khan SA. Reasonable expansion of surgical candidates for HCC treatment. Clin Liver Dis (Hoboken) 2024; 23:e0153. [PMID: 38720794 PMCID: PMC11078523 DOI: 10.1097/cld.0000000000000153] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/12/2024] [Indexed: 05/12/2024] Open
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2
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Bakkila BF, Marks VA, Kerekes D, Kunstman JW, Salem RR, Billingsley KG, Ahuja N, Laurans M, Olino K, Khan SA. Impact of COVID-19 on the gastrointestinal surgical oncology patient population. Heliyon 2023; 9:e18459. [PMID: 37534012 PMCID: PMC10391949 DOI: 10.1016/j.heliyon.2023.e18459] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023] Open
Abstract
Background The onset of the COVID-19 pandemic led to substantial alterations in healthcare delivery and access. In this study, we aimed to evaluate the impact of COVID-19 on the presentation and surgical care of patients with gastrointestinal (GI) cancers. Methods All patients who underwent GI cancer surgery at a large, tertiary referral center between March 15, 2019 and March 15, 2021 were included. March 15, 2020 was considered the start of the COVID-19 pandemic. Changes in patient, tumor, and treatment characteristics before the pandemic compared to during the pandemic were evaluated. Results Of 522 patients that met study criteria, 252 (48.3%) were treated before the COVID-19 pandemic. During the first COVID-19 wave, weekly volume of GI cancer cases was one-third lower than baseline (p = 0.041); during the second wave, case volume remained at baseline levels (p = 0.519). There were no demographic or tumor characteristic differences between patients receiving GI cancer surgery before versus during COVID-19 (p > 0.05 for all), and no difference in rate of emergency surgery (p > 0.9). Patients were more likely to receive preoperative chemotherapy during the first six months of the pandemic compared to the subsequent six months (35.6% vs. 15.5%, p < 0.001). Telemedicine was rapidly adopted at the start of the pandemic, rising from 0% to 47% of GI surgical oncology visits within two months. Conclusions The COVID-19 pandemic caused an initial disruption to the surgical care of GI cancers, but did not compromise stage at presentation. Preoperative chemotherapy and telemedicine were utilized to mitigate the impact of a high COVID-19 burden on cancer care.
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Affiliation(s)
| | | | - Daniel Kerekes
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - John W. Kunstman
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Ronald R. Salem
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin G. Billingsley
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Nita Ahuja
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Maxwell Laurans
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kelly Olino
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Sajid A. Khan
- Department of Surgery, Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
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3
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Chen EY, Kardosh A, Nabavizadeh N, Foster B, Mayo SC, Billingsley KG, Gilbert EW, Lanciault C, Grossberg A, Bensch KG, Maynard E, Anderson EC, Sheppard BC, Thomas CR, Lopez CD, Vaccaro GM. Phase 2 study of preoperative chemotherapy with nab-paclitaxel and gemcitabine followed by chemoradiation for borderline resectable or node-positive pancreatic ductal adenocarcinoma. Cancer Med 2023. [PMID: 37132281 DOI: 10.1002/cam4.5971] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Neoadjuvant treatment with nab-paclitaxel and gemcitabine for potentially operable pancreatic adenocarcinoma has not been well studied in a prospective interventional trial and could down-stage tumors to achieve negative surgical margins. METHODS A single-arm, open-label phase 2 trial (NCT02427841) enrolled patients with pancreatic adenocarcinoma deemed to be borderline resectable or clinically node-positive from March 17, 2016 to October 5, 2019. Patients received preoperative gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 on Days 1, 8, 15, every 28 days for two cycles followed by chemoradiation with 50.4 Gy intensity-modulated radiation over 28 fractions with concurrent fluoropyrimidine chemotherapy. After definitive resection, patients received four additional cycles of gemcitabine and nab-paclitaxel. The primary endpoint was R0 resection rate. Other endpoints included treatment completion rate, resection rate, radiographic response rate, survival, and adverse events. RESULTS Nineteen patients were enrolled, with the majority having head of pancreas primary tumors, both arterial and venous vasculature involvement, and clinically positive nodes on imaging. Among them, 11 (58%) underwent definitive resection and eight of 19 (42%) achieved R0 resection. Disease progression and functional decline were primary reasons for deferring surgical resection after neoadjuvant treatment. Pathologic near-complete response was observed in two of 11 (18%) resection specimens. Among the 19 patients, the 12-month progression-free survival was 58%, and 12-month overall survival was 79%. Common adverse events were alopecia, nausea, vomiting, fatigue, myalgia, peripheral neuropathy, rash, and neutropenia. CONCLUSION Gemcitabine and nab-paclitaxel followed by long-course chemoradiation represents a feasible neoadjuvant treatment strategy for borderline resectable or node-positive pancreatic cancer.
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Affiliation(s)
- Emerson Y Chen
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Adel Kardosh
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bryan Foster
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Skye C Mayo
- Division of Surgical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
| | | | - Erin W Gilbert
- Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Aaron Grossberg
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Erin Maynard
- Portland VA Medical Center, Portland, Oregon, USA
| | - Eric C Anderson
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Brett C Sheppard
- Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Radiation Oncology, Geisel School of Medicine at Dartmouth and Dartmouth Cancer Center, New Hampshire, Lebanon, USA
| | - Charles D Lopez
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Gina M Vaccaro
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, Oregon, USA
- Providence Cancer Institute, Portland, Oregon, USA
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Kerekes DM, Frey AE, Bakkila BF, Johnson CH, Becher RD, Billingsley KG, Khan SA. Hepatopancreatobiliary malignancies: time to treatment matters. J Gastrointest Oncol 2023; 14:833-848. [PMID: 37201090 PMCID: PMC10186552 DOI: 10.21037/jgo-22-1067] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/21/2023] [Indexed: 05/20/2023] Open
Abstract
Background Initiation of oncologic care is often delayed, yet little is known about delays in hepatopancreatobiliary (HPB) cancers or their impact. This retrospective cohort study describes trends in time to treatment initiation (TTI), assesses the association between TTI and survival, and identifies predictors of TTI in HPB cancers. Methods The National Cancer Database was queried for patients with cancers of the pancreas, liver, and bile ducts between 2004 and 2017. Kaplan-Meier survival analysis and Cox regression were used to investigate the association between TTI and overall survival for each cancer type and stage. Multivariable regression identified factors associated with longer TTI. Results Of 318,931 patients with HPB cancers, median TTI was 31 days. Longer TTI was associated with increased mortality in patients with stages I-III extrahepatic bile duct (EHBD) cancer and stages I-II pancreatic adenocarcinoma. Patients treated within 3-30, 31-60, and 61-90 days had median survivals of 51.5, 34.9, and 25.4 months (log-rank P<0.001), respectively, for stage I EHBD cancer, and 18.8, 16.6, and 15.2 months for stage I pancreatic cancer, respectively (P<0.001). Factors associated with increased TTI included stage I disease (+13.7 days vs. stage IV, P<0.001), treatment with radiation only (β=+13.9 days, P<0.001), Black race (+4.6 days, P<0.001) and Hispanic ethnicity (+4.3 days, P<0.001). Conclusions Some HPB cancer patients with longer time to definitive care experienced higher mortality than patients treated expeditiously, particularly in non-metastatic EHBD cancer. Black and Hispanic patients are at risk for delayed treatment. Further research into these associations is needed.
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Affiliation(s)
| | | | | | - Caroline H. Johnson
- Department of Environmental Health Sciences, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Robert D. Becher
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Sajid A. Khan
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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5
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Sutton TL, Wong LH, Walker BS, Dewey EN, Eil R, Lopez CD, Kardosh A, Chen EY, Rocha FG, Billingsley KG, Mayo SC. Hepatectomy is associated with improved oncologic outcomes in recurrent colorectal liver metastases: A propensity-matched analysis. Surgery 2022; 173:1314-1321. [DOI: 10.1016/j.surg.2022.10.019] [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] [Received: 08/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/24/2022]
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Sutton TL, Walker BS, Billingsley KG, Corless CL, Sheppard BC, Heinrich MC, Mayo SC. ASO Visual Abstract: Ten-Year Survivorship in Patients with Metastatic Gastrointestinal Stromal Tumors. Ann Surg Oncol 2022; 29:7133. [PMID: 35904656 DOI: 10.1245/s10434-022-12271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas L Sutton
- Division of General Surgery, Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | - Brett S Walker
- Division of General Surgery, Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | | | | | - Brett C Sheppard
- Division of General Surgery, Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | - Michael C Heinrich
- Division of Hematology/Oncology, Department of Medicine, Knight Cancer Institute, Portland VA Health Care System and Oregon Health and Science University, Portland, OR, USA
| | - Skye C Mayo
- Division of Surgical Oncology, Department of Surgery, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA.
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Sutton TL, Walker BS, Billingsley KG, Corless CL, Sheppard BC, Heinrich MC, Mayo SC. Ten-Year Survivorship in Patients with Metastatic Gastrointestinal Stromal Tumors. Ann Surg Oncol 2022; 29:7123-7132. [PMID: 35829795 PMCID: PMC10038195 DOI: 10.1245/s10434-022-12063-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patients developing metastatic gastrointestinal stromal tumors (mGIST) have heterogenous disease biology and oncologic outcomes; prognostic factors are incompletely characterized. We sought to evaluate predictors of 10-year metastatic survivorship in the era of tyrosine kinase inhibitor (TKI) therapy. METHODS We reviewed patients with mGIST treated at our Comprehensive Cancer Center from 2003 to 2019, including only patients with either mortality or 10 years of follow-up. Ten-year survivorship was evaluated with logistic regression. RESULTS We identified 109 patients with a median age of 57 years at mGIST diagnosis. Synchronous disease was present in 57% (n = 62) of patients; liver (n = 48, 44%), peritoneum (n = 40, 37%), and liver + peritoneum (n = 18, 17%) were the most common sites. Forty-six (42%) patients were 10-year mGIST survivors. Following mGIST diagnosis, radiographic progression occurred within 2 years in 53% (n = 58) of patients, 2-5 years in 16% (n = 17), and 5-10 years in 16% (n = 17), with median survival of 32, 76, and 173 months, respectively. Seventeen (16%) patients had not progressed by 10 years. Fifty-two (47%) patients underwent metastasectomy, which was associated with improved progression-free survival (hazard ratio 0.63, p = 0.04). In patients experiencing progression, factors independently associated with 10-year survivorship were age (odds ratio [OR] 0.96, p = 0.03) and time to progression (OR 1.71/year, p < 0.001). CONCLUSIONS Ten-year survivorship is achievable in mGIST in the era of TKIs and is associated with younger age and longer time to first progression, while metastasectomy is associated with longer time to first progression. The role of metastasectomy in the management of patients with disease progression receiving TKI therapy merits further study.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Division of General Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Brett S Walker
- Department of Surgery, Division of General Surgery, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Brett C Sheppard
- Department of Surgery, Division of General Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Michael C Heinrich
- Department of Medicine, Division of Hematology/Oncology, Portland VA Health Care System and Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA.
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8
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Sutton TL, Walker BS, Billingsley KG, Sheppard BC, Corless CL, Heinrich MC, Mayo SC. Hepatic metastases in gastrointestinal stromal tumors: oncologic outcomes with curative-intent hepatectomy, resection of treatment-resistant disease, and tyrosine kinase inhibitor therapy alone. HPB (Oxford) 2022; 24:986-993. [PMID: 34924291 DOI: 10.1016/j.hpb.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/03/2021] [Accepted: 11/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic resection for metastatic GIST (mGIST) is often performed with either curative-intent or for tyrosine kinase inhibitor (TKI)-resistant lesions. The efficacy of hepatectomy for treatment-resistant lesions (TRL) is uncertain. METHODS We reviewed patients with liver-mGIST treated from 2003 to 2018. Oncologic outcomes including overall (OS), post-operative progression-free survival (PFS), and post-progression OS were evaluated using Kaplan-Meier and Cox proportional hazards modeling. RESULTS We identified n = 91 patients; 31 (34%) underwent curative-intent hepatectomy, 60 (66%) were initially managed with TKI alone, and 17 (19%) had resection of a TRL. The median follow-up for resected patients was 102 months (range 5-209 months) with 23 (25%) managed with a major hepatectomy. Patients having curative-intent hepatectomy had 72% 10-year OS following diagnosis of liver-mGIST, compared with 58% (P = 0.50) for TRL resection and 41% (P = 0.01) for non-resected patients. Curative-intent hepatectomy (HR 0.39, P = 0.03) and age (HR 1.04, P = 0.004) were independently associated with 10-year OS, but not TRL resection. TRL resection was not associated with improved post-progression OS compared to second-line TKI therapy (HR 0.61, P = 0.21). CONCLUSIONS Curative-intent hepatectomy is associated with improved OS in liver-mGIST. The oncologic benefit of resecting treatment-resistant liver-mGIST compared to second-line TKI therapy alone remains unclear in the era of multi-line TKI therapy.
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Affiliation(s)
- Thomas L Sutton
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | - Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | | | - Brett C Sheppard
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR 97239, USA
| | | | - Michael C Heinrich
- Portland VA Health Care System and OHSU Department of Medicine, Division of Hematology and Oncology, Knight Cancer Institute, Portland, OR 97239, USA
| | - Skye C Mayo
- OHSU Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Portland, OR 97239, USA.
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9
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Walker BS, Billingsley KG, Sutton TL, Kolbeck KJ, Korngold EK, Nabavizadeh N, Dewey EN, Herzig DO, Lopez CD, Mayo SC. Hepatic arterial infusion pump chemotherapy combined with systemic therapy for patients with advanced colorectal liver metastases: Outcomes in a newly established program. J Surg Oncol 2022; 126:513-522. [PMID: 35522249 DOI: 10.1002/jso.26911] [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] [Received: 03/27/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Colorectal liver metastasis (CRLM) is a leading cause of morbidity and mortality in patients with colorectal cancer. Hepatic arterial infusion (HAI) chemotherapy has been demonstrated to improve survival in patients with resected CRLM and to facilitate conversion of technically unresectable disease. METHODS Between 2016 and 2018, n = 22 HAI pumps were placed for CRLM. All patients received systemic chemotherapy concurrently with HAI floxuridine/dexamethasone. Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method. RESULTS HAI pumps were placed in seven patients with completely resected CRLM and 15 patients with unresectable disease. Twenty-one patients received HAI floxuridine with a median of 5 total HAI cycles (interquartile range: 4-7). Biliary sclerosis was the most common HAI-related complication (n = 5, 24%). Of the 13 patients treated to convert unresectable CRLM, 3 (23%) underwent hepatic resection with curative intent after a median of 7 HAI cycles (range: 4-10). For all HAI patients, the mean OS was 26.7 months from CRLM diagnosis, while the median PFS and hepatic PFS from pump placement were 9 and 13 months, respectively. CONCLUSION Concomitant HAI and systemic therapy can be utilized at multidisciplinary programs for patients with advanced CRLM, both in the adjuvant setting and to facilitate conversion of unresectable disease.
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Affiliation(s)
- Brett S Walker
- Oregon Health & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Portland, Oregon, USA
| | | | - Thomas L Sutton
- Oregon Health & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Portland, Oregon, USA
| | - Kenneth J Kolbeck
- OHSU, Department of Interventional Radiology, Dotter Institute, Portland, Oregon, USA
| | | | | | | | - Daniel O Herzig
- OHSU, Division of Colorectal Surgery, Department of Surgery, Portland, Oregon, USA
| | - Charles D Lopez
- OHSU, Division of Hematology and Medical Oncology, Department of Medicine, Portland, Oregon, USA.,The Knight Cancer Institute at OHSU, Portland, Oregon, USA
| | - Skye C Mayo
- Oregon Health & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Knight Cancer Institute, Portland, Oregon, USA.,The Knight Cancer Institute at OHSU, Portland, Oregon, USA
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10
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Bakkila BF, Kerekes D, Nunez-Smith M, Billingsley KG, Ahuja N, Wang K, Oladele C, Johnson CH, Khan SA. Evaluation of Racial Disparities in Quality of Care for Patients With Gastrointestinal Tract Cancer Treated With Surgery. JAMA Netw Open 2022; 5:e225664. [PMID: 35377425 PMCID: PMC8980937 DOI: 10.1001/jamanetworkopen.2022.5664] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Racial disparities have been demonstrated in many facets of health care, but a comprehensive understanding of who is most at risk for substandard surgical care of gastrointestinal tract cancers is lacking. OBJECTIVE To examine racial disparities in quality of care of patients with gastrointestinal tract cancers. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of patients with gastrointestinal tract cancer included the US population as captured in the National Cancer Database with a diagnosis from January 1, 2004, to December 31, 2017. Participants included 565 124 adults who underwent surgical resection of gastrointestinal tract cancers. Data were analyzed from June 21 to December 23, 2021. EXPOSURES Race and site of cancer. MAIN OUTCOMES AND MEASURES Oncologic standard of care, as defined by negative resection margin, adequate lymphadenectomy, and receipt of indicated adjuvant chemotherapy and/or radiotherapy. RESULTS Among 565 124 adult patients who underwent surgical resection of a gastrointestinal tract cancer, 10.9% were Black patients, 83.5% were White patients, 54.7% were men, and 50.7% had Medicare coverage. The most common age range at diagnosis was 60 to 69 years (28.5%). Longer median survival was associated with negative resection margins (87.3 [IQR, 28.5-161.9] months vs 22.9 [IQR, 8.8-69.2] months; P < .001) and adequate lymphadenectomies (80.7 [IQR, 25.6 to not reached] months vs 57.6 [IQR, 17.7-153.8] months; P < .001). After adjustment for covariates, Black patients were less likely than White patients to have negative surgical margins overall (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and after esophagectomy (OR, 0.71 [95% CI, 0.58-0.87]), proctectomy (OR, 0.71 [95% CI, 0.66-0.76]), and biliary resection (OR, 0.75 [95% CI, 0.61-0.91]). Black patients were also less likely to have adequate lymphadenectomy overall (OR, 0.89 [95% CI, 0.87-0.91]) and after colectomy (OR, 0.89 [95% CI, 0.87-0.92]), esophagectomy (OR, 0.72 [95% CI, 0.63-0.83]), pancreatectomy (OR, 0.90 [95% CI, 0.85-0.96]), proctectomy (OR, 0.93 [95% CI, 0.88-0.98]), proctocolectomy (OR, 0.90 [95% CI, 0.81-1.00]), and enterectomy (OR, 0.71 [95% CI, 0.65-0.79]). Black patients were more likely than White patients not to be recommended for chemotherapy (OR, 1.15 [95% CI, 1.10-1.21]) and radiotherapy (OR, 1.49 [95% CI, 1.35-1.64]) because of comorbidities and more likely not to receive recommended chemotherapy (OR, 1.68 [95% CI, 1.55-1.82]) and radiotherapy (OR, 2.18 [95% CI, 1.97-2.41]) for unknown reasons. CONCLUSIONS AND RELEVANCE These findings suggest that there are significant racial disparities in surgical care of gastrointestinal tract cancers. Black patients are less likely than White patients to receive standard of care with respect to negative surgical margins, adequate lymphadenectomies, and use of adjuvant therapies. Both system- and physician-level reforms are needed to eradicate these disparities in health care.
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Affiliation(s)
- Baylee F. Bakkila
- currently a medical student at Yale School of Medicine, New Haven, Connecticut
| | - Daniel Kerekes
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Marcella Nunez-Smith
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kevin G. Billingsley
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Karen Wang
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Carol Oladele
- Equity Research and Innovation Center, Yale School of Medicine, New Haven, Connecticut
| | - Caroline H. Johnson
- Department of Environmental Health Sciences, Yale School of Public Health, Yale University, New Haven, Connecticut
| | - Sajid A. Khan
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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11
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Salazar MC, Canavan ME, Holaday LW, Billingsley KG, Ross J, Boffa DJ, Gross CP. Access to High-Volume Hospitals for High-Risk Cancer Surgery for Racial and Ethnic Minoritized Groups. JNCI Cancer Spectr 2022; 6:6547040. [PMID: 35603855 PMCID: PMC8997114 DOI: 10.1093/jncics/pkac024] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 01/25/2023] Open
Abstract
High-volume hospitals have been associated with better outcomes for high-risk cancer surgeries, although concerns exist concerning inequitable access to these high-volume hospitals. We assessed tendencies in access to high-volume hospitals for 4 (lung, pancreatic, rectal, esophageal) high-risk cancer surgeries for Black and Hispanic patients in the National Cancer Database. Hospitals were classified as high volume according to Leapfrog Group volume thresholds. Odds of accessing high-volume hospitals increased over time for Black and Hispanic patients for 3 surgeries, but Black patients had lower probabilities of undergoing a pancreatectomy, proctectomy, or esophagectomy at high-volume hospitals than non-Black patients (eg, 2016 pancreatectomy rate: 49.0% [95% confidence interval (CI) = 45.4% to 52.5%] vs 62.3% [95% CI = 61.1% to 63.5%]). Although for Hispanics the gap narrowed for lung resection and pancreatectomy, these populations continued to have lower probabilities of accessing high-volume hospitals than non-Hispanic patients (eg, 2016 pancreatectomy: 48.8% [95% CI = 44.1% to 53.5%] vs 61.6% [95% CI = 60.5% to 62.8%]). Despite increased access to high-volume hospitals for high-risk cancer surgeries, ongoing efforts to improve equity in access are needed.
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Affiliation(s)
- Michelle C Salazar
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA,National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA,Correspondence to: Michelle C. Salazar, MD, MHS, Department of Surgery, Yale University School of Medicine, PO Box 208088, New Haven, CT 06510-8088, USA (e-mail: )
| | - Maureen E Canavan
- Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA,Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Louisa W Holaday
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA,West Haven VA Medical Center, West Haven, CT, USA
| | - Kevin G Billingsley
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph Ross
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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12
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Sutton TL, Wong LH, Walker BS, Dewey EN, Eil RL, Ibewuike U, Chen EY, Rocha FG, Billingsley KG, Mayo SC. Surgical timing after preoperative chemotherapy is associated with oncologic outcomes in resectable colorectal liver metastases. J Surg Oncol 2022; 125:1260-1268. [PMID: 35212404 DOI: 10.1002/jso.26832] [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] [Received: 12/02/2021] [Revised: 01/24/2022] [Accepted: 02/13/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Preoperative chemotherapy (POC) is often employed for patients with resectable colorectal liver metastasis (CRLM). The time to resection (TTR) following the end of chemotherapy may impact oncologic outcomes; this phenomenon has not been studied in CRLM. METHODS We queried our institutional cancer database for patients with resected CRLM after POC from 2003 to 2019. TTR was calculated from date of last cytotoxic chemotherapy. Kaplan-Meier analysis and multivariable Cox proportional hazards modeling were used to analyze recurrence-free survival (RFS) and overall survival (OS). RESULTS We identified n = 187 patients. One hundred twenty-four (66%) patients had a TTR of <2 months, while 63 (33%) had a TTR of ≥2 months. Median follow-up was 36 months. On Kaplan-Meier analysis, patients with TTR ≥ 2 months had shorter RFS (median 11 vs. 17 months, p = 0.002) and OS (median 44 vs. 62 months, p < 0.001). On multivariable analysis, TTR ≥ 2 months was independently associated with worse RFS (hazard ratio [HR] = 1.54, 95% confidence interval [CI] = 1.06-2.22, p = 0.02) and OS (HR = 1.75, 95% CI = 1.11-2.77, p = 0.01). CONCLUSION TTR ≥ 2 months following POC is independently associated with worse oncologic outcomes in patients with resectable CRLM. We therefore recommend consideration for hepatic resection of CRLM within this window whenever feasible.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Liam H Wong
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Brett S Walker
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Elizabeth N Dewey
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert L Eil
- Division of Surgical Oncology, Department of Surgery, OHSU, Knight Cancer Institute, Portland, Oregon, USA
| | - Uchechukwu Ibewuike
- Department of Radiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Emerson Y Chen
- Division of Hematology and Oncology, Department of Medicine, OHSU, Knight Cancer Institute, Portland, Oregon, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Department of Surgery, OHSU, Knight Cancer Institute, Portland, Oregon, USA
| | | | - Skye C Mayo
- Division of Surgical Oncology, Department of Surgery, OHSU, Knight Cancer Institute, Portland, Oregon, USA
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13
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Billingsley KG. The Next Step in Tumor Board Evolution: Optimizing Care Coordination and Integration : Editorial on "Integrating a Disease-Focused Tumor Board as a Delivery-of-Care Model to Expedite Treatment Initiation for Patients with Liver Malignancies". Ann Surg Oncol 2022; 29:2146-2147. [PMID: 35084625 DOI: 10.1245/s10434-021-10992-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Kevin G Billingsley
- Department of Surgery, Yale University School of Medicine, Yale Cancer Center, 35 Park St, New Haven, CT, 06519, USA.
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14
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Wancata LM, Billingsley KG, Pailet J, Mayo SC, Sheppard BC, Hansen L. The patient's perspective: a qualitative study of individual experience with decision-making, treatment, and recovery for resectable pancreatic cancer. Support Care Cancer 2021; 30:2581-2589. [PMID: 34807295 DOI: 10.1007/s00520-021-06690-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/08/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma cancer (PDAC) remains a challenging diagnosis. The likelihood of long-term survival is limited even for patients who undergo maximal medical therapy with systemic chemotherapy and surgical resection. Within this intensive process, there remains limited understanding of patients' pretreatment expectations of PDAC treatment experience and their decision-making process. METHODS PDAC patients who underwent chemotherapy and surgical resection were retrospectively identified. Semi-structured phone interviews were completed regarding patient experience with therapy. Qualitative descriptive analysis was performed, and categories, subcategories, and themes were determined. RESULTS Fifteen patients were interviewed regarding their experience with PDAC treatment. An overall personal disease trajectory experience was identified with two phases. The first phase encompassed the patients' treatment. In this phase, patients expressed a choice, non-choice regarding therapy decisions, viewing therapy as the only option. Misconceptions about the roles of therapies and expected experience of treatment were observed. The second phase focused on life after therapy. Patients reported persistent physical changes secondary to therapy. An overall realistic understanding of the patient's limited prognosis was observed, with patients expressing appreciation of the life time gained as a benefit of treatment. CONCLUSIONS There remains critical areas for improvement in communication and care of patients with PDAC. Physicians should continue to ensure that patient's goals and wishes are respected when making treatment decisions and confirm that patients understand the roles and limitations of prescribed therapies. Additionally, patients continue to have significant physical changes post treatment which should be assessed for and managed as appropriate to maintain quality of life.
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Affiliation(s)
- Lauren M Wancata
- Virginia Mason Franciscan Health, 1100 Ninth Ave, C6-GS, WA, 98101, Seattle, USA.
| | - Kevin G Billingsley
- Yale School of Medicine, New Haven, CT, USA.,Department of Surgery, Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Jasmina Pailet
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Skye C Mayo
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Brett C Sheppard
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
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15
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Sutton TL, Billingsley KG, Walker BS, Fung AW, Maynard E, Enestvedt CK, Dewey EN, Brinkerhoff BT, Lopez CD, Orloff SL, Mayo SC. Detection of Tumor Multifocality in Resectable Intrahepatic Cholangiocarcinoma: Defining the Optimal Pre-operative Imaging Modality. J Gastrointest Surg 2021; 25:2250-2257. [PMID: 33565011 DOI: 10.1007/s11605-021-04911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/09/2020] [Accepted: 01/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple tumor foci (MTF) in intrahepatic cholangiocarcinoma (ICC), including satellitosis and true multifocality, is a known negative prognostic factor and can inform pre-operative decision-making. Lack of standardized pre-operative liver staging practices may contribute to undiagnosed MTF and poor outcomes. We sought to investigate the sensitivity of different cross-sectional imaging modalities for MTF at our institution. METHODS We identified n = 52 patients with ICC who underwent curative-intent resection from 2004 to 2017 in a multidisciplinary hepato-pancreato-biliary cancer program. Timing and modality of pre-operative imaging were recorded. Blinded review of imaging was performed and modalities were evaluated for false-negative rate (FNR) in detecting MTF, satellitosis, and true multifocality. RESULTS Forty-one (79%) patients underwent CT and 20 (38%) underwent MRI prior to hepatectomy. MTF was pre-operatively identified in six (12%) patients. An additional seven patients had MTF discovered on final surgical pathology, despite a median interval from CT/MRI to surgery of 20 days. On blinded review the FNR of MRI compared to CT for multifocality was 0% vs. 38%, 50% vs 80% for satellitosis, and 22% vs 46% for MTF as a whole. CONCLUSION CT is inadequate for pre-operative diagnosis of MTF in resectable ICC, even when performed within 30 days of hepatectomy. We recommend liver-protocol MRI as the standard pre-operative imaging modality in non-metastatic ICC.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA.,The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Brett S Walker
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA
| | - Alice W Fung
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.,Department of Radiology, OHSU, Portland, OR, 97239, USA
| | - Erin Maynard
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | | | | | - Charles D Lopez
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.,Division of Hematology Oncology, OHSU, Portland, OR, 97239, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, OHSU, Portland, OR, 97239, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Oregon Heath & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Mail Code: L-619, Portland, OR, 97239, USA. .,The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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16
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Sutton TL, Walker BS, Radu S, Dewey EN, Enestvedt CK, Maynard E, Orloff SL, Nabavizadeh N, Sheppard BC, Lopez CD, Billingsley KG, Mayo SC. Degree of biliary tract violation during treatment of gallbladder adenocarcinoma is independently associated with development of peritoneal carcinomatosis. J Surg Oncol 2021; 124:581-588. [PMID: 34115368 DOI: 10.1002/jso.26569] [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] [Received: 03/13/2021] [Revised: 05/10/2021] [Accepted: 06/01/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra-operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated. METHODS We reviewed patients with initially non-metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra-operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease-free survival (PDFS) were evaluated with Kaplan-Meier and Cox proportional hazards modeling. RESULTS Ninety-three patients were identified; the median age was 64 years (range 31-87 years). Seventy-six (82%) were incidentally diagnosed. The median follow-up was 23 months; 20 (22%) patients developed PD. The 3-year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p < 0.001; minor vs. none: p < 0.01). BTV was not associated with 5-year OS (HR 1.53, p = 0.16). CONCLUSION Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - Brett S Walker
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | | | - Elizabeth N Dewey
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - C Kristian Enestvedt
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | - Erin Maynard
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | - Susan L Orloff
- OHSU Department of Surgery, Division of Abdominal Transplant Surgery, Portland, Oregon, USA
| | | | - Brett C Sheppard
- Department of Surgery, Oregon Health & Science University (OHSU), Division of General Surgery, Portland, Oregon, USA
| | - Charles D Lopez
- OHSU Department of Medicine, Division of Hematology/Oncology, Portland, Oregon, USA.,The Knight Cancer Institute at OHSU, Portland, Oregon, USA
| | | | - Skye C Mayo
- The Knight Cancer Institute at OHSU, Portland, Oregon, USA.,OHSU Department of Surgery, Division of Surgical Oncology, Portland, Oregon, USA
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17
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Chen EY, Mayo SC, Sutton T, Kearney MR, Kardosh A, Vaccaro GM, Billingsley KG, Lopez CD. Effect of Time to Surgery of Colorectal Liver Metastases on Survival. J Gastrointest Cancer 2021; 52:169-176. [PMID: 32086781 PMCID: PMC7900034 DOI: 10.1007/s12029-020-00372-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Indexed: 12/28/2022]
Abstract
Purpose Resection of liver-only colorectal liver metastases (CRLM) with perioperative chemotherapy is potentially curative. Specific primary tumor and liver metastasis characteristics have been validated to estimate the risk of recurrence. We hypothesize that the time interval from diagnosis of CRLM to surgery, or time to surgery (TTS), is clinically prognostic. Methods Patients from a prospectively maintained institutional database at a Comprehensive Cancer Center from May 2003 to January 2018 were reviewed. Clinicopathologic, perioperative treatment, and TTS data were collected. TTS was categorized into short (< 3 months), intermediate (3–6 months), and long (> 6 months) intervals. Results Two hundred eighty-one patients were identified. While overall survival (OS) was similar across TTS, postoperative overall survival (postoperative OS) of long TTS was associated with worse survival, 44 months (95% CI, 34–52) compared to short TTS, 59 months (95% CI, 43–79), and intermediate TTS, 63 months (95% CI, 52–108), both p < 0.01. With regard to long-term OS, intermediate TTS had 5-year OS of 59% and 8-year OS of 43% compared to long TTS (5-year OS 53% and 8-year OS 18%) and short TTS (5-year OS 54% and 8-year OS 29%). Long TTS was negatively associated with postoperative OS on multivariate analysis (HR 1.6, p < 0.01) when adjusting for resection margin, CRLM size, age, and use of postoperative chemotherapy. Conclusion Short and intermediate TTS had similar survival although patients with intermediate TTS may have better odds of long-term OS. While long TTS was associated with worse survival, likely due to higher disease burden, long-term survivors were still observed. Electronic supplementary material The online version of this article (10.1007/s12029-020-00372-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emerson Y Chen
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR, 97239, USA.
| | - Skye C Mayo
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Thomas Sutton
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Matthew R Kearney
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR, 97239, USA
| | - Adel Kardosh
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR, 97239, USA
| | - Gina M Vaccaro
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Charles D Lopez
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR, 97239, USA.
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18
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Sutton TL, Walker BS, Billingsley KG, Sheppard BC, Corless CL, Heinrich MC, Mayo SC. ASO Visual Abstract: The Disease-Free Interval is Associated with Oncologic Outcomes in Patients with Recurrent Gastrointestinal Stromal Tumor. Ann Surg Oncol 2021. [PMID: 33974196 DOI: 10.1245/s10434-021-10107-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | - Brett S Walker
- Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | | | - Brett C Sheppard
- Department of Surgery, Oregon Health and Science University (OHSU), Portland, OR, USA
| | | | - Michael C Heinrich
- Portland VA Health Care System, Portland, OR, USA.,Division of Surgical Oncology, The Knight Cancer Institute at OHSU, Portland, OR, USA
| | - Skye C Mayo
- Division of Surgical Oncology, The Knight Cancer Institute at OHSU, Portland, OR, USA. .,Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA.
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Sutton TL, Walker BS, Billingsley KG, Sheppard BC, Corless CL, Heinrich MC, Mayo SC. Disease-free Interval Is Associated with Oncologic Outcomes in Patients with Recurrent Gastrointestinal Stromal Tumor. Ann Surg Oncol 2021; 28:7912-7920. [PMID: 33969462 DOI: 10.1245/s10434-021-10062-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/04/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastrointestinal stromal tumors (GIST) commonly recur following curative-intent resection. Patients with recurrent GIST display heterogeneous outcomes with limited prognostic tools. We investigated factors associated with post-recurrence survival (PRS) and progression-free survival (PFS). METHODS We performed a review of our institutional cancer registry from 2003 to 2018 for patients with GIST. Clinicopathologic and outcome data were collected. The disease-free interval (DFI) was calculated from the end of curative-intent oncologic therapy until recurrence. Outcomes were evaluated using Kaplan-Meier and Cox proportional hazards modeling. RESULTS Overall, 254 patients underwent resection of primary, non-metastatic GIST, with 81 (32%) recurrences. The median age was 58 years and more than half of the patients with recurrence (n = 44; 54%) received adjuvant imatinib. Recurrence was most common in the liver (n = 34, 42%), peritoneum (n = 31, 38%), or liver plus peritoneum (n = 10, 12%). The median DFI was 14 months (interquartile range 2-26 months); 51 (63%) patients had a DFI ≤24 months and 30 (37%) had a DFI > 24 months. The median post-recurrence follow-up was 46 months. Compared with a DFI ≤24 months, patients with a DFI >24 months had increased 10-year PRS (77% vs. 41%, p < 0.05) and 10-year PFS (73% vs. 19%, p < 0.001). On multivariable analysis controlling for mutational and clinicopathologic features, a DFI >24 months was independently associated with increased PRS (hazard ratio [HR] 0.24, p < 0.01) and PFS (HR 0.18, p < 0.001). CONCLUSIONS The DFI is independently associated with oncologic outcomes in recurrent GIST and may be useful in treatment planning. Recurrence after 24 months may signify indolent disease biology that may benefit from additional treatment, including metastasectomy.
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Affiliation(s)
- Thomas L Sutton
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Brett S Walker
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Brett C Sheppard
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Michael C Heinrich
- Portland VA Health Care System, Portland, OR, USA.,Division of Surgical Oncology, The Knight Cancer Institute at Oregon Health and Science University, Portland, OR, USA
| | - Skye C Mayo
- Division of Surgical Oncology, The Knight Cancer Institute at Oregon Health and Science University, Portland, OR, USA. .,Department of Surgery, Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA.
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20
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Wong LH, Sutton TL, Walker BS, Lopez CD, Kardosh A, Eil RL, Chen EY, Billingsley KG, Mayo SC. Surgical and oncologic outcomes following repeat hepatic resection of colorectal liver metastasis: Who benefits? Am J Surg 2021; 221:1114-1118. [PMID: 33722380 DOI: 10.1016/j.amjsurg.2021.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/09/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Resected colorectal liver metastases (CRLM) frequently recur intrahepatically. Selection criteria for repeat hepatectomy of recurrent CRLM are ill-defined. METHODS We performed an institutional review of patients with recurrent CRLM undergoing repeat hepatectomy from 2003 to 19. Post-recurrence overall (rOS) and recurrence-free survival (RFS) were analyzed with Cox proportional hazards modeling. RESULTS n = 147 experienced recurrent CRLM; 11% (n = 38) received repeat hepatectomy of which there was one Clavien-Dindo IIIa complication. Median rOS was 41 months; median RFS was 9 months. Improved rOS and RFS were independently associated with additional post-operative chemotherapy after repeat hepatectomy (HR 0.35 and 0.34, respectively); poor rOS with recurrent CRLM >3 cm (HR 4.4) and <12 months from first hepatectomy to recurrence (HR 4.8); poor RFS with ≥3 recurrence liver metastases (HR 2.8) (All P < 0.05). DISCUSSION Repeat hepatectomy for recurrent CRLM can be performed safely. Worse survival following repeat hepatectomy is independently associated with >3 cm and ≥3 liver lesions at recurrence, and <12 months to recurrence. Additional post-operative chemotherapy after repeat hepatectomy is associated with improved outcomes.
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Affiliation(s)
- Liam H Wong
- Oregon Heath & Science University (OHSU), School of Medicine, Portland, OR, 97239, USA
| | - Thomas L Sutton
- Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Brett S Walker
- Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - Charles D Lopez
- OHSU, Department of Hematology/Oncology, Portland, OR, 97239, USA
| | - Adel Kardosh
- OHSU, Department of Hematology/Oncology, Portland, OR, 97239, USA
| | - Robert L Eil
- Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Emerson Y Chen
- OHSU, Department of Hematology/Oncology, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT, 06511, USA; Department of Surgery, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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21
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Walker BS, Sutton TL, Eil RL, Korngold EK, Kolbeck KJ, Billingsley KG, Mayo SC. Conventional hepatic arterial anatomy? Novel findings and insights of a multi-disciplinary hepatic arterial infusion pump program. Am J Surg 2021; 221:1188-1194. [PMID: 33685717 DOI: 10.1016/j.amjsurg.2021.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/08/2020] [Revised: 02/14/2021] [Accepted: 02/22/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Variant hepatic arterial anatomy (vHAA) is thought to occur in 20-30% of patients. Hepatic arterial infusion (HAI) pump placement for liver cancers requires thorough hepatic artery dissection; we sought to compare vHAA identified during pump placement with established dogma. METHODS Between 2016 and 2020, n = 30 patients received a HAI pump. Intra-operatively identified vHAA was characterized and compared with published data. RESULTS vHAA was identified in 60% (n = 18) of patients, significantly higher than 19% (3671 of 19013) in the largest published series (P < 0.001). The most common variations were accessory left (n = 12; 40%) and replaced right (n = 6; 20%) hepatic arteries; six (20%) had ≥2 variants. Pre-operative imaging correctly identified 67% of variant hepatic arteries. DISCUSSION Meticulous operative dissection of the hepatic arterial tree reveals vHAA not captured by imaging or cadaveric dissection. vHAA likely has a higher prevalence than previously reported and should be addressed to optimize therapeutic efficacy of HAI pump therapy.
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Affiliation(s)
- Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - Thomas L Sutton
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - Robert L Eil
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Elena K Korngold
- OHSU, Department of Diagnostic Radiology, Section of Body Imaging, Portland, OR, 97239, USA
| | - Kenneth J Kolbeck
- OHSU, Charles T. Dotter Department of Interventional Radiology, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Skye C Mayo
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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22
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Sutton TL, Billingsley KG, Walker BS, Enestvedt CK, Dewey EN, Orloff SL, Mayo SC. Neoadjuvant chemotherapy is associated with improved survival in patients undergoing hepatic resection for intrahepatic cholangiocarcinoma. Am J Surg 2021; 221:1182-1187. [PMID: 33707077 DOI: 10.1016/j.amjsurg.2021.02.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/19/2021] [Accepted: 02/25/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The impact of neoadjuvant chemotherapy (NAC) on overall and recurrence-free survival (OS, RFS) in resectable intrahepatic cholangiocarcinoma (ICC) is poorly characterized. We sought to investigate the association of NAC with oncologic outcomes in ICC. METHODS We identified n = 52 patients with ICC undergoing hepatectomy from 2004 to 2017. Oncologic outcomes were analyzed using Kaplan-Meier and multivariate Cox proportional hazard modeling. RESULTS The median patient age was 64-years. NAC was administered in ten (19%) patients, most commonly with gemcitabine-cisplatin (n = 8, 80%). Median RFS and OS were 15 months. and 49 months, respectively. Controlling for stage and margins, NAC was independently associated with improved OS (HR 0.16, P = 0.01) but not RFS (HR 0.54, P = 0.27). NAC was not associated with major post-operative complications (P = 0.25) or R1 margins (P = 0.58). CONCLUSION NAC in ICC may hold oncologic benefits beyond downstaging borderline resectable disease, such as identifying patients with favorable biology who are more likely to benefit from resection.
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Affiliation(s)
- Thomas L Sutton
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | | | - Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- OHSU, Department of Surgery, Division of Abdominal Transplant, Portland, OR, 97239, USA
| | - Elizabeth N Dewey
- Oregon Heath & Science University (OHSU), Department of Surgery, Portland, OR, 97239, USA
| | - Susan L Orloff
- OHSU, Department of Surgery, Division of Abdominal Transplant, Portland, OR, 97239, USA
| | - Skye C Mayo
- The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA; OHSU, Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA.
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23
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Muaddi H, D'Angelica M, Wiseman JT, Dillhoff M, Latchana N, Roke R, Ko YJ, Carpizo D, Spencer K, Fields RC, Williams G, Aucejo F, Acevedo-Moreno LA, Billingsley KG, Walker BS, Mayo SC, Karanicolas PJ. Safety and feasibility of initiating a hepatic artery infusion pump chemotherapy program for unresectable colorectal liver metastases: A multicenter, retrospective cohort study. J Surg Oncol 2020; 123:252-260. [PMID: 33095919 DOI: 10.1002/jso.26270] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Hepatic artery infusion pump (HAIP) chemotherapy is a specialized therapy for patients with unresectable colorectal liver metastases (uCRLM). Its effectiveness was demonstrated from a high volume center, with uncertainty regarding the feasibility and safety at other centers. Therefore, we sought to assess the safety and feasibility of HAIP for the management of uCRLM at other centers. METHODS We conducted a multicenter retrospective cohort study of patients with uCRLM treated with HAIP from January 2003 to December 2017 at six North American centers initiating the HAIP program. Outcomes included the safety and feasibility of HAIP chemotherapy. RESULTS We identified 154 patients with HAIP insertion and the median age of 54 (48-61) years. The burden of disease was >10 intra-hepatic metastatic foci in 59 (38.3%) patients. Patients received at least one cycle of systemic chemotherapy before HAIP insertion. Major complications occurred in 7 (4.6%) patients during their hospitalization and 13 (8.4%) patients developed biliary sclerosis during follow-up. A total of 148 patients (96.1%) received at least one-dose of HAIP chemotherapy with a median of 5 (4-7) cycles. 78 patients (56.5%) had a complete or partial response and 12 (7.8%) received a curative liver resection. CONCLUSION HAIP programs can be safely and effectively initiated in previously inexperienced centers with good response.
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Affiliation(s)
- Hala Muaddi
- Division of General Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Michael D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jason T Wiseman
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Arthur G. James Comprehensive Cancer Center Cancer Cachexia Program, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nicholas Latchana
- Department of Surgery, Novant Health Carolina Surgical, Charlotte, North Carolina, USA
| | - Rachel Roke
- Division of General Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Yoo-Joung Ko
- Division of General Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada.,St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren Carpizo
- Department of Surgery, Division of Surgical Oncology, Rochester's School of Medicine and Dentistry and Wilmot Cancer Center, Rochester, New York, USA
| | - Kristen Spencer
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine and the Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri, USA
| | - Gregory Williams
- Department of Surgery, Washington University School of Medicine and the Alvin J. Siteman Comprehensive Cancer Center, St. Louis, Missouri, USA
| | - Federico Aucejo
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lou-Anne Acevedo-Moreno
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin G Billingsley
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon, USA
| | - Brett S Walker
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon, USA
| | - Skye C Mayo
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University Knight Cancer Institute, Portland, Oregon, USA
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
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24
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Boffa DJ, Judson BL, Billingsley KG, Galetta D, Fontanez P, Odermatt C, Lindner K, Mitchell MR, Henderson CM, Carafeno T, Pinto J, Wagner JA, Ancuta MM, Beley P, Turner AL, Banack T, Laurans MS, Johnson DC, Yoo PS, Morton JM, Zurich H, Davis K, Ahuja N. Pandemic Recovery Using a COVID-Minimal Cancer Surgery Pathway. Ann Thorac Surg 2020; 110:718-724. [PMID: 32417195 PMCID: PMC7227551 DOI: 10.1016/j.athoracsur.2020.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 12/30/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented disruption in health care delivery around the world. In an effort to prevent hospital-acquired COVID-19 infections, most hospitals have severely curtailed elective surgery, performing only surgeries if the patient's survival or permanent function would be compromised by a delay in surgery. As hospitals emerge from the pandemic, it will be necessary to progressively increase surgical activity at a time when hospitals continue to care for COVID-19 patients. In an attempt to mitigate the risk of nosocomial infection, we have created a patient care pathway designed to minimize risk of exposure of patients coming into the hospital for scheduled procedures. The COVID-minimal surgery pathway is a predetermined patient flow, which dictates the locations, personnel, and materials that come in contact with our cancer surgery population, designed to minimize risk for virus transmission. We outline the approach that allowed a large academic medical center to create a COVID-minimal cancer surgery pathway within 7 days of initiating discussions. Although the pathway represents a combination of recommended practices, there are no data to support its efficacy. We share the pathway concept and our experience so that others wishing to similarly align staff and resources toward the protection of patients may have an easier time navigating the process.
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Affiliation(s)
- Daniel J Boffa
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut; Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut.
| | - Benjamin L Judson
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin G Billingsley
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Domenico Galetta
- Division of Thoracic Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | | | - Marci R Mitchell
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut
| | - Cara M Henderson
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut; Yale New Haven Hospital, New Haven, Connecticut
| | | | | | | | - Michael M Ancuta
- Department of Anesthesia, Yale New Haven Hospital, New Haven, Connecticut
| | - Peggy Beley
- Yale New Haven Hospital, New Haven, Connecticut
| | | | - Trevor Banack
- Department of Anesthesia, Yale New Haven Hospital, New Haven, Connecticut
| | - Maxwell S Laurans
- Department of Neurosurgery, Yale New Haven Hospital, New Haven, Connecticut
| | - Dirk C Johnson
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - John M Morton
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kimberly Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, Connecticut; Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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25
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Zu Q, Schenning RC, Jahangiri Y, Tomozawa Y, Kolbeck KJ, Kaufman JA, Al-Hakim R, Naugler WE, Nabavizadeh N, Kardosh A, Billingsley KG, Mayo SC, Orloff SL, Enestvedt CK, Maynard E, Ahn J, Lhewa D, Farsad K. Correction to: Yttrium-90 Radioembolization for BCLC Stage C Hepatocellular Carcinoma Comparing Child-Pugh A Versus B7 Patients: Are the Outcomes Equivalent? Cardiovasc Intervent Radiol 2020; 43:1425-1426. [PMID: 32548673 DOI: 10.1007/s00270-020-02554-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The name of one of the co-authors was slightly misspelled. Kristian Enestvedt is listed currently as "Kristian K. Enestvedt" and should be listed instead as "C. Kristian Enestvedt."
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Affiliation(s)
- Qingquan Zu
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA.,Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, China
| | - Ryan C Schenning
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Younes Jahangiri
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Yuki Tomozawa
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Kenneth J Kolbeck
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - John A Kaufman
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Ramsey Al-Hakim
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Willscott E Naugler
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Nima Nabavizadeh
- Radiation Oncology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Adel Kardosh
- Medical Oncology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Skye C Mayo
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Susan L Orloff
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Erin Maynard
- Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Dekey Lhewa
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L-605, Portland, OR, 97239, USA.
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26
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Chen EYS, Tormoen GW, Kardosh A, Nabavizadeh N, Foster B, Mayo SC, Billingsley KG, Gilbert EW, Lanciault C, Grossberg A, Bensch KG, Maynard E, Anderson EC, Sheppard BC, Thomas CR, Lopez CD, Vaccaro GM. Phase II study of preoperative chemotherapy with nab-paclitaxel and gemcitabine followed by chemoradiation for borderline resectable or node-positive pancreatic ductal adenocarcinoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.697] [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: 11/20/2022] Open
Abstract
697 Background: Pre-operative therapy for resectable pancreatic ductal adenocarcinoma (PDAC) may eliminate micro-metastatic disease early and help achieve negative surgical margins. The present study is based on the hypothesis that gemcitabine/nab-paclitaxel chemotherapy followed by chemo-radiation with fluoropyrimidine is a feasible and efficacious pre-operative treatment for borderline resectable or node-positive PDAC. Methods: This is a single-arm phase II trial to evaluate pre-operative treatment with 2 cycles of gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 on days 1, 8, 15 every 28 days followed by 50.4 Gy of intensity-modulated radiation therapy over 28 fractions with concurrent 5-fluorouracil or capecitabine prior to pancreatic resection. Patients were eligible if they met borderline resectable criteria or had abnormal regional nodes visible on contrast CT. After surgery, they were eligible to receive up to 4 additional cycles of gemcitabine/nab-paclitaxel. The primary endpoint was the R0 resection rate. Secondary endpoints included response to pre-operative therapy, overall toxicities, relapse-free survival, and overall survival. Results: Nineteen of 24 screened patients have been enrolled. Median age was 68, 10 (53%) were female, and 4 (21%) were non-Caucasian. Eleven (78%) had head of pancreas cancers, 13 (68%) exhibited both arterial and venous involvement, and 12 (63%) had positive clinical nodes. All 19 patients received 2 months of gemcitabine/nab-paclitaxel, of which 17 patients continued to chemo-radiation (1 developed metastatic disease and 1 moved out of state). In the interval between chemo-radiation and surgery, 3 developed metastatic disease, 1 became unresectable, 1 withdrew from study, and 1 was deemed too frail for surgery. Nine have undergone successful pancreatic resection, and 2 are pending resection. Conclusions: Pre-operative gemcitabine/nab-paclitaxel followed by chemo-radiation with fluoropyrimidine is feasible in patients with borderline resectable PDAC and represents another strategy to FOLFIRINOX-based therapy. A planned interim analysis is ongoing. Clinical trial information: NCT02427841.
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Affiliation(s)
| | | | - Adel Kardosh
- Oregon Health & Science University, Portland, OR
| | | | - Bryan Foster
- Oregon Health & Science University, Portland, OR
| | - Skye C. Mayo
- Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | - Erin Maynard
- Oregon Health & Science University, Portland, OR
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27
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Deig CR, Beneville B, Liu A, Kanwar A, Grossblatt-Wait A, Sheppard BC, Gilbert EW, Lopez CD, Billingsley KG, Nabavizadeh N, Thomas CR, Grossberg A. Perioperative complication rates following neoadjuvant therapy in pancreatic adenocarcinoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
688 Background: Whether upfront resection or total neoadjuvant therapy is superior for the treatment of potentially resectable pancreatic adenocarcinoma (PDAC) remains controversial. The impact of neoadjuvant treatment on major perioperative complication rates for patients (pts) undergoing resection for PDAC is commonly debated. We hypothesized that rates would be comparable among patients receiving neoadjuvant chemoradiation (neo-CRT), neoadjuvant chemotherapy alone (neo-CHT), or upfront surgery. Methods: This is a retrospective study of 208 pts with PDAC who underwent resection within a multidisciplinary pancreatico-biliary program at an academic tertiary referral center between 2011-2018. Data were abstracted from the medical record, an institutional cancer registry and NSQIP databases. Outcomes were assessed using χ2, Fisher’s exact test and two-tailed Student’s t-tests. Results: 208 pts were identified: 33 locally advanced, borderline or upfront resectable pts underwent neo-CRT, 35 borderline or resectable pts underwent neoadjuvant-CHT, and 140 resectable pts did not undergo neoadjuvant therapy. There were no statistically significant differences in major perioperative complication rates between groups. Overall rates were 36.4%, 34.3%, and 26.4% for pts who underwent neo-CRT, neo-CHT alone, or upfront resection, respectively (p = 0.38). No significant difference were observed in complication rates (35.3% v. 26.4%; p = 0.19) or median hospital length of stay (10 days v. 10 days; p = 0.87) in pts who received any neoadjuvant therapy versus upfront resection. There were two perioperative deaths in the neo-CRT group (6.1%), zero in the neo-CHT group, and four in the upfront resection group (2.9%); p = 0.22. Conclusions: There were no significant differences in major perioperative complication rates, hospital length of stay, or post-operative mortality in pts who underwent neoadjuvant therapy (neo-CRT or neo-CHT alone) versus upfront surgery. Notably, neo-CRT had comparable perioperative complication rates to neo-CHT alone, which suggests neoadjuvant radiation therapy may not pose additional surgical risk.
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Affiliation(s)
| | | | - Amy Liu
- Nova Southeastern University College Of Osteopathic Medicine, Davie, FL
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28
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Muaddi H, Fields RC, Aucejo F, Billingsley KG, Walker BS, D’Angelica M, Latchana NV, Roke R, Ko YJ, Williams G, Acevedo-Moreno LA, Mayo SC, Karanicolas P. Safety and Feasibility of Hepatic Artery Infusion Pump Chemotherapy for Unresectable Colorectal Liver Metastases: A Multicenter, Retrospective Cohort Study. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.406] [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: 10/25/2022]
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29
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Byrne RM, Gilbert EW, Dewey EN, Herzig DO, Lu KC, Billingsley KG, Deveney KE, Tsikitis VL. Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Appendiceal Cancer? An Analysis of the National Cancer Database. J Surg Res 2019; 238:198-206. [PMID: 30772678 DOI: 10.1016/j.jss.2019.01.039] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/20/2018] [Accepted: 01/11/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND We sought to identify patterns of care for patients with appendiceal cancer and identify clinical factors associated with patient selection for multimodality treatment, including cytoreductive surgery and perioperative intraperitoneal chemotherapy (CRS/PIC). MATERIALS AND METHODS National Cancer Database (NCDB) data from 2004 to 2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities, as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at P ≤ 0.05. RESULTS We analyzed data on 18,055 patients. Nine thousand nine hundred ninety-two (55.3%) were treated with surgery only, 5848 (32.4%) received surgery and systemic chemotherapy, 1393 (7.71%) received CRS/PIC, 520 (2.88%) received chemotherapy alone, and 302 (1.67%) received neither surgery nor chemotherapy. Significant predictors of receiving CRS/PIC included male sex (OR 1.33, 95% CI: 1.11-1.59), white race (OR 2.00, 95% CI 1.40-2.86), non-Hispanic ethnicity (OR 1.92, 95% CI 1.21-3.05), private insurance (OR 1.52, 95% CI 1.26-1.84), and well-differentiated tumors (OR 4.25, CI: 3.39-5.32) (P < 0.05). Treatment with CRS/PIC was associated with a higher 5-year survival for mucinous malignancies, when compared to surgery alone (65.6% versus 62.4%, P < 0.01). Treatment with CRS/PIC was also associated with higher 5-year survival for well-differentiated malignancies, when compared to all other treatment modalities (74.9% versus 65.4%, P < 0.01). CONCLUSIONS Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors.
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Affiliation(s)
- Raphael M Byrne
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - Erin W Gilbert
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - Elizabeth N Dewey
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - Daniel O Herzig
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - Kim C Lu
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - Kevin G Billingsley
- Oregon Health & Science University, Department of Surgery, Division of Surgical Oncology, Portland, Oregon
| | - Karen E Deveney
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon
| | - V Liana Tsikitis
- Oregon Health & Science University, Department of Surgery, Division of GI and General Surgery, Portland, Oregon.
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30
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Zarour LR, Billingsley KG, Walker BS, Enestvedt CK, Orloff SL, Maynard E, Mayo SC. Hepatic resection of solitary HCC in the elderly: A unique disease in a growing population. Am J Surg 2019; 217:899-905. [PMID: 30819401 DOI: 10.1016/j.amjsurg.2019.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/11/2018] [Accepted: 01/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of elderly patients with solitary hepatocellular carcinoma (sHCC) is challenging with perceived clinicopathologic differences driving treatment options. We sought to determine factors predictive of disease control and survival after hepatic resection of sHCC in elderly patients. METHODS We identified n = 45 elderly patients (³≥65 yo) with sHCC treated with hepatic resection alone from our prospective database from 2003-16. Clinicopathologic data were analyzed and survival was assessed from the time of hepatic resection. RESULTS The median age was 75-years-old. Less than half of patients (47%) had viral hepatitis. At resection, the median Child-Pugh score was A6, median tumor size 5 cm, and mean AFP of 1050 (ng/mL). Major hepatectomy was performed in 23 patients (51%) with R0 resection achieved in 96%. Two patients (4%) had Grade III complications with no mortalities at 30 days and one death (2%) at 90-days. After R0 resection 44% (n = 20) had intrahepatic recurrence at a median of 32 months (95% CI: 15-46) with 20% (n = 9) developing extrahepatic recurrence at a median of 78 months (95% CI: 78-.). The median survival was 72 months (95% CI: 30-108 months). For patients with at least 3 years of follow-up, the 1-, 3-, and 5-year overall survival was 74%, 59%, and 50%, respectively. Mortality was associated with higher AFP and lower Prognostic Nutritional Index (PNI). CONCLUSION Carefully selected elderly patients with sHCC appear to have unique disease that is amenable to hepatic resection with low morbidity and mortality with excellent overall and recurrence-free survival.
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Affiliation(s)
- Luai R Zarour
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - Kevin G Billingsley
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA
| | - Brett S Walker
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA
| | - C Kristian Enestvedt
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Susan L Orloff
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Erin Maynard
- OHSU, Department of Surgery, Division of Transplant Surgery, Portland, OR, 97239, USA
| | - Skye C Mayo
- Oregon Heath & Science University (OHSU), Department of Surgery, Division of Surgical Oncology, Portland, OR, 97239, USA; The Knight Cancer Institute at OHSU, Portland, OR, 97239, USA.
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31
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Walcott-Sapp S, Naugler S, Lim JY, Wagner J, Orloff SL, Farsad K, Kolbeck KJ, Kaufman J, Maynard E, Enestvedt CK, Mayo SC, Billingsley KG. Tailored treatment of patients with hepatocellular carcinoma with portal vein invasion: experience from a multidisciplinary hepatobiliary tumor program within a NCI comprehensive cancer center. J Gastrointest Oncol 2018; 9:1074-1083. [PMID: 30603126 DOI: 10.21037/jgo.2018.08.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 12/24/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) with portal vein invasion (PVI) has a poor prognosis with limited treatment options. Intra-arterial brachytherapy (IAB) and transarterial chemoembolization (TACE) yield local control but risk accelerating liver dysfunction. The outcomes, survival, and safety of selective liver-directed treatment are reported. Methods Thirty-seven consecutive patients with HCC and PVI treated between 2009 and 2015 were reviewed from a prospectively collected database. Univariate analysis, Kaplan-Meier plots using the log-rank method, and multivariate analyses were performed. Statistical significance was defined as P<0.05. Overall survival was reported in months (median; 95% CI). Results Most patients (59%) had PVI identified at initial HCC diagnosis. The liver-directed therapy group (n=22) demonstrated a survival advantage versus the systemic/supportive care group (n=14) [23.6 (5.8, 30.9) vs. 6.0 (3.5, 8.8) months]. Patients indicated for liver directed therapy had unilateral liver involvement (100% vs. 43%, P<0.0001), lower median alkaline phosphatase (105.5 vs. 208.0, P=0.002), and lower mean Child-Turcotte-Pugh (CTP) score (5.9 vs. 7.2, P=0.04) and tolerated treatment without serious complications. Conclusions In HCC patients presenting with PVI, liver-directed therapy was safely performed in patients with limited venous involvement and preserved liver function. Liver-directed therapy extended survival for these patients indicated for palliative chemotherapy by traditional guidelines.
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Affiliation(s)
- Sarah Walcott-Sapp
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Scott Naugler
- Division of Gastroenterology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jeong Youn Lim
- Division of Biostatistics, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Jesse Wagner
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Susan L Orloff
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Khashayar Farsad
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Kenneth J Kolbeck
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - John Kaufman
- Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Erin Maynard
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - C Kristian Enestvedt
- Abdominal Transplant Division, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Skye C Mayo
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
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Gast CE, Silk AD, Zarour L, Riegler L, Burkhart JG, Gustafson KT, Parappilly MS, Roh-Johnson M, Goodman JR, Olson B, Schmidt M, Swain JR, Davies PS, Shasthri V, Iizuka S, Flynn P, Watson S, Korkola J, Courtneidge SA, Fischer JM, Jaboin J, Billingsley KG, Lopez CD, Burchard J, Gray J, Coussens LM, Sheppard BC, Wong MH. Cell fusion potentiates tumor heterogeneity and reveals circulating hybrid cells that correlate with stage and survival. Sci Adv 2018; 4:eaat7828. [PMID: 30214939 PMCID: PMC6135550 DOI: 10.1126/sciadv.aat7828] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/01/2018] [Indexed: 05/06/2023]
Abstract
High lethality rates associated with metastatic cancer highlight an urgent medical need for improved understanding of biologic mechanisms driving metastatic spread and identification of biomarkers predicting late-stage progression. Numerous neoplastic cell intrinsic and extrinsic mechanisms fuel tumor progression; however, mechanisms driving heterogeneity of neoplastic cells in solid tumors remain obscure. Increased mutational rates of neoplastic cells in stressed environments are implicated but cannot explain all aspects of tumor heterogeneity. We present evidence that fusion of neoplastic cells with leukocytes (for example, macrophages) contributes to tumor heterogeneity, resulting in cells exhibiting increased metastatic behavior. Fusion hybrids (cells harboring hematopoietic and epithelial properties) are readily detectible in cell culture and tumor-bearing mice. Further, hybrids enumerated in peripheral blood of human cancer patients correlate with disease stage and predict overall survival. This unique population of neoplastic cells provides a novel biomarker for tumor staging, as well as a potential therapeutic target for intervention.
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Affiliation(s)
- Charles E. Gast
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Alain D. Silk
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Luai Zarour
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Lara Riegler
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Joshua G. Burkhart
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Kyle T. Gustafson
- Center for Early Detection Advanced Research, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239, USA
| | - Michael S. Parappilly
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Minna Roh-Johnson
- Division of Basic Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA
| | - James R. Goodman
- Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Brennan Olson
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Mark Schmidt
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - John R. Swain
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Paige S. Davies
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Vidya Shasthri
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Shinji Iizuka
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Patrick Flynn
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Spencer Watson
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - James Korkola
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Sara A. Courtneidge
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Jared M. Fischer
- Center for Early Detection Advanced Research, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR 97239, USA
| | - Jerry Jaboin
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR 97239, USA
| | - Kevin G. Billingsley
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Charles D. Lopez
- Department of Medicine, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Julja Burchard
- Department of Computational Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Joe Gray
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Lisa M. Coussens
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Brett C. Sheppard
- Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Melissa H. Wong
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA
- Corresponding author.
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Chen EYS, Mayo SC, Billingsley KG, Vaccaro GM, Kearney M, Lopez CD. Effect of time to resection of colorectal liver metastases on recurrence risk. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.3541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Skye C. Mayo
- Memorial Sloan Kettering Cancer Center, New York, NY
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Lu E, Perlewitz KS, Hayden JB, Hung AY, Doung YC, Davis LE, Mansoor A, Vetto JT, Billingsley KG, Kaempf A, Park B, Ryan CW. Epirubicin and Ifosfamide with Preoperative Radiation for High-Risk Soft Tissue Sarcomas. Ann Surg Oncol 2018; 25:920-927. [DOI: 10.1245/s10434-018-6346-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Indexed: 11/18/2022]
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Abstract
PURPOSE Major hepatic resections are performed for primary hepatobiliary malignancies, metastatic disease, and benign lesions. Patients with chronic liver disease, including cirrhosis and steatosis, are at an elevated risk of malnutrition and impaired strength and exercise capacity, deficits which cause increased risk of postoperative complications and mortality. The aims of this report are to discuss the pathophysiology of changes in nutrition, exercise capacity, and muscle strength in patient populations likely to require major hepatectomy, and review recommendations for preoperative evaluation and optimization. METHODS Nutritional and functional impairment in preoperative hepatectomy patients, especially those with underlying liver disease, have a complex and multifactorial physiologic basis that is not completely understood. RESULTS Recognition of malnutrition and compromised strength and exercise tolerance preoperatively can be difficult, but is critical in providing the opportunity to intervene prior to major hepatic resection and potentially improve postoperative outcomes. There is promising data on a variety of nutritional strategies to ensure adequate intake of calories, proteins, vitamins, and minerals in patients with cirrhosis and reduce liver size and degree of fatty infiltration in patients with hepatic steatosis. Emerging evidence supports structured exercise programs to improve exercise tolerance and counteract muscle wasting. CONCLUSIONS The importance of nutrition and functional status in patients indicated for major liver resection is apparent, and emerging evidence supports structured preoperative preparation programs involving nutritional intervention and exercise training. Further research is needed in this field to develop optimal protocols to evaluate and treat this heterogeneous cohort of patients.
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Affiliation(s)
- Sarah Walcott-Sapp
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA.
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA
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36
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Leichman CG, McDonough SL, Smalley SR, Billingsley KG, Lenz HJ, Beldner MA, Hezel AF, Velasco MR, Guthrie KA, Blanke CD, Hochster HS. Cetuximab Combined With Induction Oxaliplatin and Capecitabine, Followed by Neoadjuvant Chemoradiation for Locally Advanced Rectal Cancer: SWOG 0713. Clin Colorectal Cancer 2017; 17:e121-e125. [PMID: 29233486 DOI: 10.1016/j.clcc.2017.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 10/14/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCRT) is standard treatment for locally advanced rectal cancer. Pathologic complete response (pCR) has associated with improved survival. In modern phase III trials of NCRT, pCR ranges from 10% to 20%. Cetuximab improves response in KRAS (KRAS proto-oncogene) wild type (wt) metastatic colorectal cancer. S0713 was designed to assess improvement in pCR with additional use of cetuximab with induction chemotherapy and NCRT for locally advanced, KRAS-wt rectal cancer. PATIENTS AND METHODS Patient eligibility: stage II to III biopsy-proven, KRAS-wt rectal adenocarcinoma; no bowel obstruction; adequate hematologic, hepatic and renal function; performance status of 0 to 2. Target enrollment: 80 patients. TREATMENT induction chemotherapy with wCAPOX (weekly capecitabine and oxaliplatin) and cetuximab followed by the same regimen concurrent with radiation (omitting day 15 oxaliplatin). If fewer than 7 pCRs were observed at planned interim analysis after 40 patients received all therapy, the study would close. Eighty eligible patients would provide 90% power given a true pCR rate > 35% at a significance of 0.04. The regimen would lack future interest if pCR probability was ≤ 20%. RESULTS Between February 2009 and April 2013, 83 patients registered. Four were ineligible and 4 not treated, leaving 75 evaluable for clinical outcomes and toxicity, of whom 65 had surgery. Of 75 patients, 20 had pCR (27%; 95% confidence interval [CI], 17%-38%); 19 (25%) had microscopic cancer; 36 (48%) had minor/no response (including 10 without surgery). Three-year disease-free survival was 73% (95% CI, 63%-83%). CONCLUSION Our trial did not meet the pCR target of 35%. Toxicity was generally acceptable. This regimen cannot be recommended outside the clinical trial setting.
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Affiliation(s)
| | | | | | - Kevin G Billingsley
- Division of Surgical Oncology, Oregon Health & Science University, Portland, OR
| | - Heinz-Josef Lenz
- Division of Medical Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Matthew A Beldner
- Southeast Cancer Control Consortium-Upstate NCORP/Lowcountry Hematology Oncology, Mt Pleasant, SC
| | - Aram F Hezel
- Department of Medicine, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Mario R Velasco
- Heartland NCORP/Cancer Care Specialists of Central Illinois, Decatur, IL
| | | | - Charles D Blanke
- SWOG Group Chair's Office/Oregon Health & Science University, Portland, OR
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37
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Zarour LR, Anand S, Billingsley KG, Bisson WH, Cercek A, Clarke MF, Coussens LM, Gast CE, Geltzeiler CB, Hansen L, Kelley KA, Lopez CD, Rana SR, Ruhl R, Tsikitis VL, Vaccaro GM, Wong MH, Mayo SC. Colorectal Cancer Liver Metastasis: Evolving Paradigms and Future Directions. Cell Mol Gastroenterol Hepatol 2017; 3:163-173. [PMID: 28275683 DOI: 10.1016/j.jcmgh.2017.01.0068] [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] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/11/2017] [Indexed: 05/25/2023]
Abstract
In patients with colorectal cancer (CRC) that metastasizes to the liver, there are several key goals for improving outcomes including early detection, effective prognostic indicators of treatment response, and accurate identification of patients at high risk for recurrence. Although new therapeutic regimens developed over the past decade have increased survival, there is substantial room for improvement in selecting targeted treatment regimens for the patients who will derive the most benefit. Recently, there have been exciting developments in identifying high-risk patient cohorts, refinements in the understanding of systemic vs localized drug delivery to metastatic niches, liquid biomarker development, and dramatic advances in tumor immune therapy, all of which promise new and innovative approaches to tackling the problem of detecting and treating the metastatic spread of CRC to the liver. Our multidisciplinary group held a state-of-the-science symposium this past year to review advances in this rapidly evolving field. Herein, we present a discussion around the issues facing treatment of patients with CRC liver metastases, including the relationship of discrete gene signatures with prognosis. We also discuss the latest advances to maximize regional and systemic therapies aimed at decreasing intrahepatic recurrence, review recent insights into the tumor microenvironment, and summarize advances in noninvasive multimodal biomarkers for early detection of primary and recurrent disease. As we continue to advance clinically and technologically in the field of colorectal tumor biology, our goal should be continued refinement of predictive and prognostic studies to decrease recurrence after curative resection and minimize treatment toxicity to patients through a tailored multidisciplinary approach to cancer care.
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Key Words
- 5-FU, fluorouracil
- Biomarkers
- CDX2, caudal-type homeobox transcription factor 2
- CEA, carcinoembryonic antigen
- CK, cytokeratin
- CRC, colorectal cancer
- CRLM, colorectal cancer liver metastasis
- CTC, circulating tumor cells
- Colorectal Cancer Liver Metastasis
- DFS, disease-free survival
- EGFR, epidermal growth factor receptor
- EpCAM, epithelial cell adhesion molecule
- HAI, hepatic arterial infusion
- Hepatic Arterial Infusion
- High-Risk Colorectal Cancer
- IL, interleukin
- LV, leucovorin
- MSI, microsatellite instability
- OS, overall survival
- PD, programmed death
- Recurrence
- TH, T-helper
- cfDNA, cell-free DNA
- dMMR, deficient mismatch repair
- miRNA, microRNA
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Affiliation(s)
- Luai R Zarour
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Sudarshan Anand
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon; The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon; The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - William H Bisson
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon; Environmental and Molecular Toxicology, Oregon State University, Corvallis, Oregon
| | - Andrea Cercek
- Department of Gastrointestinal Medical Oncology, Solid Tumor Division, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael F Clarke
- Stanford Institute for Stem Cell and Regenerative Medicine, Stanford University, Stanford, California; Division of Oncology, Department of Medicine, Stanford University, Stanford, California
| | - Lisa M Coussens
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon; The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Charles E Gast
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon
| | - Cristina B Geltzeiler
- Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Lissi Hansen
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon; School of Nursing, Oregon Heath and Science University, Portland, Oregon
| | - Katherine A Kelley
- Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Charles D Lopez
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon; Division of Hematology and Medical Oncology, Department of Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Shushan R Rana
- Department of Radiation Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Rebecca Ruhl
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon
| | - V Liana Tsikitis
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon; Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Gina M Vaccaro
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon; Division of Hematology and Medical Oncology, Department of Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Melissa H Wong
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon; The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Skye C Mayo
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon; The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
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38
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Zarour LR, Anand S, Billingsley KG, Bisson WH, Cercek A, Clarke MF, Coussens LM, Gast CE, Geltzeiler CB, Hansen L, Kelley KA, Lopez CD, Rana SR, Ruhl R, Tsikitis VL, Vaccaro GM, Wong MH, Mayo SC. Colorectal Cancer Liver Metastasis: Evolving Paradigms and Future Directions. Cell Mol Gastroenterol Hepatol 2017; 3:163-173. [PMID: 28275683 PMCID: PMC5331831 DOI: 10.1016/j.jcmgh.2017.01.006] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/11/2017] [Indexed: 02/08/2023]
Abstract
In patients with colorectal cancer (CRC) that metastasizes to the liver, there are several key goals for improving outcomes including early detection, effective prognostic indicators of treatment response, and accurate identification of patients at high risk for recurrence. Although new therapeutic regimens developed over the past decade have increased survival, there is substantial room for improvement in selecting targeted treatment regimens for the patients who will derive the most benefit. Recently, there have been exciting developments in identifying high-risk patient cohorts, refinements in the understanding of systemic vs localized drug delivery to metastatic niches, liquid biomarker development, and dramatic advances in tumor immune therapy, all of which promise new and innovative approaches to tackling the problem of detecting and treating the metastatic spread of CRC to the liver. Our multidisciplinary group held a state-of-the-science symposium this past year to review advances in this rapidly evolving field. Herein, we present a discussion around the issues facing treatment of patients with CRC liver metastases, including the relationship of discrete gene signatures with prognosis. We also discuss the latest advances to maximize regional and systemic therapies aimed at decreasing intrahepatic recurrence, review recent insights into the tumor microenvironment, and summarize advances in noninvasive multimodal biomarkers for early detection of primary and recurrent disease. As we continue to advance clinically and technologically in the field of colorectal tumor biology, our goal should be continued refinement of predictive and prognostic studies to decrease recurrence after curative resection and minimize treatment toxicity to patients through a tailored multidisciplinary approach to cancer care.
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Key Words
- 5-FU, fluorouracil
- Biomarkers
- CDX2, caudal-type homeobox transcription factor 2
- CEA, carcinoembryonic antigen
- CK, cytokeratin
- CRC, colorectal cancer
- CRLM, colorectal cancer liver metastasis
- CTC, circulating tumor cells
- Colorectal Cancer Liver Metastasis
- DFS, disease-free survival
- EGFR, epidermal growth factor receptor
- EpCAM, epithelial cell adhesion molecule
- HAI, hepatic arterial infusion
- Hepatic Arterial Infusion
- High-Risk Colorectal Cancer
- IL, interleukin
- LV, leucovorin
- MSI, microsatellite instability
- OS, overall survival
- PD, programmed death
- Recurrence
- TH, T-helper
- cfDNA, cell-free DNA
- dMMR, deficient mismatch repair
- miRNA, microRNA
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Affiliation(s)
- Luai R. Zarour
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Sudarshan Anand
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Kevin G. Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - William H. Bisson
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon,Environmental and Molecular Toxicology, Oregon State University, Corvallis, Oregon
| | - Andrea Cercek
- Department of Gastrointestinal Medical Oncology, Solid Tumor Division, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Michael F. Clarke
- Stanford Institute for Stem Cell and Regenerative Medicine, Stanford University, Stanford, California,Division of Oncology, Department of Medicine, Stanford University, Stanford, California
| | - Lisa M. Coussens
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Charles E. Gast
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon
| | - Cristina B. Geltzeiler
- Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Lissi Hansen
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon,School of Nursing, Oregon Heath and Science University, Portland, Oregon
| | - Katherine A. Kelley
- Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon
| | - Charles D. Lopez
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon,Division of Hematology and Medical Oncology, Department of Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Shushan R. Rana
- Department of Radiation Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Rebecca Ruhl
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon
| | - V. Liana Tsikitis
- Division of Colorectal Surgery, Department of Surgery, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Gina M. Vaccaro
- The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon,Division of Hematology and Medical Oncology, Department of Medicine, Oregon Heath and Science University, Portland, Oregon
| | - Melissa H. Wong
- Department of Cell Developmental and Cancer Biology, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon
| | - Skye C. Mayo
- Division of Surgical Oncology, Department of Surgery, Oregon Heath and Science University, Portland, Oregon,The Knight Cancer Institute, Oregon Heath and Science University, Portland, Oregon,Correspondence Address correspondence to: Skye C. Mayo, MD, Department of Surgery, Oregon Heath and Science University, 3181 SW Sam Jackson Park Road, Mailcode L223, Portland, Oregon 97239. fax: (503) 494–8884.Department of SurgeryOregon Heath and Science University3181 SW Sam Jackson Park Road, Mailcode L223PortlandOregon 97239
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39
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Leichman CG, McDonough SL, Smalley SR, Billingsley KG, Lenz HJ, Beldner MA, Hezel AF, Velasco MR, Guthrie KA, Blanke CD, Hochster HS. S0713: A phase II study of cetuximab (CET) added to induction chemotherapy (ICT) of oxaliplatin (OX) and capecitabine (CAP), followed by neoadjuvant chemoradiation (NACR) for locally advanced rectal cancer (LARC). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.3516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Aram F. Hezel
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | | | | | | | - Howard S. Hochster
- Department of Medical Oncology, Yale University School of Medicine, New Haven, CT
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40
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Abstract
Techniques in liver surgery have improved considerably during the last decades, allowing for liver resections with low morbidity and mortality. Preoperative patient selection, perioperative management, and intraoperative blood-sparing techniques are the cornerstones of modern liver surgery. Multimodal treatment of colorectal liver metastases has expanded the group of patients who are potential candidates for liver resection. Adjunctive techniques, including preoperative portal vein embolization and staged hepatectomy, have facilitated the safe performance of extensive liver resection. This article provides an overview of indications for liver resection and a systematic description of the technical approach to the most commonly performed resections.
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Affiliation(s)
- Christoph W Michalski
- Division of Surgical Oncology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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Geltzeiler CB, Nabavizadeh N, Kim J, Lu KC, Billingsley KG, Thomas CR, Herzig DO, Tsikitis VL. Chemoradiotherapy with a Radiation Boost for Anal Cancer Decreases the Risk for Salvage Abdominoperineal Resection: Analysis From the National Cancer Data Base. Ann Surg Oncol 2014; 21:3616-20. [DOI: 10.1245/s10434-014-3849-5] [Citation(s) in RCA: 9] [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: 03/11/2014] [Indexed: 12/28/2022]
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Louis SG, Barton JS, Riha GM, Orloff SL, Sheppard BC, Pommier RF, Underwood SJ, Differding JA, Schreiber MA, Billingsley KG. The international normalized ratio overestimates coagulopathy in patients after major hepatectomy. Am J Surg 2014; 207:723-7; discussion 727. [DOI: 10.1016/j.amjsurg.2013.12.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/17/2013] [Accepted: 12/21/2013] [Indexed: 12/21/2022]
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Tsikitis VL, Lu K, Kim JS, Billingsley KG, Thomas CR, Herzig D. Nomogram for predicting overall and colostomy-free survival for patients with anal cancer. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.400] [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: 11/20/2022] Open
Abstract
400 Background: The incidence of anal cancer, currently about 5,000 persons a year, is increasing in the United States. Its treatment has evolved from a radical surgical treatment including abdominoperineal resection to a combined chemoradiotherapy (CRT) (Nigro protocol) approach which allows for sphincter preservation. The specific aim of this study was to develop an accurate model and nomogram to predict overall (OS) and colostomy free survival (CFS) for patients (pts) presenting with anal cancer. Methods: Pts with de novo anal cancer were selected from the National Cancer Database (NCDB) from years 1998-2010. The database included 53,523 pts. After excluding anal margin cancer pts and pts with missing data points; 1,823 pts were included and their data analyzed. Variables included time to death, censoring indicator, age, race, sex, tumor size, surgery status, nodal status, radiation (RT) and chemotherapy (CT) separately and as a CRT. A stratified Cox proportional hazards model for OS and a logistic regression model for CFS were developed, respectively. For each primary end point, our final model was validated to ascertain whether predicted values from the model are likely to accurately predict responses on future subjects or subjects not used to develop our model. Results: Statistically significant variables in the CFS model were age, nodal status, TNM stage, RT (p ≤ 0.0001), and tumor size (p = 0.010). Similarly, for OS model statistically significant variables (all with p ≤ 0.005) fitted across the strata of TNM clinical stage included age, sex, tumor size, nodal status, and CRT. Nomograms that predict events are based on our final models with the estimated mean absolute bootstrap calibration error being only 0.011 for OS model and 0.02 for CFS model, respectively. Conclusions: A nomogram can predict OS and CFS over lifetime. Such outcome prediction tools may potentially be used as prognostic and decision support tools to guide therapy and predict pts that may need surgery in their lifetime.
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Affiliation(s)
| | - Kim Lu
- Oregon Health & Science University, Portland, OR
| | - Jong Sung Kim
- Department of Mathematics and Statistics, Portland State University, Portland, OR
| | | | - Charles R. Thomas
- Knight Cancer Institute at Oregon Health and Science University, Portland, OR
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Gur I, Diggs BS, Wagner JA, Vaccaro GM, Lopez CD, Sheppard BC, Orloff SL, Billingsley KG. Safety and outcomes following resection of colorectal liver metastases in the era of current perioperative chemotherapy. J Gastrointest Surg 2013; 17:2133-42. [PMID: 24091909 DOI: 10.1007/s11605-013-2295-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 12/19/2012] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative chemotherapy is increasingly utilized in the treatment of colorectal liver metastases (CRLM). Although this strategy may improve resectability, long-term advantages of preoperative chemotherapy for resectable CRLM are less clear. The objective of this study is to report safety and outcomes when perioperative chemotherapy is routinely added to surgery for CRLM. METHODS A retrospective review of patients undergoing liver resections for CRLM during 2003-2011 in single academic oncology center. Demographic data, tumor characteristics, chemotherapy, surgical details, complications and survival were analyzed. RESULTS The study included 157 patients that underwent 168 liver operations. One hundred eighteen patients (70 %) underwent preoperative chemotherapy (75 % oxaliplatin-based). Preoperative portal vein embolization was utilized in 16 (10.1 %) patients. Overall survival (OS) was 89, 57, and 27 % at 1, 3, and 5 years, respectively (median survival-42.8 months). Eleven (7 %) patients had repeat resections for liver recurrence. Thirty-day mortality was 1.26 %, morbidity-24 % (6 %-liver related). Complications were not significantly different in patients that had preoperative chemotherapy. On a multivariate analysis advanced age and >3 lesions predicted poor OS, while advanced age, lesions >5 cm, synchronous lesions, margin-positivity and resection less than hepatectomy were associated with decreased DFS. CONCLUSIONS Our results suggest that even with chemotherapy and resection only a subset of patients remain disease-free after 5 years. However, even in a high-risk patient with multiple lesions, preoperative chemotherapy can be administered safely without apparent increase in postoperative complications. Perioperative chemotherapy should be considered particularly in patients with multifocal or large lesions, synchronous disease and short disease-free interval.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA,
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Barton JS, Riha GM, Differding JA, Underwood SJ, Curren JL, Sheppard BC, Pommier RF, Orloff SL, Schreiber MA, Billingsley KG. Coagulopathy after a liver resection: is it over diagnosed and over treated? HPB (Oxford) 2013; 15:865-71. [PMID: 23458574 PMCID: PMC4503284 DOI: 10.1111/hpb.12051] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [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: 07/31/2012] [Accepted: 10/17/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prothrombin time-international normalized ratio (PT-INR) is widely utilized to guide plasma therapy and initiation of thromboprophylaxis after a hepatectomy. Thrombelastography (TEG) monitors shear elasticity, which is sensitive to cellular and plasma components in blood, allowing for functional assessment of the life of the clot. The objective of this study was to prospectively compare PT-INR and TEG in liver resection patients. METHODS Forty patients were enrolled before undergoing an elective hepatectomy. Patients underwent a liver resection utilizing a low central venous pressure (CVP) anaesthetic technique and intermittent Pringle manoeuver. PT-INR and TEG were drawn prior to incision, post-operatively, and post-operative days 1, 3 and 5. RESULTS All post-operative PT-INR values increased significantly when compared with pre-operative PT-INR (P < 0.01). The time of onset to clot (R-value) decreased significantly at the post-operative time point (P = 0.04), consistent with a relative hypercoagulability. Subsequent R-values were not different compared with the pre-operative R-value. The strength of the clot (maximum amplitude, MA) was unchanged when comparing pre- and post-operative time points. DISCUSSION In spite of an elevation in PT-INR, patients undergoing a liver resection demonstrated a brief hypercoagulable state, followed by normal coagulation function based on TEG. These data call into question the practice of utilizing PT-INR to guide plasma transfusion and timing of prophylactic anticoagulation after a liver resection.
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Affiliation(s)
- Jeffrey S Barton
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Gordon M Riha
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Jerome A Differding
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Samantha J Underwood
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Jodie L Curren
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Brett C Sheppard
- Division of General Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Rodney F Pommier
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Susan L Orloff
- Division of Liver and Pancreas Transplantation, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health & Science UniversityPortland, OR, USA,Correspondence, Kevin G. Billingsley, Oregon Health & Science University, Division of Surgical Oncology, L619, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA. Tel: +1 503 494 5501. Fax: +1 503 494 1211. E-mail:
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Eil R, Hansen PD, Cassera M, Orloff SL, Sheppard BC, Diggs B, Billingsley KG. Bile duct involvement portends poor prognosis in resected gallbladder carcinoma. Gastrointest Cancer Res 2013; 6:101-105. [PMID: 24147157 PMCID: PMC3782874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/23/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Gallbladder cancer (GBC) carries an unfavorable prognosis with high mortality. This retrospective study was conducted to identify prognostic factors after resection of GBC, to assist in selecting appropriate surgical and adjuvant therapy. METHODS Sixty-two patients from two institutions were identified with GBC by pathology. In 25, the cancer was unresectable at presentation. The remaining 37 patients comprised the study population. Log-rank analysis was used to assess univariate association with disease-free survival (DFS) and disease-specific survival (DSS). Cox regression was used for multivariate analysis. RESULTS Median DFS and DSS were 22.6 and 28.5 months respectively, with a median follow-up of 44.2 months. On univariate analysis, bile duct (BD) involvement was significantly associated with decreased DFS (P ≤ .001) and DSS (P = .004). BD involvement was uniformly fatal. LN involvement was not significantly associated with DFS or DSS (P = .85, P = .54). CONCLUSIONS All patients with BD involvement in our population died of the disease. The subset of patients with resectable GBC and BD involvement is a group that is at high risk for recurrence and should be treated as such. In our small population, preoperative and intraoperative methods evaluating BD involvement were unreliable.
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Affiliation(s)
- Robert Eil
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Paul D. Hansen
- Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland, OR
| | - Maria Cassera
- Hepatobiliary and Pancreatic Surgery Program Providence Portland Medical Center Portland, OR
| | - Susan L. Orloff
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Brett C. Sheppard
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Brian Diggs
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
| | - Kevin G. Billingsley
- Division of Surgical Oncology Oregon Health and Sciences University Portland, OR
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Hessman CJ, Bubbers EJ, Billingsley KG, Herzig DO, Wong MH. Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer. Am J Surg 2012; 203:649-653. [PMID: 22405917 DOI: 10.1016/j.amjsurg.2012.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/05/2012] [Accepted: 01/05/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) progression is mediated by cancer stem cells (CSCs). We sought to determine if the expression of the CSC marker aldehyde dehydrogenase 1 (ALDH1) in CRC tumors varies by American Joint Committee on Cancer stage or correlates to clinical outcomes. METHODS Primary and metastatic CRC samples from 96 patients were immunostained with antibodies to ALDH1 and imaged to evaluate marker expression. The percentage of ALDH1(+) cells was correlated to clinical outcomes. RESULTS ALDH1 was overexpressed in CRC tumors compared with nonneoplastic tissue. Marker expression was highest in nonmetastatic tumors. The loss of expression was associated with advanced stage and metastatic disease. No significant correlation was found between ALDH1 expression and metastasis, recurrence, or survival. CONCLUSIONS ALDH1 was highly expressed in nonmetastatic CRC, but expression was lost with advancing stage. ALDH1 could be an effective therapeutic target in early CRC but not late-stage disease. No correlation was found between ALDH1 and disease prognosis.
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Affiliation(s)
- Crystal J Hessman
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223, Portland, OR 97239, USA.
| | - Emily J Bubbers
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223, Portland, OR 97239, USA
| | - Kevin G Billingsley
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Daniel O Herzig
- Department of Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Melissa H Wong
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA; Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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Massimino KP, Kolbeck KJ, Enestvedt CK, Orloff S, Billingsley KG. Safety and efficacy of preoperative right portal vein embolization in patients at risk for postoperative liver failure following major right hepatectomy. HPB (Oxford) 2012; 14:14-9. [PMID: 22151446 PMCID: PMC3252986 DOI: 10.1111/j.1477-2574.2011.00402.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Right portal vein embolization (RPVE) has been utilized with or without segment IV (RPVE + IV) prior to hepatectomy to induce hypertrophy and prevent liver insufficiency in patients with a predicted future liver remnant (FLR) of ≤30% or cirrhosis. METHODS Records of patients who underwent RPVE during 2006-2010 were retrospectively reviewed. Patient demographics, operative outcomes and complications were analysed. Computed tomography-based volumetrics were performed to determine FLR volume and degree of hypertrophy. Patients were stratified by segment IV embolization. Short-term outcomes following RPVE and liver resection are reported. RESULTS A total of 23 patients were identified. Ten patients underwent RPVE and 13 underwent RPVE + IV. The RPVE procedure resulted in a 38% increase in FLR volume. Liver volumes, hypertrophy rates and outcomes were similar in both groups. Rates of operative complications in the RPVE and RPVE + IV groups were similar at 50% and 54%, respectively, and most complications were minor. Complication rates as a result of embolization were 30% in the RPVE group and 31% in the RPVE + IV group. One patient underwent modified operative resection as a result of a complication of RPVE. CONCLUSIONS Right portal vein embolization (±segment IV) is a safe and effective modality to increase FLR volume. Post-embolization complications and short-term outcomes after resection are acceptable and are similar in both RPVE and RPVE + IV.
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Affiliation(s)
| | - Kenneth J Kolbeck
- Division of Vascular and Interventional Radiology, Department of Diagnostic RadiologyPortland, OR, USA
| | | | - Susan Orloff
- Division of Abdominal Organ Transplantation, Department of Surgery, Oregon Health and Science UniversityPortland, OR, USA
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Leichman LP, Goldman BH, Bohanes PO, Lenz HJ, Thomas CR, Billingsley KG, Corless CL, Iqbal S, Gold PJ, Benedetti JK, Danenberg KD, Blanke CD. S0356: a phase II clinical and prospective molecular trial with oxaliplatin, fluorouracil, and external-beam radiation therapy before surgery for patients with esophageal adenocarcinoma. J Clin Oncol 2011; 29:4555-60. [PMID: 22025151 DOI: 10.1200/jco.2011.36.7490] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Pathologic complete response (pCR) after neoadjuvant therapy for locally advanced esophageal adenocarcinoma is associated with improved survival. The Southwest Oncology Group designed a trimodality, phase II, single-arm trial with objectives of achieving a pCR rate of 40% with prospective exploratory analyses of intratumoral molecular markers postulated to affect response and survival. PATIENTS AND METHODS Patients with clinically staged II or III esophageal adenocarcinoma received oxaliplatin 85 mg/m(2) on days 1, 15, and 29; protracted-infusion fluorouracil (PI-FU) 180 mg/m(2)/d on days 8 through 43; and external-beam radiation therapy (EBRT) 5 days a week at 1.8 Gy/d for 25 fractions; surgery was performed 28 to 42 days after neoadjuvant therapy. Chemotherapy was planned after surgery. Tumors were analyzed for mRNA expression and polymorphisms in genes involved in drug metabolism and DNA repair. RESULTS Ninety-three patients were evaluable. Two deaths (2.2%) were attributable to preoperative therapy, and two deaths (2.2%) were attributable to surgery. Grade 3 and 4 toxicities were recorded for 47.3% and 19.4% of patients, respectively. Seventy-nine patients (84.9%) underwent surgery; 67.7% of patients had R0 resections. Twenty-six patients (28.0%) had confirmed pCR (95% CI, 19.1% to 38.2%). At a median follow-up of 39.2 months, estimates of median and 3-year overall survival (OS) were 28.3 months and 45.1%, respectively. Intratumoral ERCC-1 gene expression was inversely related to progression-free survival and OS. CONCLUSION Neoadjuvant oxaliplatin, PI-FU, and EBRT for esophageal adenocarcinoma is active and tolerable. Because the regimen failed to meet the primary end point, it does not define a new standard. However, future trials can be built on this platform to validate the role of ERCC-1 in determining the best systemic regimen for individual patients.
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Affiliation(s)
- Lawrence P Leichman
- Gastrointestinal Malignancies, Desert Regional Medical Center Comprehensive Cancer Center, and Aptium Oncology, 1180 N Indian Canyon Dr, Palm Springs, CA 92262;
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Hammill CW, Billingsley KG, Cassera MA, Wolf RF, Ujiki MB, Hansen PD. Outcome after laparoscopic radiofrequency ablation of technically resectable colorectal liver metastases. Ann Surg Oncol 2011; 18:1947-54. [PMID: 21399885 DOI: 10.1245/s10434-010-1535-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND There continues to be controversy surrounding the appropriate use of radiofrequency ablation (RFA) for the treatment of colorectal liver metastases (CRLM). This study analyzes outcomes data of CRLM patients who underwent laparoscopic RFA. Outcomes of patients determined to be technically resectable were compared to patients with unresectable disease. METHODS Data from all patients with CRLM who underwent laparoscopic RFA between 1996 and 2006 were retrospectively reviewed. A blinded independent hepatobiliary-trained surgical oncologist reviewed preoperative diagnostic imaging studies to determine resectability. Outcomes data for patients with disease deemed anatomically resectable and unresectable were analyzed and compared. Survival was calculated by the Kaplan-Meier method. The log rank test was performed to assess significance in survival. RESULTS A total of 113 patients who underwent laparoscopic RFA for CRLM were identified. Twelve patients who underwent concurrent hepatic resection were excluded. Of the remaining patients, 64 were determined to have disease that was be technically resectable and 37 unresectable as a result of tumor number and/or distribution. Median and 5-year survival of the potentially resectable group was 4.3years and 48.7%, compared to 2.2 years and 18.4% in the unresectable group (P = 0.002). Median disease-free survival in the resectable group was 15.0 months, compared to 16.4 months in the unresectable group (P = 0.796). No postoperative mortality was reported in the technically resectable group, and the rate of major complications was 3.1%. CONCLUSIONS Laparoscopic RFA of resectable CRLM can produce comparable long-term survival to hepatic resection in carefully selected patients, with favorable morbidity and mortality.
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Affiliation(s)
- Chet W Hammill
- Liver and Pancreas Surgery Program, Providence Portland Medical Center, Portland, OR, USA
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